What is Genito-Urinary Syndrome of Menopause?
Menopause symptom research focus a lot on hot flashes, insomnia, weight gain, mood disorders and lowered libido; which can be experienced differently for everyone. But what is genito-urinary syndrome of menopause (GSM)? Basically, GSM includes a collection of genital, sexual, urinary, and somatic symptoms that correlate with ageing and menopause. The term used to be known as Vulvovaginal Atrophy (VVA), but only had a focus on the affects of lowered sex hormones and the impact they had on the vulvar and vaginal cavity. Research has shown that there is so much more involved in the decline of estrogen, progesterone and even testoterone has on the body, and studies have found that GSM can not always be rectified with estrogen therapy (Gilbert, GG., et. al. 2023; Nappi, RE., et. al. 2019).
Symptoms of GSM
Genital: A decline in sex hormones affects the vaginal wall (all of its 4 layers) and the blood supply to the area, causing anatomical and physiological changes. these can include: shortening and narrowing of the vagina, paleness (due to lack of blood supply), thinning of epithelium, decreased moisture, and increased kertatinisation to the tissue. This can lead to symptoms of vaginal dryness, burning, irritation (itchiness), vaginal pain (vagimisis) , pain during sexual intercourse (dyspareunia), and bleeding can occur due to tearing (Gilbert, GG., et. al. 2023). A few papers stated that a vaginal pH of >5 is a good indicator of vaginal atrophy (Johnston, S.L., 2019). An alkaline pH reading (normal is 3.8-4.5) indicates vaginal dysbiosis, which can be be caused by other vaginal health conditions too.
Urinary: There are also estrogen receptors in the bladder and urethra, and with the reduced estrogen levels with menopause, urinary symptoms can consist of urgency or Over Active Bladder (OAB), recurrent Urinary Tract Infections (UTI), urinary incontinence (UI). Sometimes medication can also magnify UI symptoms (diuretics) (Johnston, S.L., 2019).
Sexual: Due to vaginal atrophy and lack of lubrication, and lowered libido can impact sexual wellbeing, arousal and orgasm. In a study of 4,000 women, 45% complained of vaginal symptoms and how the symptoms effected their quality of life, self esteem, and intimacy (Porterfield, L. et. al. 2022).
Pelvic Floor: Pelvic floor tissue responds to estrogen and can lead to structural and/or function failure (also being a cause of OAB). Pelvic Floor Dysfunction (PFD) can also lead to coital dysfunction because of the changes in the vaginal wall. Pelvic floor integrity is maintained by the muscles, nerves and connective tissue. The drop in estrogen reduces blood flow to the area and collagen synthesis decrease, tissue repair is compromised and just becomes a cascade of events that all intertwine with each other! (Johnston, S.L., 2019). There are also other causes to PFD, but the focus is on GSM related PFD for now…
One research paper (Porterfield, L. et. al. 2022), stated that 84% of women exhibit signs of GSM of up to 6 years after menopause! You don’t need to be experiencing ALL of the symptoms above to have GSM either.
What’s are the treatmentoptions?
First I will discuss the non-hormonal treatment for GSM and these include:
Lubricants, moisturisers, and pessaries: These are all useful for vaginal dryness and lubrication. I have given a list of products in the post, How Menopause can Change your Vaginal Microbiome .
Counselling: GSM impacts the quality of life, self esteem, and intimacy. Counselling can provide an environment to discuss these issues either in couple counselling or individual sessions (Nappi, RE., 2019).
Herbs: There are many herbs for perimenopause and menopause, but keeping within context and focusing on GSM symptoms there are herbs for vaginal dryness (wild yam, shatavari and black cohosh), connective tissue weakness and repair (for pelvic floor restoration) would include herbs such as gotu kola, japanese knotwood, echinacea, and withania). For low libido herbs such as shatavari, wild yam, korean ginseng, and for boosting estrogen levels (during perimenopause) can entail chaste tree, ladies mantle, peony, and shatavari. Herbs all come with their own contra-indications and required dosage. Be mindful of buying herbs online without consulting a herbalist/naturopath. The wonderful thing about herbs is that a herbal tincture can be made specific to you!
Pelvic Floor Physiotherapist: If you haven’t got a physio specialising in pelvic floor, get yourself one now! Even if you don’t have symptoms, they can give your preventative resources (trust me your future self will thank you for it). Check out this list of Pelvic Floor Physiotherapists Directory in Australia.
Laser Therapy has been studied to improve vaginal health, reduce vulvovaginal atrophy symptoms and help with sexual dysfunction (Salvatore, S. et. al. 2023).
Hormonal Treatments for GSM:
Localised (either topical or inserted into vagina): Vaginal estrogen therapy (creams, gels (estrogel) , tablets or slow release intra vaginal rings), intravaginal DHEA pessary is an androgen metabolite and is converted to estrogen and testosterone (Intrarosa), available in Australia mid 2024. Vagifem is also a slow release estradiol pessary. Any estrogen derived treatment needs to be avoided or consult your G.P for people at risk of estrogen derived cancers.
Systemic: Hormone Replacement Therapy (HRT) for more information on types the Australasian Menopause Society has an overview, or there are Bio-identical Hormones
References
Gilbert G.G. Donders & Francesca H.W.V. Donders (2023) New developments in the management of vulvovaginal atrophy: a comprehensive overview, Expert Opinion on Pharmacotherapy, 24:5, 599-616, DOI: 10.1080/14656566.2023.2194017
Nappi RE, Martini E, Cucinella L, Martella S, Tiranini L, Inzoli A, Brambilla E, Bosoni D, Cassani C and Gardella B (2019) Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Front. Endocrinol. 10:561. doi: 10.3389/fendo.2019.00561
Porterfield L, Wur N, Delgado ZS, Syed F, Song A, Weller SC. Vaginal Vitamin E for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review of Randomized Controlled Trials. J Menopausal Med. 2022 Apr;28(1):9-16. https://doi.org/10.6118/jmm.21028
S. L. Johnston (2019) Pelvic floor dysfunction in midlife women, Climacteric, 22:3, 270-276, DOI: 10.1080/13697137.2019.1568402
S. Salvatore, A. F. Ruffolo, C. Phillips, S. Athanasiou, L. Cardozo, M. Serati & the EUGA Working Group (2023) Vaginal laser therapy for GSM/VVA: where we stand now – a review by the EUGA Working Group on Laser, Climacteric, 26:4, 336-352, DOI: 10.1080/13697137.2023.2225766