Synonyms
vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy
Subdivisions
General Discussion
Genitourinary syndrome of menopause (GSM) is a condition characterized by several signs and symptoms attributed to low estrogen levels, often associated with menopause. GSM is a very common problem that can result in vaginal dryness, sexual pain, and urinary concerns. It affects most postmenopausal women, and 15% of premenopausal women experience GSM-like symptoms due to low estrogen levels. (1,2) When premenopausal women have these symptoms, the condition is called hormonally mediated vestibulodynia. Please refer to the Hormonally Mediated Vestibulodynia article for more details. These symptoms can have a significant impact on women and negatively affect their quality of life, especially those who are sexually active. (3)
Unlike hot flashes which eventually improve with time, the symptoms of GSM get worse with time. Approximately 65% of women experience symptoms one year after menopause, and the number increases to 84% of women who may experience symptoms 6 years after menopause (4,5).
GSM is a relatively new term which replaces the previously known diagnosis of vulvovaginal atrophy. The terminology was changed in 2014 by a consensus of the International Society for the Study of Women’s Sexual Health and the North American Menopause Society because GSM is a comprehensive term which includes symptoms of vulvar and vaginal atrophy as well as urinary symptoms related to menopause. It also avoids the negative connotations associated with the term atrophy. (6)
Signs & Symptoms
Genital symptoms may include vaginal dryness, vaginal discharge, genital itching, thinning pubic hair, vaginal or pelvic pain and pressure, shortening/tightening of the vaginal canal, or pelvic organ prolapse. Urinary symptoms may present as painful urination, urinary urgency and/or frequency, urinary incontinence (leaking urine), or recurrent urinary tract infections. Women experiencing sexual problems due to GSM may encounter pain with sexual activity, vaginal dryness, bleeding after sex, decreased desire, decreased arousal, and changes with orgasm, including painful orgasms.
Causes
GSM is caused by low estrogen levels, which makes the vaginal tissues thin and dry. When this happens, the tissues have less elasticity and are more fragile. Estrogen levels start to decrease in the years leading up to menopause (perimenopause), and they decrease even more after menopause. Unfortunately, the symptoms only worsen if not treated. (5) Other conditions may contribute to low estrogen levels: surgical menopause (removal of ovaries), breast-feeding, and certain medications such as birth control pills, patches, and rings, and spironolactone. Infertility medications and treatment for endometriosis can also contribute to changes in the vulvovaginal tissues. In addition, many cancer treatments can lead to low estrogen levels: pelvic radiation for cancer, chemotherapy, and hormonal treatment for breast cancer.
GSM-like symptoms in premenopausal women are also caused by medications such as birth control, infertility or endometriosis treatments, and spironolactone. Birth control pills and other treatments can decrease estrogen levels and increase the production of a protein called sex hormone binding globulin (SHBG), which attaches to testosterone and renders it inactive. The higher the SHBG level, the less free testosterone that the body can use. This results in lower hormone levels and changes in the vulvar tissues causing hormonally mediated vestibulodynia. Discontinuing the offending medication is usually not enough to resolve the vulvovaginal problems because hormone levels remain low for a long time. (7) Women often benefit from treatment with a hormone cream, and one that has shown to be helpful is a compounded cream with estradiol and testosterone. (8) Likewise, breastfeeding can contribute to GSM-like symptoms due to hormonally mediated vestibulodynia. Prolactin levels are high and estrogen levels are low during this time, and treatment with an estradiol cream can be helpful.
Affected Populations
- Perimenopausal women
- Menopausal women
- Breast feeding
- Women taking chemotherapy, radiation, or hormone treatments for breast cancer, endometriosis, or infertility
- Women taking hormonal contraception (pills, patches, or ring)
Diagnosis
The diagnosis of GSM is made by your medical provider after taking a history of your symptoms and performing a pelvic exam to evaluate the external genitalia and vagina. The physical exam may reveal vaginal atrophy, thinning or tearing of the skin, posterior fourchette fissures, changes in color (pale or red), tenderness with lightly touching some areas, and decreased lubrication.
Lab tests are generally not required to make the diagnosis of GSM because the diagnosis is based on history and physical exam, not hormone levels. A culture or biopsy may be done if the appearance of the tissue is not typical. A urine test may be requested if you are having urinary symptoms, and an acid balance test may be done to check the pH of the vagina.
However, checking hormone levels can be helpful for the diagnosis in premenopausal women experiencing GSM-like symptoms since medications, especially birth control pills, patches, and rings can result in low hormone levels that cause vulvovaginal dryness, pain, and other changes in sexual function. Checking total testosterone and SHBG levels and then using the values to calculate a free testosterone level using a calculator found at http://www.issam.ch/freetesto.htm is thought to be an accurate method for determining free testosterone. Direct measurement of free testosterone may not be accurate, depending on the type of test, and the calculated measurement gives a more accurate value. Just measuring the total testosterone may not reveal a low hormone state if the SHBG is elevated. In this case, the total testosterone may be normal and the free (active) testosterone may be low because the majority of the testosterone is bound to SHBG and inactive. (7)
Read related article: Hormonally Mediated Vestibulodynia
Standard Therapies
Lubricants and Moisturizers
Lubricants and moisturizers help with sexual comfort and pleasure and are helpful for women with mild to moderate vaginal dryness. Lubricants provide short-term relief of vaginal dryness and discomfort with sexual activity. Vaginal moisturizers must be used regularly and on an ongoing basis every 2-3 days in order to be effective. They do not work well if used intermittently or only with sexual activity. They provide longer lasting relief by increasing mucosal moisture and decreasing pH.
Low-Dose Vaginal Estrogen Therapy
Vaginal estrogen helps restore thickness and elasticity of the vaginal tissue. It can actually reverse the thinning and dryness of the vagina to relieve pain associated with sexual activity and urinary symptoms such as frequency, urgency, incontinence, and urinary tract infections. Localized vaginal estrogen treatment uses low doses of estrogen which have minimal effect on the rest of the body, and it comes in various formulations: creams, tablets, rings, and vaginal inserts. The treatment must be used consistently in order to be effective; it does not work well if used sporadically or as needed.
A note about safety of low dose vaginal estrogen therapy: Systemic estrogen therapy (estrogen pills, patches, creams which are used to treat hot flashes and increase estrogen levels in the blood) has been associated with increased risk of blood clots, heart attacks, stroke, and invasive breast cancer (with combination estrogen + progestogen). These risks of systemic estrogen and estrogen + progestogen were applied to estrogen class labeling, which were then applied to all estrogen preparations, even though there was no clinical evidence indicating that low dose vaginal estrogen caused the same risks. A study of 45,663 women was published in the journal Menopause in 2018, and there was no increased risk of heart attacks, stroke, blood clots, or cancer in the women using low dose vaginal estrogen compared to those who did not use vaginal estrogen. These results provide reassurance regarding the safety of low dose vaginal estrogen therapy. (10)
Selective Estrogen Receptor Modulator
Selective estrogen receptor modulators (SERMs) are pills that have a positive estrogen effect on some tissues and an anti-estrogen effect on other tissues. Of the currently available SERMs, only ospemifene is FDA approved for the treatment of moderate to severe dyspareunia (painful sex) caused by GSM in postmenopausal women. Ospemifene may be a good option if you prefer to avoid a low-dose vaginal estrogen treatment.
Vaginal DHEA
Dehydroepiandrosterone (DHEA) is a steroid precursor hormone and is converted by the body to testosterone and estradiol within the vaginal cells. Prasterone is a DHEA vaginal suppository approved by the FDA for the treatment of GSM and is inserted in the vagina every night at bedtime.
Investigational Therapies
Laser treatments
Recently, laser devices have been used as an alternative treatment modality for GSM. The therapy has been tested in smaller clinical trials with mixed results, and many of the studies have shown positive results. However, longer term safety and efficacy studies are needed before laser treatments can be recommended as a standard therapy for GSM.
Support Available
North American Menopause Society - www.menopause.org
References
- Palma F., Volpe A., Villa P, Cagnacci, . Maturitas. Vaginal atrophy of women in postmenopause. Results from a multicentric observational study. Marturitas. 2016; 83:40-4.
- Shifren, Jan L. Genitourinary Syndrome of Menopause. Clin Obstet Gynecol. 2018 Sep;61(3):508-516.
- Simon J.A., Nappi R.E., Kingsberg S.A., Maamari R., Brown V. Clarifying Vaginal Atrophy's Impact on Sex and Relationships (CLOSER) survey: emotional and physical impact of vaginal discomfort on North American postmenopausal women and their partners. Menopause. 2014; 21: 137-142
- Vaginal atrophy of women in postmenopause. Results from a multicentric observational study: The AGATA study. Palma F, Volpe A, Villa P, Cagnacci A. Maturitas. 2016;83:40–44.
- The North American Menopause Society (NAMS). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020 Sep;27(9):976-992
- Portman D.J., Gass M.L. Vulvovaginal Atrophy Terminology Consensus Conference Panel Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society. Maturitas. 2014; 79: 349-354
- Panzer C, Wise S, Fantini G, Kang D, et. al. Impact of oral contraceptives on sex hormone binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. J Sex Med. 2006;3:104-13.
- Burrows, LJ, Goldstein AT. The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med. 2013;1:30-33.
- Nilsson K, Risberg B, Heimer G. The vaginal epithelium in the post menopause - cytology, histology, and pH as methods of assessment. Maturitas 1995;21:51-56.
- Crandall C, Hovey K, Andrews C, et.al. Breast cancer, endometrial cancer, and cardiovascular events in participants who use vaginal estrogen in the women’s health initiative observational study. Menopause. 2018; 25(1):11-20.
