Updated: Oct 3
You've made it! You're postmenopausal. The hot flashes and mood swings have stopped, and you breathe a sigh of relief. Then you start to notice itchiness, dryness, and pain in your genital area, and you start to have urinary tract infections. What's happening now? Although menopause is a natural part of a woman's life, it can bring with it some uncomfortable changes to the genitourinary system (genital/urinary). Called Genitourinary Syndrome of
Menopause (GSM), it includes a variety of symptoms and issues that occur in women during menopause and into post menopause because of low levels of estrogen. These symptoms can affect various parts of a woman's genital area, including the labia, clitoris, vagina, urethra, and bladder. Although it is more common in post-menopausal women, any condition or event in a women’s life that reduces estrogen can bring on symptoms of GSM, including during postpartum, lactation, premature menopause, surgical removal of ovaries, PCOS and more. (1)
Changes to tissue occur when estrogen decreases including:
1. Thinning of the vaginal tissue, which can make it more prone to bleeding and injuries, especially during sex or medical exams.
2. Lower levels of good bacteria in the vagina, which can lead to infections and discomfort.
3. Loss of elasticity and shortening of the vaginal canal, making it less flexible.
4. Reduction in vaginal secretions, which can cause dryness.
5. Increase in vaginal pH, which can make it more hospitable for bad bacteria.(1)
These physical changes can lead to genital dryness, burning or itching, pain or discomfort during sex, vaginal bleeding or irritation, loss of libido, and urinary frequency, incontinence, or bladder infections. (1) Furthermore, symptoms can greatly reduce a woman’s quality of life. Women with GSM report less sexual intimacy, which may significantly impact relationships. Those with overactive bladder, or frequent bladder infections experience poorer sleep quality, reduced daytime functioning, social isolation and the potential for infections to become systemic and serious. (2)
There are effective treatments for GSM. Lifestyle factors that exacerbate symptoms of GSM should be explored. Although women may avoid sexual intimacy due to pain, regular coitus or masturbation may help with vaginal health. Irritants such as soaps, perfumes or spermicides in condoms should be avoided. Triggers such as caffeine and cigarette smoking should be reduced or discontinued. Finally, weight loss may help to improve urinary incontinence. (2)
There are a variety of OTC, or prescription treatments for GSM. Vaginal lubricants and moisturizers can be used; however, they don’t improve vaginal tissue, or help with urinary symptoms. Low dose vaginal estrogen products (cream, tablet, sustained-release ring) demonstrate improvement in GSM. Because systemic absorption is limited, progesterone therapy is not required for almost all these products. Unlike oral estrogen, vaginal estrogen products show benefit in reducing urinary incontinence and infections. The oral SERM, ospemifene, and vaginal DHEA (dehydroepiandrosterone) are both very effective for GSM symptoms. Finally, intravaginal laser therapy has shown efficacy for GSM, but requires further research. Women who have had estrogenic cancers may still be able to use some of these products but should discuss them with their oncologists. (2)
Although treatment for vaginal dryness works, the extent to which it is effective depends on the severity of the dryness when a woman starts the treatment. Waiting too long means you will never return to a pre-menopause level. Unfortunately, 70% of women don’t discuss symptoms of GMS with their providers. Some are embarrassed, some think the changes are what to expect as an aging woman, even urinary incontinence. Women should be encouraged to talk to their health care providers about symptoms, and providers should ask the questions. This is especially important since symptoms may not be GSM, but some other condition such as trauma, infection, or malignancy. A full assessment and discussion of treatment options are warranted. (1)
Genitourinary syndrome of menopause is common outcome of menopause, yet it is not commonly addressed. Women should be aware of GSM prior to the menopause transition and encouraged to seek treatment for symptoms early on to ensure they are fully assessed and to mitigate the impact on their quality of life.
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1. Bachmann, G., Pinkerton, J. V. (2022). Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis. UpToDate.
2. Society of Obstetricians and Gynecologists of Canada. (2021). Guideline No. 422b: Menopause and Genitourinary Health. SOGC Clinical Practice