Genitourinary Syndrome and Menopause

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There are several vaginal symptoms women commonly experience during menopause, and there hasn't really been a name to describe all of them - until now. Genitourinary Syndrome of Menopause, or GSM, is a relatively new term that was created to encompass many of the genital, sexual, and urinary symptoms women experience in midlife. This article covers what GSM is and how to manage it effectively. 

What is Genitourinary Syndrome?

Genitourinary Syndrome of Menopause is a term coined in 2014 by the International Society for the Study of Women's Sexual Health and the North American Menopause Society. It is meant to encompass better the multitude of symptoms that countless women experience during menopause, related to their bladder-urethral and vulvovaginal areas, with minimal negative associations.

Before the GSM terminology was introduced, health providers used the terms vulvovaginal atrophy and atrophic vaginitis to describe some of the most frequent genital, urinary, and sexual symptoms reported by women during menopause. However, these terms didn't really cover the full spectrum of what women experience. Plus, they didn't take into account the reduction in estrogen levels as the root cause of menopausal impairments. Moreover, the word ‘atrophy’ has permanent implications that are not warranted, as many of these symptoms are readily treatable with estrogen.

The new terminology also recognizes the multiple negative impacts genitourinary issues can have on the quality of life that many women experience during and after menopause. It aims to help women partner with their healthcare provider to find better diagnostic, management, and treatment opportunities for their GSM symptoms. 

How prevalent is GSM in menopausal women?

GSM can be found in up to 90% of postmenopausal women who are evaluated for it. Still, the number of women experiencing GSM is more than likely under-recognized and, therefore, under-treated. Only about one-quarter of women discuss their symptoms with their provider, oftentimes due to a belief that their discomfort is a part of aging.

The majority of GSM symptoms stem from the loss of estrogen that occurs naturally in a woman's body during midlife. 

Some of the most common symptoms include:

  • Dryness, burning, and irritation of the vagina

  • Lack of vaginal lubrication leading to discomfort, pain, and decreased sexual satisfaction during intercourse

  • Increase in urinary urgency and recurrent urinary tract infections

Understanding GSM Terminology

The medical profession has a tendency to create complicated terminology when describing body parts, diagnoses, and other clinical matters. Here are a few definitions to help you understand the key parts of your body involved in GSM.

  • Vulva – your vulva is the external opening of the vagina. It includes the clitoris, vaginal labia, and the opening of the vagina. It is commonly misidentified as the vagina, which is actually the inside part.

  • Vagina – the vagina is the muscular tube leading from the external genitals to the cervix of the uterus. When you have sex, birth a baby, or insert a tampon, the vagina expands.

  • Clitoris – the clitoris is a small, sensitive, erectile part at the top of the vulva where the lips meet. With 8,000 nerve endings, it is highly sensitive. For many women, stimulating the clitoris is the best way to orgasm.

  • Urethra – the urethra is the tube that leads from the bladder and transports and discharges urine outside the body. The small opening where urine comes out is right below the clitoris.

Management of Genitourinary Syndrome 

GSM symptoms are unfortunately often chronic, rarely go away on their own, and can worsen if left untreated. This sounds scary and, even though GSM is not life-threatening, these symptoms can absolutely take a toll on a woman's quality of life and relationships. Therefore, finding an appropriate treatment is really important.

The primary goal of GSM treatment is to help women manage their symptoms better and, ultimately, improve their quality of life. 

Common treatments for symptoms that aren't related to sexual activity include: 

  • Vaginal moisturizers

  • Low dose vaginal estrogen

For symptoms that are related to sexual activity, treatment options include:

  • Non-hormonal vaginal lubricants to use with intercourse

  • Vaginal moisturizers that are long-acting

  • Low dose vaginal estrogen therapies (e.g., creams, intravaginal tablets or rings)

  • Systemic hormonal therapies (e.g., oral and transdermal hormone applications) using estrogen or estrogen plus progestin

The first choice of treatment is usually over-the-counter topical moisturizers and lubricants. Your physician can work with you to evaluate whether you need a prescription-based therapy.

How effective are these treatments? It depends, but here's what the research shows in a nutshell.

Local therapies, or hormonal and non-hormonal treatments used to target local symptoms, are commonly used and can be effective for many women when used appropriately. Over-the-counter vaginal lubricants and moisturizers are widely used during intercourse with great success. Lubricants and moisturizers work a little different and may work best together. Hormonal treatments like estrogen tablets, creams, or vaginal rings can be effective in improving symptoms like urine leakage and urgency and urinary tract infections. 

Systemic therapies, like hormone therapy (HT), selective ER modulators (SERMs), bazedoxifene (BZA) and conjugated estrogens (CE), have mixed effectiveness in their applications. HT is effective in many menopausal symptoms, including vulvovaginal, but it's not recommended as a sole treatment for decreased libido or sexual function, and may actually worsen urinary incontinence in some women. Ospemifene and DHEA (prasterone) are the SERMs approved by the FDA for use in treating painful intercourse for menopausal women, and may also help vaginal pH and dryness. The combination of BZA and CE has been found to be effective in improving vulvovaginal symptoms and dyspareunia (painful sexual intercourse due to medical or psychological causes), with the added benefit of preventing menopausal bone loss. 

Alternative therapies to help manage menopausal symptoms are becoming more common, but there's insufficient high-quality medical evidence to support their efficacy and application. One example is black cohosh, an herb that some women have reportedly tried in place of hormonal therapies for certain GSM symptoms like vaginal atrophy. Results have been mixed, but primarily show that it has no significant impact. Additionally, vaginal lasers have recently started being used for GSM to stimulate collagen growth and improve vaginal strength, though more research is needed. 

What Not To Do for GSM 

The worst things you can do for your vaginal area includes douching and using fragrance-containing products near your vagina, like bubble baths, and scented soaps and lotions. Think of your vaginal area as a self-cleaning oven. It doesn’t need any help to stay clean. In fact, newer research has discovered that your vulvovaginal area has its own microbiome, and applying the wrong products can upset its healthy balance. If you smoke, now is a great time to stop. Tobacco use has been linked with vaginal atrophy. You can also try sticking to breathable cotton underwear and avoiding shaving or waxing practices to limit skin irritation.

Best Practices for Genitourinary Syndrome

You might be wondering, with all of those options and scenarios, what's the best treatment for my GSM symptoms? The best way to figure this out is to speak to your gynecologist, who will be able to have a comprehensive discussion with you to come up with an appropriate plan of action. 

In the meantime, lifestyle changes can also help with some GSM symptoms. For instance, having more frequent intercourse may improve certain symptoms for some women. In general, getting regular exercise, eating a healthy diet, and taking care of your mental health are all things that play a big role in your overall wellbeing as you age.

Many women disregard their symptoms as a "normal" part of getting older or a "normal" experience during menopause, but it doesn't have to be this way! If you're experiencing something out of the ordinary to you, especially if it's causing discomfort, pain, or an overall reduction in your quality of life - please speak to your healthcare provider. 

For more information about managing menopausal symptoms and improving your quality of midlife, join the community at Lisa Health

Dr. Nanette Santoro is a leading clinician and researcher in Reproductive Endocrinology. She is currently Professor and E Stewart Taylor Chair of Obstetrics & Gynecology at the University of Colorado School of Medicine. She also directed the Division of Reproductive Endocrinology at 2 medical schools: New Jersey Medical School and the Albert Einstein College of Medicine. She is the author of over 120 scientific publications and two books. Dr. Santoro’s major research interests include the reproductive endocrinology of premature, peri-, and postmenopause, infertility, and the physiology of gonadotropin-releasing hormone secretion. She has been involved with numerous large-scale industry- and government-supported clinical trials, including the Study of Women’s Health Across the Nation (SWAN), the Kronos Early Estrogen Prevention Study (KEEPS), and the Reproductive Physiology of Ovarian Failure, and is a co-editor of the Textbook of Perimenopausal Gynecology. Dr. Santoro received her medical degree at Albany Medical College and completed her residency at Beth Israel Medical Center and fellowship at Massachusetts General Hospital, Harvard Medical School.

Dr. Ivy Lin is a resident physician at the University of Colorado. Her interests include infertility and obesity. Dr. Lin is currently a resident at the University of Colorado School of Medicine in the Department of Obstetrics and Gynecology. She received her medical degree from University of Iowa Carver College of Medicine where she graduated with a research distinction track award.

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