Sarah Chopra 2/21/24 Sarah Chopra 2/21/24

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

Sarah Chopra 2/20/24 Sarah Chopra 2/20/24

How Menopause can change your Vaginal Microbiome

Your vaginal microbiome is strongly influenced by your ethnicity and is mostly comprised of the bacteria genus, Lactobacillus. Research demonstrates that if you are an African-American or Hispanic decent, that you might have other species that are dominate other than Lactobacillus (Ravel et. al. 2011).

Lactobacillus produce an acidic environment in your vagina. Most pathogens won’t exist in an acid environment and therefore, it is very beneficial to have a dominance of Lactobacillus species. Lactobacillus species feed off a carbohydrate called glycogen. Where does glycogen come from? Glycogen is expressed from oestrogen!

During menopause your oestrogen and progesterone levels naturally decline. This means LESS fuel to FEED the Lactobacillus species. Lactobacillus numbers decline and vaginal dysbiosis can occur. This where there is an imbalance in the vaginal microbiome and pathogens can have a party!

What type of pathogens?

Vaginal dysbiosis can create an environment for Bacterial Vaginosis (BV), Vulvovaginal candidiasis (also known as thrush. Thrush is not common during menopause- one good thing!), there is also more of a risk in developing an STI (sexually transmitted infection). This can also be because your pH balance may shift to a more alkaline balance. Healthy vaginal pH levels are between 3.6-4.5.

With the decrease in oestrogen levels and a risk in having lower Lactobacillus species in your vaginal cavity, this also makes the lining of your vagina thin (causing vaginal atrophy) and can lead to irritation, painful intercourse, and tearing. These symptoms are also associated with Genito-urinary Syndrome of Menopause (more on that in another post!)

Other factors to consider..

Menopause comes with a lot of changes; mentally, stress levels are generally high, physically, metabolically, and neurologically (plus if you have any other comorbid conditions to add into the mix).

Natural ways to feed your Lactobacillus species

Fortunately, there are natural ways that you can increase your Lactobacillus species and support irritation (yay!):

Diet: Eat foods that are high in polyphenols or contain phyto-estrogens (as long as there in no history of oestrogen dominant cancers).

Create an acidic environment: There are pessaries that are high in lactic acid and can be inserted into your vagina to increase acid levels. Probiotics can either be taken orally or vaginally to increase Lactobaciluus species (probiotic needs to be strain specific for your vaginal microbiome) and with the rise in Lactobacillus species, this will create a more acidic pH.

Green tea taken in a capsule (or in a herbal tincture) orally and vaginally to recolonise Lactobacillus species (Tuzil. J., 2020) and has anti-microbial properties (Kim, YW., 2013) for treating vaginal dysbiosis. Also drinking green tea will help too. Green tea is also a polyphenol, which is also another reason why it is beneficial.

Lactulose is a carbohydrate that can be used as a fuel for your healthy vaginal microbes and increase your Lactobacillus species due to its prebiotic activities (Collins et. al. 2018) . This can be taken as a pessary and inserted into your vagina or used as an irrigation. There is a green tea and lactulose capsule that is also available that can be taken orally or vaginally, or you can take it as a liquid. For some people, lactulose can cause unwanted tummy symptoms such as bloating, abdominal pain or loose stools. Another option is to dip a tampon in 6ml of liquid lactulose and insert into your vaginal canal (the tampon needs to have absorbed the liquid, but not too much where you can’t insert).

Alternative options for other symptoms:

Vaginal atrophy can be soothed with oil based lubricants such as sea buckthorn (Larmo, P.S., 2014) and Vitamin D (Riazi, H. 2019) used topically and taken orally. Other oil based lubricants that can be purchased online are: Olive and Bee Intimate Cream (used to soothe vulva and vaginal tissue) or can be used as a personal lubricant during intercourse, Sea Buckthorn oil by Byron Bay Love Oils soothes and regenerates vaginal tissue integrity, YES OB lubricant is an oil based lubricant used as a massage oil or a personal lubricant during intercourse or try Vitamin E capsules (Porterfield, L. et. al. 2022) that can either be inserted internally into the vagina or a capsule can be broken and used to heal and soothe your vulva and labia majora.
Fennel oil can be used to reduce inflammation and support vaginal atrophy. Fennel oil can used as a personal lubricant, topically with olive oil, as a moisturiser, or in a pessary (Yaralizadeh, M. et. al. 2016)
Vitamin D is a promotor of the proliferation of the vaginal epithelium (Gilbert, 2023) and can be used as a capsule inserted into the vagina.

What next?

Perhaps you are able to self administer some of your symptoms or you can go one step further and complete of Vaginal Microbiome test and discover what microbes are living in your vagina! Everyone is individual and there are many external (and internal) factors that can influence the health of your vagina. The benefits of visiting a naturopath is that they can also include other aspects that might be influencing your vaginal microbiome.

As I mentioned above, these symptoms are part of Genito-Urinary Syndrome of Menopause. You can read more on this here.

References:

Collins, S. L., McMillan, A., Seney, S., van der Veer, C., Kort, R., Sumarah, M. W., & Reid, G. (2018). Promising Prebiotic Candidate Established by Evaluation of Lactitol, Lactulose, Raffinose, and Oligofructose for Maintenance of a Lactobacillus-Dominated Vaginal Microbiota. Applied and environmental microbiology, 84(5), e02200-17. https://doi.org/10.1128/AEM.02200-17

Kim, YW., Chun, H.J., Kim, IW. et al. RETRACTED ARTICLE: Antimicrobial and antifungal effects of green tea extracts against microorganisms causing vaginitis. Food Sci Biotechnol 22, 713–719 (2013). https://doi.org/10.1007/s10068-013-0136-3

Larmo, P. S., Yang, B., Hyssälä, J., Kallio, H. P., & Erkkola, R. (2014). Effects of sea buckthorn oil intake on vaginal atrophy in postmenopausal women: A randomized, double-blind, placebo-controlled study. Maturitas, 79(3), 316–321. https://doi.org/10.1016/j.maturitas.2014.07.010

Ravel, J., Gajer, P., Abdo, Z., Schneider, G. M., Koenig, S. S. K., McCulle, S. L., Karlebach, S., Gorle, R., Russell, J., Tacket, C. O., Brotman, R. M., Davis, C. C., Ault, K., Peralta, L., & Forney, L. J. (2011). Vaginal microbiome of reproductive-age women. Proceedings of the National Academy of Sciences - PNAS, 108(Supplement 1), 4680–4687. https://doi.org/10.1073/pnas.1002611107

Riazi H, Ghazanfarpour M, Taebi M, Abdolahian S. Effect of Vitamin D on the Vaginal Health of Menopausal Women: A Systematic Review. J Menopausal Med. 2019 Dec;25(3):109-116. https://doi.org/10.6118/jmm.19194

Tuzil J, Filkova B, Jircikova J, et al. Tea Extract Vaginal Ovule for Intermediate Flora: Randomized Blinded Vehicle-Controlled Multicenter Pilot Clinical Trial with Microbiome Analysis. Journal of Biologically Active Products from Nature. 2020;10:357-372.

Yaralizadeh, M., Abedi, P., Najar, S., Namjoyan, F., & Saki, A. (2016). Effect of Foeniculum vulgare (fennel) vaginal cream on vaginal atrophy in postmenopausal women: A double-blind randomized placebo-controlled trial. Maturitas, 84, 75–80. https://doi.org/10.1016/j.maturitas.2015.11.005