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.
GnRH agonists (leuprolide, nafarelin)
SERMs (such as tamoxifen)
Lifestyle risk factors including
Cigarette smoking, Alcohol abuse | Sexual abstinence | Lack of exercise | Lack of vaginal birth
Treating Postmenopausal Vaginal Atrophy When Estrogen is Not an Option
If a patient complains of dyspareunia, and clinical examination is consistent with postmenopausal vaginal atrophy / atrophic vaginitis, local estrogen is the first line of treatment, but there are alternatives that can be considered if the following two criteria are met:
Ascertain if the patient can, indeed, use estrogen and ensure that option was offered and an informed decision to decline was met
Screen for a history of breast or uterine cancer, history of blood clots or liver conditions
Some postmenopausal patients will not or cannot use local estrogen replacement therapy to treat vaginal atrophy/atrophic vaginitis. Common situations in which this is the case may include personal history of estrogen-sensitive breast cancer or endometrial cancer, although NAMS guidelines do recommend that low-dose local HT may be an option, in consultation with a patient’s oncologist in certain situations. Fortunately, a number of effective options are available for these women.
When a clinician cannot prescribe local estrogen, alternatives for postmenopausal vaginal atrophy include
Ospemifene – 60 mg daily
Should not be used concomitantly with estrogens
Should be used for 12 continuous weeks in order to gauge effectiveness
Ospemifene is a SERM
According to the FDA, there is insufficient data to use ospemifene in women with breast cancer
While there do not appear to be any cases of ospemifene causing endometrial cancer, a potential risk for this particular malignancy is mentioned in a boxed warning
Prasterone – One vaginal insert (6.5 mg) each evening at bedtime
FDA approved, steroid-based treatment for postmenopausal vaginal atrophy
Use is appropriate for women who complain of dyspareunia due to dryness and thinning of the vaginal mucosa
Based on the fact that there is minimal data on safety in the setting of hormonally sensitive malignancy, the FDA warns against using prasterone if there is a history of or known or suspected breast cancer
Have been found to be efficacious and may help alleviate symptoms
Laser Treatment – FDA Statement
The FDA has released a statement (August 2018) warning that “…safety and effectiveness of these devices hasn’t been evaluated or confirmed by the FDA for “vaginal rejuvenation.” In addition to the deceptive health claims being made with respect to these uses, the “vaginal rejuvenation” procedures have serious risks.”
ACOG supports the FDA statement and has a position statement advising that while there is there is FDA clearance of fractional C02 laser, indications do not specify treatment of vulvovaginal atrophy, but do include
incision, excision, ablation, vaporization, and coagulation of body soft tissues in medical specialties, including aesthetic (dermatology and plastic surgery), podiatry, otolaryngology (ENT), gynaecology, neurosurgery, orthopaedics, general and thorasic surgery (including open and endoscopic), dental and oral surgery and genitourinary surgery
NAMS has also responded and while welcoming the FDA’s mandate requiring companies to provide adequate data, the NAMS statement includes the following to assist with counseling
NAMS recommends that healthcare providers discuss the benefits and risks of all available treatment options for vaginal symptoms, including over-the-counter lubricants, vaginal moisturizers, and FDA-approved vaginal therapies such as vaginal estrogen and
intravaginal dehydroepiandrosterone and oral therapies such as hormone therapy and ospemifene to determine the best treatment for women with GSM. When discussing vaginal energy-based therapies, informed discussion should include that these are FDA-approved devices for gynecology but have not received FDA approval for vaginal rejuvenation or procedures for GSM, sexual function, incontinence, or pelvic laxity and that even though short-term data are promising, more robust, sham-controlled, and longer-term data are needed.
While alternative treatments will address vaginal dryness and atrophy, patients should be informed of the limitations of these treatments
Treatments that are effective for managing vaginal atrophy, may not help with other menopausal symptoms such as hot flashes, night sweats or mood
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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