Genitourinary Syndrome of Menopause
Genitourinary Syndrome of Menopause
Genitourinary Syndrome of Menopause
org
Genitourinary syndrome of
menopause: an overview of clinical
manifestations, pathophysiology,
etiology, evaluation, and management
Jason Gandhi, MS; Andrew Chen, BA; Gautam Dagur, MS; Yiji Suh; Noel Smith, MD;
Brianna Cali, BS; Sardar Ali Khan, MD
TABLE 1
External genital, urological, and sexual manifestations of genitourinary syndrome of menopause
External genital Urological Sexual
Signs and symptoms Complications Signs and symptoms Complications Signs and symptoms
Vaginal/pelvic pain Labial atrophy Frequency Ischemia of vesical trigone Loss of libido
and pressure Vulvar atrophy and lesions Urgency Meatal stenosis Loss of arousal
Dryness Atrophy of Bartholin glands Postvoid dribbling Cystocele and rectocele Lack of lubrication
Irritation/burning Intravaginal retraction Nocturia Urethral prolapse Dyspareunia
Tenderness of urethra Stress/urgency Urethral atrophy Dysorgasmia
Pruritus vulvae Alkaline pH (5e7) incontinence Retraction of urethral meatus Pelvic pain
Decreased turgor and elasticity Reduced vaginal and Dysuria inside vagina associated with Bleeding or spotting
Suprapubic pain cervical secretions Hematuria vaginal voiding during intercourse
Leukorrhea Pelvic organ prolapse Recurrent urinary Uterine prolapse
Ecchymosis Vaginal vault prolapse tract infection Urethral polyp or caruncle
Erythema Vaginal stenosis and
Thinning/graying pubic hair shortening
Thinning/pallor of vaginal Introital stenosis
epithelium
Pale vaginal mucous membrane
Fusion of labia minora
Labial shrinking
Leukoplakic patches on
vaginal mucosa
Presence of petechiae
Fewer vaginal rugae
Increased vaginal friability
Gandhi. Genitourinary syndrome of menopause. Am J Obstet Gynecol 2016.
women with mild or moderate GSM of prevalence and degree of atrophy vulvovaginal and urologic effects; uro-
are asymptomatic, making diagnosis include vaginal dryness (in 75% genital tissue receptors are dependent
particularly challenging. Only a weak postmenopausal women), dyspareunia on endogenous estrogen levels to
correlation has been found between 12
(38%) and vaginal itching, discharge, maintain normal physiology. During
symptom score and physical examina- 10,11
and pain (15%). When the vulvo- postmen-opause, the number of
9
tion of GSM. vaginal epithelium is inadequately estrogen re-ceptors continue to
Manifestations of GSM are primarily lubricated, ulceration and fissures can decrease but never fully disappear.
divided into external genital and uro- develop during intercourse, causing However, in the presence of exogenous
logical signs and symptoms (Table 1), dyspareunia. Vaginismus, or painful administration of estrogen, one can
2
which can be observed through physical spasm of vaginal muscles, can also replenish lost estrogen receptors.
1
examination. Genitourinary complica- occur as a physiological response when In the vulvovaginal tissue, estrogen
tions experienced secondary to GSM are there is anxiety toward expected sexual receptor-a is predominantly present in
included in Table 1 to further guide pain. Sexual manifestations are an premenopausal and postmenopausal
clinicians and health care providers. extension of those of the external women, whereas estrogen-b appears to
There may be a linking of certain signs genitalia (Table 1). only be expressed in premenopausal
13
and complications, eg, vaginal vault women. Estrogen is a vasoactive hor-
prolapse and urinary incontinence. Pathophysiology 11
mone that increases blood flow. Vaginal
Introital stenosis to a width <2 fingers, During female embryologic develop- lubrication is caused by fluid
decreased vaginal depth, and vaginal ment, the urogenital sinus, mllerian transudation from blood vessels, and
dryness must be diagnosed before ducts, and sinovaginal node (ie, Mller from endocervical and Bartholin glands.
insertion of the speculum, otherwise the tubercle) form the vaginal vestibule and Activated estrogen receptors also
pelvic examination will cause consider- lower fifth of vagina, urinary bladder, encourage epithelial proliferation with
able pain. Vaginoscopy is an alternative if trigone, and the entire urethra. Fused redundant smooth muscle tissue layer.
the practitioner is unable to perform a mllerian ducts form the uterus and The formation of rugae aids in expand-
pelvic/vaginal examination. upper four-fifths of the vagina. The ability, distensibility, and lubrication of
GSM is most commonly diagnosed genitalia and lower urinary tract share the vagina during sexual stimulation.
when the patient presents with dys- common estrogen receptor function. Vaginal secretions, lubrication, and
pareunia secondary to vaginal dryness. Due to the common embryological improved blood flow of vaginal walls all
Common signs and symptoms in order origin, hypoestrogenism has both help to increase vaginal mechanical
As with all hormone replacement Contraindications to the use of ET Vaginal ET trials have also demon-
therapies, some risks accompany the include known or suspected cases of strated relief of urinary symptoms of
benefits of treatment. Each woman breast cancer, estrogen-dependent can- urgency, frequency, nocturia, and stress/
should discuss her situation with her cers, undiagnosed vaginal bleeding, his- 23
urgency urinary incontinence. Vaginal
physician to determine the duration and tory of thromboembolism (ie, blood tablets, creams, and rings are the routes
severity of her series of symptoms. clotting disorders), endometrial hyper- of low-dose local estrogen; the 2006
Women may prefer to avoid hormone plasia or cancer, hypertension, hyper- Cochrane Database of Systematic Re-
therapy and approach the option of lipidemia, liver disease, hypersensitivity views stated that all types are equally
over-the-counter vaginal creams for to active compounds in ET, history of effective in resolution of dyspareunia,
27
symptomatic relief. stroke, venothrombotic events, coronary vaginal itching, and dryness.
Although side effects are uncommon, heart disease, pregnancy, smoking in Women should choose the option of
systemic ET is associated with breast those age >35 years, migraines with low-dose vaginal ET based on their
tenderness and/or enlargement, vaginal neurologic symptoms, and acute personal preference and lifestyle. Women
bleeding or spotting, nausea, and modest cholecystitis/cholangitis. may select the tablet over the cream due
weight gain. In cases where the patch is to reduction in mess. Creams are
used, some irritation at application sites Systemic. Systemic hormone replace- currently the most common choice of
may occur. The most common side effect ment therapy is suggested to patients who vaginal product for the treatment of GSM
of hormone replacement therapy is seek relief from GSM symptoms in and provide flexibility of dosage and
increased systemic estrogen. Addition- addition to relief from hot flashes and frequency of administration. Advantages
ally, some women might experience 26 of estradiol-releasing vaginal rings are
protection from osteoporosis. Due to
headache, back pain, abdominal pain, and concomitant use of progestin in women that they are long-acting over a period of
vaginal yeast infections. Breast with a uterus, systemic ET is associated 3 months and require less sustained effort
tenderness most often decreases with with adverse effects such as endometrial to use. However, there are reports of
time, and taking oral estrogen with food bleeding, breast tenderness, increased risk occasional vaginal ring expulsion so
can prevent nausea. Common side effects of stroke, venous thromboembo-lism, and adequate dexterity is required for
of intravaginal products include vaginal breast cancer. Potential adverse effects of insertion and removal. Cystoceles or
secretion, vaginal spotting, and genital estrogen-progestin therapy may cause the rectoceles may also cause the ring to
pruritus. To avoid any harmful long-term therapy to be contra-indicated and become displaced and fall out.
side effects of hormone replacement unacceptable to some women. Women
therapy, many physicians advise patients taking systemic hor-mone therapy with Roughly 80-90% of women on local
to use the cream or gel for unresolved ET report subjective improvement
therapy options do not reverse most Cessation of smoking can help relieve 4. Keil K. Urogenital atrophy: diagnosis,
sequelae, and management. Curr Womens
vaginal atrophic effects and have effec- symptoms. Lastly, wearing looser un-
Health Rep 2002;2:305-11.
tiveness length of <24 hours. Hence, dergarments and legwear may improve 5. Mac Bride MB, Rhodes DJ, Shuster LT.
they are more useful and recommended air circulation, discouraging growth of Vul-vovaginal atrophy. Mayo Clin Proc
to women with mild symptoms, or microorganisms. 2010;85: 87-94.
should be used in conjunction with sys- 6. Nappi RE, Kokot-Kierepa M. Vaginal
temic or topical ET. Moisturizers may health: insights, views and attitudes
Conclusion
(VIVA)eresults from an international survey.
contain polycarbophil-based polymers Genitourinary syndrome of meno-pause Climacteric 2012;15: 36-44.
that adhere to the epithelial and mucin is the latest terminology instated to 7. Nappi RE, Panay N, Rabe T, Krychman
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24 REVIVE (REal Womens VIew of Treatment
moisture levels. When selecting a stigma of the genitourinary sequelae and
Options for Menopausal Vulvar/Vaginal
lubricant or moisturizer, it is advised sexual dysfunction associated with
ChangEs) survey. 10th Congress of the
that the product should mimic vaginal postmenopausal hypoestrogenism. ET is European Menopause and Andropause
secretions in terms of osmolality, pH, the mainstay of medical treatment but the Society; May 20-22, 2015; Madrid, Spain.
48 risks and benefits should be thor-oughly 8. Castelo-Branco C, Biglia N, Nappi RE,
and composition.
discussed with each patient. More Schwenkhagen A, Palacios S. Characteristics
of post-menopausal women with genitourinary
Homeopathic remedies importantly the physician and patient
syndrome of menopause: implications for
It is estimated that 10% of women should work together to find the optimal vulvovaginal atrophy diagnosis and treatment
experiencing vaginal symptoms of GSM combination of lifestyle changes and selection. Maturitas 2015;81:462-9.
are using herbal therapies such as black management options. Global assessment 9. Davila GW, Singh A, Karapanagiotou I, et
cohosh, dong quai, phytomedicines, scales for GSM are currently seeing al. Are women with urogenital atrophy symp-
development; a proposed tool rates tomatic? Am J Obstet Gynecol 2003;188:
nettle (250 mL infusion/d), comfrey root, 382-8.
motherwort, soy foods, and chaste tree elasticity, lubrication, and tissue integrity;
10. Wines N, Willsteed E. Menopause and
extract. Other alternatives and state and color of individual vulvovaginal the skin. Australas J Dermatol 2001;42:149-
complementary therapies are chickweed and urethral anatomy; as well as pH and 58; quiz 159.
49 11. North American Menopause Society. The
tincture, wild yam, and acidophilus VMI. Such assessment tools may help a
role of local vaginal estrogen for treatment of
capsules. Although homeopathic rem- physician to tailor treatment based on the vaginal atrophy in postmenopausal women:
edies show improvement in vaginal objective and subjective severity of signs 2007 position statement of the North American
tissue flexibility, studies show that there and symp-toms. Newer treatments such Menopause Society. Menopause 2007;14: 355-
is no proven efficacy on the vaginal as laser therapy are promising but require 69; quiz 370-1.
16 12. Goldstein I. Recognizing and treating uro-
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genital atrophy in postmenopausal women. J
Some vitamins such as vitamin E and D Womens Health (Larchmt) 2010;19:425-32.
have been used for GSM therapy; efficacy. - 13. Chen GD, Oliver RH, Leung BS, Lin LY,
vitamin D may help generate keratino- Yeh J. Estrogen receptor alpha and beta
cyte proliferation and differentiation in ACKNOWLEDGMENT expression in the vaginal walls and
24 uterosacral ligaments of premenopausal and
the vaginal epithelium. The authors are thankful to Drs Kelly Warren,
post-menopausal women. Fertil Steril
Todd Miller, and Peter Brink for departmental
1999;71: 1099-102.
Lifestyle modifications support, as well as Mrs Wendy Isser and Ms
14. Nappi RE, Palacios S. Impact of vulvovagi-
Grace Garey for literature retrieval.
Increased sexual activity is advised for nal atrophy on sexual health and quality of life
maintaining robust vaginal muscle con- at postmenopause. Climacteric 2014;17:3-9.
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