Genitourinary Syndrome of Menopause: New Name, Old Problem

Previously known as atrophic vaginitis, vulvovaginal atrophy (VVA), or urogenital atrophy, genitourinary syndrome of menopause (GSM) is a composite of genital, urologic and sexual sequelae of chronic hypoestrogenism.  Sexual dysfunction and quality of life impairment are important to identify, as treatment options are available. Incidence is unknown as the syndrome is often underreported by women due to embarrassment, disregard, or a sense of inevitability.

KEY POINTS:

Risk Factors

• Lactation
• Hyperprolactinemia
• Autoimmune disorders
• Bilateral oophorectomy
• Pelvic radiation
• Chemotherapy
• Medications including
  • GnRH agonists (leuprolide, nafarelin)
  • SERMs (such as tamoxifen)
  • Aromatase inhibitors,
  • Danazol
  • Progestins
• Lifestyle risk factors including
  • Cigarette smoking, Alcohol abuse | Sexual abstinence | Lack of exercise | Lack of vaginal birth

Diagnosis

• Include the following on history
  • Irritants: Lubricants, powders, soaps, spermicides, panty liners
  • Hypoestrogenism: Oophorectomy, antiestrogen medications, radiation, chemotherapy
• Ask about the following symptoms
  • Vulvovaginal: Itching, burning, pain, discharge, dyspareunia
  • Urinary: Frequency, dysuria, urgency, dribbling, incontinence, recurrent urinary tract infections
• On pelvic exam look for the following
  • Pale vaginal epithelium with areas of erythema
  • Lacerations, stenosis, friable epithelium, labial fusion
• Consider the following on differential diagnosis
  • Infection
  • Contact irritants
  • Foreign body
  • Sexual trauma
  • Neoplasm
  • Radiation effect
  • Dermatologic conditions such as lichen sclerosis or lichen planus
• Diagnostic tests should be individualized and risk-based
  • Vaginal pH (5-7 in GSM)
  • Vaginal cytology (primarily basal cells)
  • Wet mount
  • Cervical cytology
  • Depending on history and physical findings, other tests to consider
    • Transvaginal ultrasound
    • Hysteroscopy

Treatment

Estrogen Therapy (Summary of dosage regimens can be found in the ObG NAMS entry below)

• Management of moderate/severe GSM is best treated with estrogen therapy (ET)
  • Up to 90% of women will improve with local ET, whether vaginal ring, cream, gel, or tablet
    • Progestin is not necessary to protect the endometrium
    • Treatment is long term
• Consider systemic ET in patients with GSM and/or vasomotor symptoms, risk factors for osteoporosis
  • Progestin needed in women with an intact uterus
  • Both systemic and local ET may be necessary based on clinical response

Estrogen Therapy Alternatives (More information including medications can be found in ObG entries below)

• Be mindful of contraindications and precautions related to ET use (see “Special Populations” below)
  • Known/suspected breast cancer | Estrogen-dependent cancers | Undiagnosed vaginal bleeding | Endometrial hyperplasia/cancer | Hypertension | Hyperlipidemia | Liver disease | History of CVA/VTE/CAD or thrombophilic disorders (e.g., protein C, protein S, antithrombin deficiency) | Pregnancy | Smoking | Migraine with aura | Acute cholecystitis/cholangitis

• Other options include the following
  • SERMs, such as ospemifene and bazedoxifene
    • Contraindications: Undiagnosed abnormal genital bleeding | Known or suspected estrogen-dependent neoplasia | Active arterial thromboembolic event
  • Vaginal dehydroepiandrosterone (DHEA) – Prasterone
    • Contraindications: Undiagnosed abnormal genital bleeding
  • Tibolone (Not available in US or Canada)
  • Moisturizers and lubricants
• Homeopathic remedies have no proven efficacy on the vaginal epithelium and treatment of GSM
• Smoking cessation may be helpful

Special Populations: History of Estrogen Dependent Breast Cancer

Nonhormonal Methods: First Line Therapy

• Lubricants: Silicone | Polycarbophil | Water based
• Moisturizers: Hyaluronic acid | Polyacrylic acid | Polycarbophil based
• Vaginal suppositories: Vitamin E | Vitamin D
• 4% aqueous lidocaine: Applied to vulvar vestibule
• Laser therapy: Not currently FDA approved | Additional research needed before recommending

Hormonal Methods: Consider if Nonhormonal Treatments Fail 

• Low dose vaginal estrogen 
  • Discuss risks/benefits 
  • Can be used with history of breast cancer 
  • Can be used if taking tamoxifen 

Note: If patient taking aromatase inhibitor, decision should involve oncologist 

• Vaginal Dihydroepiandrosterone (DHEA) or testosterone 
  • Can help with dyspareunia and vaginal atrophy 
  • Second line to vaginal estrogen 

• Ospemifene/SERMs 
  • Long term safety data in patients with ER-dependent breast cancer is limited 
  • Can be considered 

Learn More – Primary Sources:

ACOG Practice Bulletin 141: Management of Menopausal Symptoms

Perspective on prescribing conjugated estrogens/bazedoxifene for estrogen-deficiency symptoms of menopause: a practical guide

Kaunitz and Manson: Management of Menopausal Symptoms

ACOG Clinical Consensus 2: Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer

Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation and management

Effect of a pH-balanced vaginal gel on dyspareunia and sexual function in breast cancer survivors who were premenopausal at diagnosis: a randomized controlled trial

JAMA Insights: Treatment of Vulvovaginal Atrophy