Genitourinary Syndrome

Menopause is a transitional period characterized by hormonal changes which can lead to a host of symptoms, such as changes in weight, fluctuations in mood, and more. Genitourinary syndrome of menopause (GSM) is a chronic condition that affects the vagina, vulva, and lower urinary tract. 

Previously referred to as vulvovaginal atrophy or atrophic vaginitis, GSM is characterized by:

  • vulvovaginal pain and discomfort
  • pain during sex
  • decreased libido
  • urinary tract issues

In this article, we’ll explore what genitourinary syndrome of menopause is, including the causes, symptoms, treatment, and overall outlook for those with this condition.

Causes

In the years leading up to and including menopause, the ovaries reduce their production of estrogen. Estrogen is a sex hormone that plays a role in:

  • puberty
  • menstruation
  • glucose metabolism
  • insulin sensitivity
  • bone health

After menopause, and in those who may have hormonal imbalances not related to menopause, the production of estrogen from the ovaries is extremely low. Low estrogen levels are the primary cause for the symptoms of genitourinary syndrome of menopause.

Estrogen receptors can be found in the tissues of the:

  • vagina
  • vulva
  • urethra
  • bladder

When estrogen levels begin to decrease, it can lead to changes in the anatomy and function of these tissues, which can lead to symptoms of GSM. Changes to these tissues include a reduction in:

  • skin thickness
  • elasticity
  • muscle function
  • blood flow

Certain people are more at risk for developing GSM than others, including those who:

  • are undergoing or have undergone menopause
  • have had surgery to remove the ovaries, or oophorectomy
  • have a history of smoking
  • have a history of alcohol abuse
  • do not engage in sexual activity often
  • are practicing abstinence
  • are undergoing certain cancer treatments

If you are concerned that you might be at risk for developing GSM, schedule a visit with a doctor or gynecologist to discuss your options.

Symptoms

Genitourinary syndrome of menopause primarily affects the genitals and urinary tract and can cause a variety of symptoms, including:

Many symptoms of GSM are also found in other conditions that affect the genitals or urinary tract, which can make it difficult to diagnose this condition. However, the most commonly reported symptoms of GSM are vaginal dryness and painful intercourse, so if you have these symptoms, schedule a visit with a medical professional. 

Unfortunately, GSM remains largely underdiagnosed in the menopausal population, primarily because it can be embarrassing for some people to discuss the symptoms listed above — especially those that are traditionally described as a normal part of aging.

Treatment

If your doctor or gynecologist suspects that you may have genitourinary syndrome of menopause, they will perform a physical examination and a thorough review of your symptoms and medical history. Your doctor will also want to discuss when these symptoms began and may ask about your sexual history.

A physical examination of the vulvovaginal area — called a pelvic exam — can allow the doctor to physically feel for the physical changes associated with GSM. Laboratory and diagnostic testing can also identify other underlying conditions that may be causing your symptoms, such as sexually transmitted infections (STIs).

Treatment of genitourinary syndrome of menopause is aimed at relieving symptoms to improve your quality of life. Common treatment options include:

  • local estrogen/DHEA therapy
  • systemic estrogen therapy
  • topical lubricants and moisturizers
Local estrogen/DHEA therapy

Low-dose vaginal estrogen therapy involves an estrogen supplement inserted directly into the vagina. Vaginal estrogen may come in the form of a suppository, an insert, or a ring, all of which are inserted into the vaginal canal. Local estrogen therapy is the most common treatment option for GSM.

In one review, researchers analyzed 44 studies for the effectiveness of vaginal estrogen in treating the symptoms of GSM. They found that vaginal estrogens improved the symptoms of vaginal dryness; painful intercourse; and urinary urgency, frequency, and incontinence associated with GSM. In addition, vaginal estrogen also helped reduce the frequency of urinary tract infections associated with this condition.

Also, local administration of dehydroepiandrosterone (DHEA) has been suggested to help improve GSM symptoms. DHEA is a hormone metabolized to estrogen in the bloodstream, which can help naturally increase estrogen levels. Research suggests that local DHEA therapy can improve sexual arousal and increase libido in those with GSM.

Systemic estrogen therapy

Oral estrogen therapy involves medications taken orally to increase or alter estrogen levels. Ospemifene has been an effective oral estrogen option for reducing vaginal dryness and pain during intercourse in people with GSM.

In a review from 2019, researchers reviewed available studies on the use of ospemifene for symptoms of GSM. Study results found that ospemifene was effective in reducing vaginal dryness, one of the most common complaints of GSM. In addition, it was able to improve vaginal tissue health, balance pH levels, reduce painful intercourse, and improve sexual function.

Topical lubricants and moisturizers

Topical lubricants and moisturizers can help improve symptoms of GSM by increasing hydration and lubrication of the vulvovaginal area. Lubricants and moisturizers are an important treatment option for those who may not be able to take estrogen to otherwise improve dryness and reduce pain.

However, it’s important to know that not every lubricant or moisturizer is effective for GSM. If you are interested in using these products help alleviate symptoms, make sure to choose a lubricant or moisturizer that is pH balanced and as close to natural lubrication as possible. Using products that are not balanced properly can potentially increase symptoms of GSM.

Experimental treatment options

Research is still being performed on some of the more experimental treatment options for GSM. For example, research has suggested that fractional laser therapy can potentially help reduce symptoms of GSM by enriching the vaginal tissue, which improves:

  • circulation
  • elasticity
  • pH
  • tightness
  • urination 

However, more research is still needed in this area.

Quality of life

Whether you are sexually active or not, the symptoms of genitourinary syndrome of menopause can be uncomfortable, frustrating, and even debilitating. If you have been dealing with the chronic symptoms of GSM, discuss this issue with a health professional.

Once you receive a proper diagnosis, treatment options can help decrease symptoms and improve your overall quality of life.

When to seek care

Genitourinary syndrome of menopause is a highly personal condition that can sometimes leave people feeling embarrassed and hesitant to reach out. However, you do not have to suffer the symptoms of GSM alone — and you shouldn’t be ashamed to reach out for help.

Schedule an appointment a health professional to discuss treatment options for GSM.

Bottom line:

Genitourinary syndrome of menopause is a chronic condition that often remains undiagnosed, despite how much it can negatively impact someone’s quality of life. GSM can cause a wide variety of symptoms, including significant pain in the:

  • vulva
  • vagina
  • urethra
  • bladder 

Treatment options for GSM, particularly local estrogen therapy and personal lubricants, can help reduce symptoms of this condition.

If you have been experiencing symptoms of GSM, reach out to a medical professional for treatment.

References:
https://www.healthline.com/reviewers/shilpa-amin-md-caq-faafp
https://www.healthline.com/authors/eleesha-lockett
https://www.healthline.com/health/menopause/genitourinary-syndrome-of-menopause
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Archer DF, et al. (2019). Ospemifene for the treatment of menopausal vaginal dryness, a symptom of the genitourinary syndrome of menopause.
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Edwards D, Panay N. (2016). Treating vulvovaginal atrophy/genitourinary syndrome of menopause: How important is vaginal lubricant and moisturizer composition?
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Faubion SS, et al. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society.
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