Pay attention ladies. Every one of you will experience the so-called genitourinary syndrome of menopause (GSM) if you live long enough. For a lucky few, the symptoms will be mild. For others, know that there are things you can do to delay and/or reverse some of the symptoms.
GSM is a chronic, progressive condition of the vulva, vagina, and lower urinary tract that begins during menopause and continues throughout a woman's life. Not unexpectedly, since it starts during menopause, most of the symptoms arise as a consequence of low estrogen. Women may experience vaginal dryness, itching, burning and pain with intercourse, decreased libido, difficulty with orgasm, and decreased lubrication during sex. Additionally, women describe painful urination, urgency, incontinence, recurrent urinary tract infections (UTIs), and benign tumors on the urethra. GSM also occurs in younger women who have primary ovarian insufficiency, though who have had their ovaries removed, as a consequence of hormone imbalance postpartum and during breastfeeding, after some cancer treatments, and when taking some medications like aromatase inhibitors used in breast cancer patients and GnRH agonists used to treat endometriosis, fibroids, infertility, and a few other conditions.
The question I get most often when I talk to my patients about GSM is "why has no one mentioned this to me in the past?" You won't be surprised to learn that the answer is that societal pressure to not talk about women's healthcare, from puberty to periods to pregnancy to postpartum to menopause, persists from an out-dated and incorrect belief that women's genitals are "unclean." According to that belief system, no one should talk about, look at, or otherwise acknowledge the genitals of women. It would be one thing if those beliefs had no impact, but the truth is that those beliefs have limited research into women's healthcare for centuries and resulted in untold amounts of needless suffering by women who have not been provided basic information about their bodies, even by those they trust like their parents, teachers, and doctors. In 2010, a study of women in western countries, including the US, asked whether women had discussed their GSM symptoms with their healthcare provider. Over 70% of women (and these women had moderate to severe symptoms) reported feeling uncomfortable talking about it, even with their doctor. Over 50% of the women in the US were unaware that there were treatments. Most women stated that they thought GSM was part of aging and they just had to live with it. A separate study of women in the US, including 1/3 of whom had vaginal discomfort, reported that they had not talked with anyone - friend, relative, doctor - about it. Most women believed that their doctor should bring up the topic. I'm hopeful that we, as a society, are inching closer to bringing women's health issues into the forefront with more education, research, treatments, and attention by medical professionals.
Symptoms common in GSM overlap with some other causes like infections, vaginismus (which is a condition wherein the muscles of the vagina tense involuntarily), and exposure to irritants or some medications. It's important that your doctor do a thorough exam to rule out other causes before making a treatment plan.
Without controversy, vaginal estrogen is the gold standard for treatment of GSM. Estrogen applied to the vagina via creams, tablets, inserts, and rings have significant effect on surrounding tissues but do not raise the overall (systemic) amount of estrogen above a typical menopausal level. The use of vaginal estrogen in women who have had estrogen-sensitive cancers remains controversial since research on the risk is not conclusive to date. Another hormonal treatment, prescription vaginal DHEA (prasterone), also is effective at decreasing pain with sex and relieving other GSM symptoms. DHEA is one of a class of hormones called androgens. Although the exact mechanism of action of prasterone is unknown, it is known that it metabolizes in the vagina to estrogen and testosterone. Women should work with their OBGYN and oncologist to decide if the benefits of the use of hormonal treatments for GSM outweigh the risk.
There are other non-hormone and lifestyle treatment options for GSM. None has the effectiveness of vaginal estrogen, but they can provide significant symptom relief. Women with less severe symptoms can try vaginal moisturizers (I recommend Bezwecken Hydrating Ovals 2X Plus) several times a week and lubricants during sex (I recommend Good Clean Love Almost Naked Personal Lubricant, Überlube Silicone Lubricant, and AH! YES OB - Natural Plant Oil Based Personal Lubricant. Make sure the lubricant you choose is safe to use with condoms and/or sex toys, if pertinent.) Hyaluronic acid and lidocaine are other topical therapies that are supported by data for treatment of GSM; however, both treat the symptom only and not the underlying tissue health. Ospemifene is an oral drug that has been FDA-approved to treat pain with sexual intercourse. It's a selective estrogen receptor modulator (SERM) that acts on the estrogen receptors in the vagina in a way similar to estrogen.
Women with vaginal narrowing should consider the use of vaginal dilators in increasingly graduated sizes to restore and maintain vaginal function for sex, particularly with regard to penetrative sex. Notably, having intercourse regularly will increase natural lubrication and maintain the vaginal opening. Vibrators are on the rise for medical use. The vibration results in improved vascular flow and sensation with regular use. Pelvic floor physical therapy can be effective at reducing pain with sex and improving urinary symptoms. In women experiencing primarily urinary symptoms, other therapies like the prescription drug oxybutynin and/or pessary placement may be effective.
Vulvo-vaginal fractional CO2 laser therapy has shown positive effect in some studies to reduce the symptoms of GSM. The procedure works by making microtears in the vulvo-vaginal area which improves bloodflow, increases collagen formation and causes tissue thickening. Unfortunately, the treatment is expensive (~$1000 per session with 3-5 recommended) and has to be repeated every 6-12 months (one session) since GSM is a condition that continues to worsen as you age. A final word of caution if you choose laser therapy - skip the locations offering "vaginal rejuvenation" in favor of seeing a trained gynecologist.
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