What you should already know
The term genitourinary syndrome of the menopause (GSM) was introduced in 2014 to replace the terms atrophic vaginitis and vulvovaginal atrophy. This term more accurately describes the postmenopausal hypoestrogenic state of the genitourinary tract.1
GSM is very common; some studies have shown that around 70% of women have symptoms, yet only around 7% of women receive treatment.2
Oestrogen receptors are present in the vagina, urethra, bladder trigone and pelvic floor musculature. The fall in oestrogen levels after the menopause can result in the loss of superficial epithelial cells, collagen and elastin, resulting in loss of vaginal rugae. The vaginal epithelium becomes pale and friable and can tear and bleed, particularly during intercourse. Loss of subcutaneous fat in the labia majora results in shrinkage of the introitus with prominence of the urethral meatus leading to an increased risk of irritation and infection.
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As a result, women can experience symptoms of vulvar and vaginal dryness, discharge, itching, dyspareunia, urinary frequency and urgency, dysuria, nocturia and recurrent urinary tract infections. These symptoms negatively affect sexual health, interpersonal relationships and quality of life. Even in women who are not sexually active, these symptoms have been reported to affect self-esteem and reduce quality of life.3 Some women find their symptoms stop them wearing trousers, exercising or even sitting down for long periods.
One study on the effect of vaginal atrophy on sex and relationships showed that 28% of women did not tell their partners when they first experienced vaginal discomfort, because they felt ‘it was just a natural part of growing older’ (52%) or because of ‘embarrassment’ (21%).4 Having sex less often, less satisfying sex and putting off having sex were the main effects of GSM.
There are health benefits of love and sex in maintaining a healthy heart, reducing blood pressure, coping with stress, and reducing the risk of peptic ulcers and angina, as well as boosting the immune response.5
Unlike hot flushes related to the menopause that usually resolve over time, GSM has a chronic progressive nature throughout the menopausal transition and beyond, so symptoms usually worsen rather than improve.
If the right questions are asked in the right clinical setting, women are more likely to be open about their symptoms.
What isn’t as widely known, but you should think about
Consider asking postmenopausal women about symptoms, regardless of their presentation.6 Nurses undertaking cervical screening are well placed to enquire about symptoms, as are all healthcare professionals to whom postmenopausal women present with genitourinary symptoms.
Vaginal moisturisers and lubricants should be considered for women with GSM. YES, Sylk and Regelle are available on prescription and are less likely to cause irritation than some over-the-counter preparations. Vaginal moisturisers used on a regular basis offer relief from symptoms of vaginal dryness, whereas vaginal lubricants are intended for use with sexual or penetrative activity, which includes pelvic examination and cervical screening.
Although these preparations do not restore normal vaginal physiology, they are suitable for women who choose a non-hormonal solution for personal or medical reasons.7 They can also be used in addition to local vaginal oestrogen preparations. Oil-based lubricants can damage condom integrity.8
Vaginal oestrogen can be used for the majority of women with GSM and is available as a cream, tablet and a ring. There is no need for endometrial surveillance or additional progestogen for endometrial protection with these products, even when used in the long term. Local oestrogen can and should be used in the long term.9,10 Women using systemic HRT can also use local oestrogen treatments. Women with a history of breast cancer can use vaginal oestrogens; the only exclusion is women taking aromatase inhibitors. Around 20% of women on systemic HRT will still experience symptoms and should use local oestrogen.
Questions to ask
- Have you experienced any vaginal soreness, burning or irritation?
- Do you have any itching around your vagina or vulval area?
- Is sexual intercourse painful or uncomfortable?
- Have you noticed changes in any vaginal discharge (either increased or reduced) or increased dryness?
- Have you noticed any urinary symptoms such as increased urinary frequency or being less able to hold on to urine?
- Do you have any discomfort on passing urine?
New treatment options
Ospemifene is an orally active selective oestrogen receptor modulator (from the same chemical class as tamoxifen) that acts as an oestrogen agonist in the vagina. Ospemifene may be used in women with breast cancer once treatment is completed.11
Prasterone is a new treatment for vulvar and vaginal atrophy in post-menopausal women with moderate to severe symptoms. The active ingredient is identical to DHEA (dehydroepiandrosterone). This is administered locally in the vagina and is converted intracellularly to androgens and oestrogens. It has been demonstrated to improve dyspareunia, vaginal pH and vaginal epithelium.12
Laser therapy can encourage collagen production and vaginal wall regeneration with improved elasticity and moisture. Advocates of the carbon dioxide laser13 or the infrared/Erbium laser14 propose this outpatient treatment for the improvement of sexual function, vaginal tightening, vaginal dryness and stress incontinence. This treatment is not currently available on the NHS.
Dr Alice Duffy is a GP and clinical teaching fellow at the University of Nottingham
Dr Louise Newson is a GP and menopause specialist in Stratford-upon-Avon and a director of the Primary Care Women’s Health Forum