What Is Genitourinary Syndrome of Menopause?
The late comedian Joan Rivers used to joke that her vagina was so dry, when she got into a bathtub, she absorbed all the water. Yet symptoms like this are no laughing matter for millions of postmenopausal women who suffer from vaginal and urinary problems caused by lack of estrogen. This drop in estrogen occurs during menopause (which typically begins at age 51, though women can go into earlier menopause due to cancer treatment) and can lead to symptoms, such as vaginal dryness and frequent urinary tract infections.
The condition was dubbed ’genitourinary syndrome of menopause,’ or GSM in 2014, after previously being known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. Medical experts hoped the new, more accurate name would help women feel less embarrassed about reporting their symptoms.
Common GSM Symptoms
About 90% of postmenopausal women have visible signs of GSM when they are examined by their doctors. But only about one-third, or 17 million American women, report symptoms. Surveys show many women are uncomfortable bringing up those types of concerns or assume what they are experiencing is a normal part of aging that they just have to live with. Yet, if you're a 51-year-old woman today, you can expect to live another 32 years, so that's a lot of time to live with painful and distressing symptoms that can seriously impair your quality of life.
Common GSM symptoms affect both the genitals and the urinary system, since the cells of both include estrogen receptors. When estrogen declines as you age (or after you lose ovaries for other reasons, such as cancer treatment or surgery), vaginal tissues thin, dry out, and become prone to injury; urination also is affected.
Here are the most likely symptoms you may experience with GSM:
- Vaginal dryness
- Vaginal and vulval itching, burning and irritation
- Lack of lubrication and pain during sexual intercourse
- Frequent urinary tract infections
Genitourinary syndrome of menopause is a chronic and progressive condition, meaning it can't be cured and it is likely to get worse if not treated. If ignored, it can progress to genital and urinary complications such as:
- Pelvic organ or vaginal vault prolapse
- Introital stenosis (narrowing of the vaginal canal)
- Urologic complications, such as meatal stenosis (abnormal narrowing of the urethral opening)
- Urethral prolapse or atrophy
- Urethral polyp and caruncle (benign tumor)
In addition, women with signs and symptoms of GSM may experience negative emotional and psychological effects. Surveys show 62% feel less confident due to GSM, 42% report impaired mood, and one-third say GSM symptoms make them "feel old." About 40% say GSM has had a negative impact on their sex lives and 55% say their intimacy and relationships with their partner have been impaired. About 61% reported hiding their symptoms from their partners and 42% make excuses to avoid intercourse.
GSM Treatments That Can Help Relieve Symptoms
A variety of remedies exist to alleviate GSM symptoms. These include restoration of estrogen. Decades ago, menopausal women commonly were prescribed hormone replacement therapy that did just this. However, in 2002, Women's Health Initiative Clinical Trials found that giving hormones, such as estrogen, could raise a woman's risk for breast cancer, heart disease, and stroke. Those findings resulted in the U.S. Preventive Services Task Force recommending against hormone replacement therapy (HRT) in postmenopausal women and in women who have had a hysterectomy.
However, more recent studies of the use of low-dose estrogen applied just to the vagina have found that serious health risks from such treatment are, in general, "rare and unlikely" (though long-term studies are still needed). Yet, FDA black-box warnings—designed to warn women about potential dangers from systemic hormone therapy—are still placed on packaging for localized, vaginal estrogen. This can frighten away women who might otherwise be willing to try such treatment, says the North American Menopause Society, which has been trying to get the FDA to remove or modify the warnings.
Other research has found that the dangers of HRT discovered by the Women's Health Initiative study may not apply equally to all women. Some women, depending on their health histories and medication regimens, may find more benefit than risk in such treatment, which can help with GSM symptoms as well as hot flashes and other undesirable menopausal symptoms.
Here is a list of hormonal treatments used today, as well as nonhormonal and over-the-counter remedies for menopausal and postmenopausal symptoms:
- Vaginal estrogen therapy, which is considered first-line treatment for GSM. Products include low-dose creams and suppositories, such as Premarin and Estrace; sustained-release rings (Estring); and a soft-gel vaginal insert (Imvexxy).
- Systemic estrogen therapy, such as estradiol tablets, may be recommended if a woman has hot flashes or other symptoms in addition to GSM. If a woman still has her uterus, she may also need to take a progestogen to help avoid complications from estrogen-only HRT.
- Prasterone (a man-made form of a naturally occurring hormone called DHEA, or dehydroepiandrosterone, and marketed as Intrarosa) was approved by the FDA in 2016 to treat pain during sex in menopausal women. It is a vaginal suppository that is converted by the body into androgens and estrogens.
- Ospemifene (Osphena) is a pill first approved by the FDA in 2013 to overcome painful sex, and in January 2019 specifically authorized by the FDA for use in treatment of vaginal dryness.
- Vaginal lubricants (such as Astroglide, K-Y jelly and Sliquid) are used during sex to help prevent pain.
- Vaginal moisturizers (such as Replens, K-Y Liquibeads and others) can be used several times a week to help rehydrate vaginal tissues and can be used in conjunction with estrogen or other therapies. Some contain hyaluronic acid, which small studies have indicated may help with GSM symptoms.
- Pelvic floor therapy involves working with specially trained physical therapists on pelvic floor and other exercises, which can help alleviate GSM symptoms.
- Vaginal dilators can help reverse vaginal atrophy by promoting stretching; vibratory stimulation to reduce pain may be helpful.
Another type of treatment—vaginal laser therapy (such as the MonaLisa Touch)—has not been approved by the FDA to treat GSM symptoms. In 2018, the FDA issued a warning letter noting the safety and effectiveness of such treatments had not been established. They warn that using "energy-based devices" like lasers or radiofrequency tools on the vagina "may lead to serious adverse events, including vaginal burns, scarring, pain during sexual intercourse and recurring/chronic pain."
Lifestyle Changes That May Help
Lifestyle changes like quitting smoking also may help with vaginal atrophy and dryness, as smoking can reduce blood flow and oxygen to the vaginal and nearby areas. Smoking also cuts the effects of any naturally occurring estrogens you may have in your body. Maintaining regular sexual activity (whether with a partner or just with yourself) can also help by increasing blood flow to the area and keeping vaginal tissues more elastic.
Visit With Your Healthcare Provider
If you have symptoms or questions about GSM, bring up your concerns with your healthcare provider. You can learn more about your options and discuss which treatment might be right for you based on your health history (women at risk for breast cancer, for example, need to take special care with hormonal medications). If you are having trouble finding a physician aware of GSM issues and treatments, the North American Menopause Society offers a searchable database of providers on its website.