Addressing the symptoms of the genitourinary syndrome of the menopause

We often hear of women later in life struggling with urinary incontinence, prolapse, vaginal irritation and pain. All these conditions are often severe forms of the genitourinary syndrome of the menopause (GSM). While it is fabulous that we are finally discussing our menopause more openly and seeking help when needed, we still have a way to go in being open at this level of taboo.

GSM needs to be urgently addressed to prevent women experiencing severe forms in their 70’s & 80’s that may well have been prevented if treated earlier around the perimenopause and menopause.

Traditionally called vaginal atrophy, due to the thinning, reduced lubrication, and fragility of the vaginal epithelial tissue, this terminology is now outdated as we are aware that hormonal decline includes changes to both the lower urinary tract and the genital tract, resulting in symptoms that effect both the urinary and vulvovaginal areas.

70% of women develop symptoms related to GSM, however as it is still such an intimate topic, these issues are rarely adequately addressed in medical consultations, with only 7% of women with GSM receiving treatment. Women developing symptoms and not being adequately treated are more likely to have progression of disease resulting in the severe forms of GSM later in life.

The role of hormones in our genitourinary tract

The genital tract and the lower urinary tract have common embryological origin, with widespread oestrogen, progesterone and testosterone receptors found in the vagina, urethra, bladder and pelvic floor.

The hormone, Oestrogen, has a direct role in supporting the vaginal structure, hydration, its microbiome, and blood flow. Oestrogen’s decline or absence can cause havoc with vaginal health causing many unpleasant symptoms. 20% of postmenopausal women develop lower urinary tract symptoms due to the thinning of the lining of the bladder and urethra.

Common vulvovaginal GSM symptoms

· Thinning of the vaginal tissue

· Vaginal dryness

· Vaginal pain on intercourse or any form of medical intervention

· Vulvovaginal, swelling, itching and irritation

· Vulvovaginal infections such as bacterial vaginosis, thrush & lichen sclerosus

· Thinning of vaginal tissue causing tears, spotting of blood, on penetration

Common urinary tract symptoms

· Increased frequency of urination

· Increased frequency of night-time urination

· Urinary incontinence ranging from mild to severe

· Recurrent urinary tract infections

· Urinary urgency

· Pain on urination

GSM can affect us all differently, however the impact on our sexual health and intimate relationships is often a cause for women to seek help. The physical changes that affect our sexual health can often result in psychosexual effects as we are more hesitant and cautious of having intercourse. This may include avoiding sex due to pain, perceived changes to our bodies, our sexuality and level of enjoyment.

Common sexual symptoms and implications:

· Reduced sexual desire/libido

· Painful intercourse

· Reduced lubrication

· Reduced ability to orgasm

· Reduced arousal

Recommendations

As GSM progresses, so does the impact on our relationships, quality of life and our ability to complete daily activities without impact. Recognising the early signs of GSM, such as urinary frequency, vaginal dryness or the need to use lubrication for intercourse and discomfort of the vulva or vagina is important, so that treatment can prevent progression. Strengthening our pelvic floor with kegel exercises can help improve mild to moderate incontinence. Using vaginal moisturisers and lubricants that are free of nasty chemicals can improve comfort and pleasure. Being able to directly address your symptoms with healthcare professionals is key to getting effective treatment and indeed being confident to discuss issues with sexual partners helps to aid any psychosexual issues that have arisen due to GSM.

Treatment options

1. Local vaginal oestrogens, these come in various forms such as tablets, pessaries, creams and rings to release oestrogen directly into the vagina. Local vaginal oestrogen treatment has been shown to restore the normal pH of the environment reducing the chances of infection, helps to improve lubrication, blood flow and vaginal tissue thickness.

2. Vaginal moisturisers: choose products such as YESVM, Sylk, Replens. Regelle, Hyalofemme which are products specifically developed to gently hydrate the vagina. These helps to reduce dryness and discomfort during intercourse.

3. Talking therapies to support relationships and psychosexual symptoms

Non-menopausal causes of oestrogen decline

Breast-feeding is another period during a women’s life when oestrogen levels are significantly lowered to cause symptoms. Many medical interventions can also cause low oestrogen levels such as using the progesterone-only contraceptive pill, pelvic radiation for cancer treatment, chemotherapy, and many breast cancer treatments aim to block or eliminate the effects of oestrogen.

Women being treated/recovering from breast cancer

Women who are being treated for breast cancer often use chemotherapy and other medications that block the effects of oestrogen on the whole body. Women can often experience severe GSM symptoms as a result.

We are more confident that the systemic absorption of local oestrogen is very limited. Using local oestrogen therapy alongside aromatase inhibitors and tamoxifen for breast cancer treatment is becoming more acceptable to oncologists and menopause specialists. Seeking professional advise can help to get you effective treatment.

Kate Organ, Consultant clinical pharmacist with specialist interests in the menopause and mental health. Founder The Menopause Specialists