jsafoms

10.5005/jp-journals-10032-1139
Recent Advances in the Management for Genitourinary Syndrome of Menopause
REVIEW ARTICLE

Recent Advances in the Management for Genitourinary

Syndrome of Menopause
1
Seetesh Ghose, 2Palai Pallavee, 3Rupal Samal

ABSTRACT and signs related to genitourinary system following

Menopausal women suffer from various symptoms related to menopause. Although atrophic vaginitis signifies inflam-
genital tract and urinary tract. These symptoms are due to low mation or infection of vagina, it does not form a primary
estrogen level at this stage of life. Although this is commonly change associated with menopause. In addition, it does
termed as vulvovaginal atrophy or atrophic vaginitis, it does not reflect the underlying lower urinary tract symptoms,
not reflect the presence of underlying urinary symptoms. So,
which are related to menopause. Besides all of the above,
to encompass full spectrum of symptoms, a broad term like
genitourinary syndrome of menopause (GSM) is being used the words vulva and vagina are not commonly used in
more recently in place of vulvovaginal atrophy or atrophic vagi- social discussion or media.1 Therefore, the Board of Direc-
nitis. It describes various symptoms and signs of menopause tors of the International Society for the Study of Women’s
which include genital symptoms, such as dryness, irritation and Sexual Health and the Board of the North American
burning, urinary symptoms like urgency, dysuria, and recurrent
urinary tract infection (UTI) and sexual symptoms like lack of
Menopause Society (NAMS) emphasized the introduction
lubrication and discomfort or pain. Wide range of treatments of a new terminology in place of terms like vulvovaginal
are available which include nonhormonal black cohosh, a phy- atrophy and atrophic vaginitis in a terminology consensus
toestrogen, lubricants or moisturizers for symptom relief, vaginal conference which was organized in 2013. The term GSM
estrogen therapies, systemic hormonal therapies (HTs), tissue- was finally approved in 2014.
specific estrogen complex [combination of selective estrogen
receptor modulators (SERM) and estrogen] besides newer The GSM narrates various menopausal symptoms
therapies. These newer therapy include laser, radiofrequency and signs related to changes in the vulva, vagina, and
(RF), and magnetic therapy. As the GSM have negative impact, lower urinary tract as well. The genital symptoms of
awareness, recognition and appropriate treatment of GSM will GSM include dryness, burning, and irritation, and sexual
improve the quality of postmenopausal women.
symptoms include lack of lubrication, discomfort or
Keywords: Genitourinary syndrome of menopause, Meno- pain, and urinary symptoms include dysuria, urgency,
pause, Vulvovaginal atrophy. and recurrent UTI. With the increasing life expectancy,
How to cite this article: Ghose S, Pallavee P, Samal R. women spend considerable period of life in postmeno-
Recent Advances in the Management for Genitourinary Syn- pausal period. Hypo-estrogenic state of this period causes
drome of Menopause. J South Asian Feder Menopause Soc many health problems. Of these problems, vasomotor
2018;6(1):65-68.
symptoms like hot flushes and night sweating often get
Source of support: Nil better over the time, whereas genitourinary symptoms
Conflict of interest: None which are chronic, rarely resolve of its own and rather
Date of received: 10 January 2018 worsen, if left untreated.2
Although these manifestations are not a deathly
Date of acceptance: 27 January 2018
illness, they worsen and have deep impact on the quality
Date of publication: August 2018 of life (QOL) of postmenopausal women. It affects not
only their self-esteem but also intimacy with their partners
INTRODUCTION negatively.3 Moreover, GSM may appear following surgi-
cal menopause, use of gonadotropin-releasing hormone
Vulvovaginal atrophy or atrophic vaginitis was the term agonists, because of cancer treatments like chemotherapy,
commonly used until recently to describe the symptoms pelvic radiation, or endocrine therapy.4 So, taking care of
postmenopausal women with genitourinary symptoms
has evolved as an important problem in our society.
1
Professor and Head, 2Professor, 3Associate Professor
1-3
Department of Obstetrics & Gynecology, Mahatma Gandhi PREVALENCE OF GSM
Medical College & Research Institute, Puducherry, India
Vulvovaginal Symptoms and Sexual Dysfunction
Corresponding Author: Seetesh Ghose, Professor and Head
Department of Obstetrics & Gynecology, Mahatma Gandhi In a study by Iosif and Bekassy,5 15% reported itch, dis-
Medical College & Research Institute, Puducherry, India, Phone: charge, whereas 38% reported dyspareunia and vaginal
+914132615449458, e-mail: [email protected]
dryness. Stenberg et al,6 in a cohort study, reported that
Journal of South Asian Federation of Menopause Societies, January-June 2018;6(1):65-68 65
Seetesh Ghose et al

among 59% sexually active women, 43% had vaginal epithelium, altered smooth muscle cell function, increase
dryness and 10% had sensation of vaginal burning. In in connective tissue density, and fewer blood vessels. All
cohort surveys of Western populations, 45 to 63% of post- these lead to reduce vaginal elasticity, increased vaginal
menopausal women mention experiencing vulvovaginal pH, vaginal flora change, and reduced lubrication,
symptoms, vaginal dryness being most common; other which in turn predispose the postmenopausal women
symptoms included were vaginal irritation, dyspareunia, to increased vaginal irritation and trauma.16,17 Due to its
itching sensation, and vaginal spotting during inter- common embryological source, i.e., urogenital sinus, in
course.3,7,8 In a Korean study, 49% of postmenopausal both genital tract and lower urinary tract, hypo-estrogenic
women had experienced similar symptoms.9 Levine et al10 state of menopause is responsible for lower urinary tract
reported that vulvovaginal symptoms were four times symptoms, such as dysuria, urgency, frequency, nocturia,
more common in postmenopausal sexually active women. urinary incontinence, and recurrent UTI.12
Among them with vulvovaginal symptoms, 40% also had
overall sexual dysfunction, 34% arousal difficulties, 24% MANAGEMENT OF GSM: THE PRIMARY FOCUS
lack of desire, whereas 19% had orgasm difficulties. The OF TREATMENT IN GSM IS TO RELIEVE
Study of Women’s Health Across the Nation in the USA SYMPTOMS
reported vaginal dryness to be an important factor associ-
Currently available treatments can be classified into non-
ated with pain, arousal, masturbation, physical pleasure,
hormonal and hormonal. Nonhormonal includes black
and emotional satisfaction.11
cohosh which is a phytoestrogen, lubricants or moistur-
Dysfunction of Lower Urinary Tract izers for symptom relief, whereas HT consists of local use
of estrogen (vaginal cream, tablets, ring), systemic use
Iosif and Bekassy5 in their study showed that 29.2% had of estrogen (oral and transdermal), and tissue-specific
varied degrees of urinary incontinence. Among them, estrogen complex (combination of SERM and estrogen).
11.8% of the women reported stress incontinence, 7.9% However, advancement in the management of GSM
urge incontinence, 9.5% had mixed incontinence, and includes laser, RF, and magnetic therapy. ·
13% had recurrent UTI. They also reported that 48.8%
had lower genital tract problem. Stenberg et al,6 in a Local Treatment
population-based cohort study, reported that 73% of the
women experienced urinary incontinence of which 33% Nonhormonal Treatment
were of severe degree; 31% experienced urge incontinence According to NAMS, the nonhormonal lubricants, i.e.,
of which 14% were severe. In a study by Robinson and water-, silicone-, or oil-based, are the first-line treatment
Cardozo,12 the proportion of severe urge incontinence during intercourse for postmenopausal women who
and stress incontinence were 20 and 50% respectively. suffer from vulvovaginal symptoms. Besides that, long-
The study by Hyun et al13 revealed intrinsic sphincteric acting, locally active moisturizing agents can decrease
dysfunction as a result of altered connective tissue due pH of vaginal to premenopausal levels, but they do
to hypo-estrogenic state as the prime cause of urinary not ameliorate the vaginal maturation index. 4 The
incontinence in postmenopausal women, whereas ana- Society of Obstetricians and Gynecologists of Canada
tomical change was the most common responsible factor guidelines also affirm that regular topical application
for urinary incontinence in premenopausal women. of vaginal moisturizers is equally effective to that of
Studies have shown that bacteriuria was associated with vaginal estrogen applied topically for alleviating vul-
15 to 20% of women aged 65 to 70 years, and 20 to 50% vovaginal symptoms, such as itching, irritation, and
of women aged > 80 years.14,15 dyspareunia. So, it should be recommended to women
who wish to avoid the application of estrogen because
ETIOPATHOLOGY OF GSM of health concerns.18
The hypo-estrogen levels after menopause are directly
Hormonal Treatment
related to these symptoms. During reproductive life,
estrogen receptors are commonly present in the vagina, Short-term application of local estrogen preparations can
vulva, urethra, bladder trigone, musculature of the pelvic ameliorate clinical picture of GSM when nonhormonal
floor, and endopelvic fascia. But with menopause, their treatment fails. In the presence of vasomotor symptoms,
levels decline, which may be restored by treatment with application of systemic estrogen works better, whereas
estrogen. Due to hypo-estrogenic state following meno- genitourinary symptoms respond better to local applica-
pause, the content of collagen, hyaluronic acid, and the tion of estrogen.4 Usually, application of vaginal estrogen
levels of elastin reduce. This leads to thinning of the is safe to use for symptomatic relief of GSM, but it is

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 jsafoms

Recent Advances in the Management for Genitourinary Syndrome of Menopause

admonished in women with undiagnosed bleeding either to sub-urethral reinforcement, it is useful for the correc-
from vaginal or uterine. Its use is controversial in women tion of mild-to-moderate stress urinary incontinence and
with neoplasia of breast and endometrium, which are vaginal canal tightening with subsequent improvement
estrogen-dependent.19 of sexual gratification. The treatment protocol for vaginal
tightening and stress urinary incontinence is nicknamed
Systemic Treatment as IntimaLase and IncontiLase respectively. Similarly,
the treatment protocol for the pelvic organ prolapse and
• Systemic treatment with estrogen or combination of
vaginal atrophy is called ProlapLase and RenovaLase. The
estrogen and progestogen relieves both menopausal
IntimaLase protocol involve two 8 to 10 minute sessions
symptoms and vulvovaginal symptoms. However,
at 4- to 6-week interval, whereas IncontiLase involves two
its use to relieve sexual dysfunction in terms of
15-minute sessions with the same interval. The protocol
improving libido, arousal is not evidenced by current for treatment of ProlapLase follows the same principle
research.20 as that of vaginal tightening and incontinence, but only
• Selective ER modulators: Systemic estrogen has difference is in the treatment intensity (duration) and the
stimulatory effects on endometrium and breast, pre- major area treated, i.e., the prolapsed part of the vaginal
disposing to malignancy in long-term use. So, use of wall. The ProlapLase protocol requires 3 to 5 sessions at
SERMs was introduced. SERMs have positive effects 4- to 6-week interval.
on targeted tissues, but very little negative influence The RenovaLase is based on a concept of milder
on other tissues. Of SERMs, the only drug which is hyperthermia. Here, the mucosa is warmed up to 45°C.
approved for the treatment of moderate-to-severe This causes the stimulation of cell proliferation via heat
dyspareunia is ospemifene. It has a positive impact shock protein activation, an increase of collagen produc-
on vaginal tissue in postmenopausal women. Its main tion, and anti-inflammatory action as well. This protocol
use is to prevent postmenopausal osteoporosis.21,22 consists of three sittings at intervals of 3 weeks.25
• Bazedoxifene (BZA) and conjugated estrogens (CEs):
The combination of BZA (20 mg) and CE (0.45 or Radiofrequency Wave
0.625 mg) is a tissue-selective estrogen complex. It
It is another treatment option designed on the principle of
has been designed to alleviate vasomotor and dys-
bulk heating of tissue to reach the required temperature
pareunia, but has no positive effect on vagina. It also in collagen for shrinkage and neocollagenesis. However,
averts bone loss while being invulnerable for the RF heats the epithelium to a higher temperature, making
endometrium and breast.23,24 treatment unpleasant. Moreover, RF needles require local
anesthesia.25
Newer Treatment Modalities
Laser Treatment Functional Magnetic Stimulation

A beam of photons with specific wavelength is gener- It has performed well for treatment of all types of urinary
ated by Laser equipment. Biological tissues, i.e., blood, incontinence. This causes faster regeneration of muscles
melanin, and water absorb and react to this beam. This is and other tissues of pelvic floor, resulting in stronger
of two types, i.e., micro-ablative CO2 laser and nonabla- pelvic floor muscles. It does not require insertion of
tive Vaginal erbium:yttrium aluminum garnet smooth unpleasant electrode. During the therapy, patients sit
laser (VEL). The CO2 laser uses the ablative approach. dressed in a comfortable chair and a treatment is carried
It generates high temperature in the tissue by creating out twice or thrice a week for twenty minutes. As it does
micro-thermal zone (MTZ), which are basically minute not come in contact with the skin directly, the treatment
holes that are made in the vaginal wall. These MTZs is not painful or uncomfortable and has no side effect.25
induce shrinkage of tissue, but are not as effective as
CONCLUSION
in initiating neogenesis of collagen. The VEL produces
collagen hyperthermia up to 65°C in the epithelium and The GSM is a broad term that encompasses lower urinary
lamina propria, resulting in breaking of the intermo- tract symptoms and vulvovaginal symptoms related to
lecular crosslinks that stabilize collagen’s triple-helix hypo-estrogenic state. Very few women relate symp-
structure, causing rapid contraction of the collagen toms to menopause or hypo-estrogenic state, whereas
fibers. This in turn results in shrinkage and greater tissue most women consider them as part of normal and avoid
rigidity and also initiates neocollagenesis in vivo. As it consulting a gynecologist for that. Although a varied
increases the density of the connective tissue, stimulat- range of accomplished treatment options are available
ing collagen remodeling and neo-angiogenesis, leading from nonhormonal local application to noninvasive laser
Journal of South Asian Federation of Menopause Societies, January-June 2018;6(1):65-68 67
Seetesh Ghose et al

treatment including local and systemic HT, many women Study of Women’s Health Across the Nation. Menopause
are still diffident to accept HT because of its concern of 2009 May-Jun;16(3):442-452.
12. Robinson D, Cardozo LD. The role of estrogens in female
adverse effects including cancer.
lower urinary tract dysfunction. Urology 2003 Oct;62
However, since the GSM may have a considerable (4 Suppl 1):45-51.
adverse impact on the QOL of postmenopausal women, 13. Hyun HS, Park BR, Kim YS, Mun ST, Bae DH. Urodynamic
they should be made aware of these problems and treated characterization of postmenopausal women with stress
appropriately. urinary incontinence: retrospective study in incontinent pre-
and post-menopausal women. J Korean Soc Menopause 2010
Dec;16(3):148-152.
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