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

Supporting Your Mental Health

As things start to return to normal for us folk in Perth , Western Australia, there are other places in Australia and the rest of the world that are still feeling the pinch of Coronavirus.

Today I visited my local beauticians. I am not generally one for waxing and spending money on such things, but I guess it is the usual feeling of when things are suddenly taken away from you- you miss them!

There have been many a funny meme on social media of image of (mostly women) people that had regrowth, broken nails and hairy legs and eyelashes falling of their faces. You honestly have to laugh of the first world problems that we live in.

While many businesses have their staff working from home, I am back at taking face to face clients. It was so lovely to step back into the space that I know and love - EarthPoint Energy Centre in East Perth. It is a combination of the smell, the amazing women that I work along side with and the atmosphere that does something supportive to your nervous system.

I hindsight, I hope this pandemic has made more people aware about the importance of mental health during these times. Fortunately for me I have been one of the lucky ones. But for many, the home environment can be volatile and unsafe. Or the workplace can be for some people their only interaction with others and gives them a sense of belonging.

Has this time been a positive or negative experience for you?

The amount of online services supporting people’s wellbeing has increased greatly from free mediation sessions, online yoga classes and Zoom meetings.

My 3 pillars to health: MIND, MOVEMENT & MICROBIOME are always at the forefront of my mind for creating an ideal life for my clients. For if we don’t have a balance of all of these components, then we can become out of balance and experience low mood or digestive upsets.

I know living or even attempting to live a healthy lifestyle can be daunting and overwhelming. Knowing where to start can be off putting and can often lead to no action at all.

My approach is always taking one step at a time and focus on what is the easiest for you. No use in setting you up for failure before you have even started!

If you feel you need support with your mood or your tummy troubles….fill out my online enquiry form and see if I can help you.

Know Your Stress Triggers

There is one culprit that has a lot to answer for, and that my friends is stress.

Many times I will have a client in front of me that has symptoms due to long term stress. And they will often reply 'But I don't feel stressed!' Then 3 months later I will see them again and they may have made some significant changes in their life such as quitting their job or reducing their daily load. And many of them will reflect and say...'Yeah, I feel so much better now I think I was under a lot of stress back then.'

By all means I don't want you to race out and quit your day job (unless you really want to). But it's when we finally slow down and STOP, that we realise how busy we are and what for?

Our bodies are very adaptable vehicles and will adjust your responses to stress in a way that we can adapt without noticing. Think about all of the little 'stresses' we have in our daily lives......

• 24/7 access to notifications (email, texts, group chats, social apps and calendar reminders) from your mobile (don't forget the 'pings and dings' that can come with those notifications)

• Work demands

• Health demands- Fitness, diet and lifestyle

• Community demands- Clubs, schools, business, friends all expecting a piece of you

• Future concerns

• Past conversations going over in your head

• Financial worries

• Relationship concerns

• Expectations that you need to fit it ALL in with ease.....

How does our body respond to these little stressors?

• Your adrenals will release cortisol and adrenaline to get ready to fight the threat. You see, our mind has no way of differentiating between a real stress (the Saber tooth tiger kind) or the answering your daily email stress- it's all the same!

• With this added adrenal spark, your sympathetic nervous system will kick into action- your pupils will dilate, heart beat will increase, blood pressure will rise, digestion will slow down, sugar will stay in your blood stream (so you have enough energy for action) and your immune system will kick in to put out the potential fire threat.

• Have you ever gone on holidays and then on the first couple of days you end up getting sick? Argh! So frustrating! This happens because when you are busy at work, your adrenals are in full swing- putting out the fire with all the anti-inflammatory guys (a.k.a immune system). As soon as the fire goes away (work), so does your cortisol levels. And then bingo! A bug comes in from the back door and you get sick from exhaustion.

• Short term this is okay, but long term stress can disrupt your bodies natural response and end up getting what is called cortisol resistance. Your body starts to not respond because the stress is there ALL THE TIME. Your immune system will drop and inflammation gets out of control...

How do you react to stress?

I know when I have a full schedule on the things that are good for me and would actually support me in times of stress (or even busyness), are the first to get dropped.

Exercise? Who has time for exercise when your chasing your tail?

Eat well? (scoff), Let's just be thankful that the family gets some form of food into them (even if it is just from one food group and the same colour). No prizes for best phyto nutrient dish in this house that's for sure!

And generally that's not where it ends. Because your day is so time poor you end up staying up later = less sleep.

You may reward yourself with a bickie or two. You may even feel the need to 'unwind' with a glass of wine...

At the time these stress releases may seem ideal, but you will end up burning the candle at both ends and disrupting your circadian rhythm and increase more of your sympathetic nervous system by adding stimulants as your coping mechanisms.

We have all done it. But how can you make better choices to support your stress response?

The most difficult part is identifying your stress triggers. Most of the time we just continue in the rat race thinking this is normal. Think about your actions AND your emotions (sometimes this is the easiest at the end of the day- but whatever works for you). Make a little self note of you might be reacting to a situation instead of responding to it.

Like I said, this is not easy. Even if you do know what your triggers are, the hardest part can be changing your reaction. Short term rewards that aren't beneficial to your health may seem great at the time (otherwise we wouldn't do them!), but how are they affecting you long term.

Are you stimulating your nervous system instead of supporting it? (eating sweets, staying up late, watching copious amounts of T.V, drinking coffee or alcohol, eating take away foods with little nutritional value).

These go-to's can be okay as a one off. But repeating this behaviour is not helping you in the long run. Try replacing these responses or actions with things that will nourish you. Here are some examples:

• Go for a walk

• Read a book

• Put your T.V watching on a timer (30 minutes)

• Have a bath

• Go in a quiet room, close your eyes and notice the sensations of your breath as you breath in and out

• Ring a friend or relative - sharing (or venting) does wonders for your soul)

• Unplug- yep you heard me!

• Schedule some joy into your life

To help you identify your triggers, download my Know Your Triggers Work Sheet here

If you would like to ask a question regarding your health, please contact me.

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Living with SIBO

It was back in 2014 when I took my first Hydrogen breath test to see if I had SIBO (Small Intestinal Bacterial Overgrowth) or not. And sure enough I was positive for both Hydrogen & Methane gases.

I immediately started to treat and eradicate my SIBO by following Dr. Jacobi's Bi-Phasic diet. During my herbal treatment, I noticed instant results. My skin began to improve (SIBO and acne rosacea are linked- and the initial reason for testing), my bloating decreased and my bowel motion improved.

Looking back on the determination in following the diet and finally knowing the cause of my acne rosacea was the end of years of frustration and embarrassment.

If you have ever had to follow a restricted diet you will understand how difficult it is to live a 'normal' life that doesn't impact you and the ones you life with.

But considering my main problem had been eradicated, I began to slowly add the foods in that I was eating previously (It is also strongly advised that you should not follow any restricted diet long term).

Low and behold.....my skin didn't get effected!!!

Sure, the obvious items would cause a flare, such as alcohol and wheat. But I had never had an issue with onions or any other high FODMAP foods.

But slowly over time, even though my skin never returned back to its acne state (thank goodness!), my bloating returned and my bowels also decided to slow down too...….

Bring in test number 2 in 2017. And yep, I tested positive yet again for both Hydrogen and Methane gases. SIBO was back with even more bite!!

So what did I do???

Nothing.

I certainly felt disheartened with a capital D, but after treating so many others for SIBO in my practice I had noticed a trend...….

it comes back!

Knowing the cause of your SIBO is imperative!

The thing about SIBO is that you need to find the cause, and if you don't find the cause, it WILL come back.

What's my cause?

Most likely poor gut motility and a leaky gut to match.

But I didn't want to go in with the big guns (anti microbial herbs) to get rid of the unwanted bacteria and Archea. It didn't want to go on the super restricted diet for months on end.

Nup.

By this stage I had a fair idea of what would cause my bloating. I mentioned a couple of them previously- wheat and alcohol. You can add potatoes, rice and refined sugars onto that list too. But do I avoid them? No. I just know that I should keep potatoes down to once per week and if I am going to eat wheat, it will be with good quality sourdough stuff.

And what about legumes?

Yes, they can cause havoc with SIBO and make anyone look 6 months pregnant in seconds. But once again, I have identified the ones that cause more symptoms than others (for me it's kidney beans and chickpeas).

But I still eat them, because I know how beneficial they are for me and they provide fuel for all of the anti-inflammatory bacteria that live in your colon.

And I have also noticed that by keeping my fibre up that my bowel habits improve (it's not rocket science!).

So lets go back to the cause again.....

The cause of your SIBO is a big clue if you are going to get rid of SIBO once and for all. Unfortunately for some, the cause can be due to adhesions and scar tissue in the pelvic region due to past operations. Constant visceral manipulation is required to reduce the scar tissue within the area. With this comes a very long time frame of healing...….

I discovered that I also have umbilical hernia (another causative factor for SIBO). But after I had met with a surgeon and understood what was involved in the operation, I decided to not go ahead. I felt that the scar tissue post op was going to be far worse than my little sticky outy belly button.

So its not all doom and gloom, and I certainly don't want to put you off in treating your SIBO. For some, it can be a simple cause such as post infectious IBS (just a little bit of gut dysbiosis and a teeny bit of inflammation). But the main take home point is that EVERYONE is different. And yes, it's worth exploring what is causing your unwanted gut symptoms and take the necessary treatment from there.

I just felt that I wanted to share my journey with living with SIBO. I have accepted it (that doesn't mean you should have to too). But I do know that my overall gut microbiome is a lot happier and healthier by me including a high variety of foods into my daily diet.

I also keep my symptoms down by adding movement into my life (yoga) and by keeping on top of my stress levels by ensuring my nervous system is supported and making sure my cup is always full (well 3/4 anyway!)…..

If you would like to listen more about my SIBO story, you can on The GUT GURU podcast.

If you would like support in your gut journey, you can by joining the FB group- Happy gut, Happy you

Do you still have a question?

Send me a message below.....