New Classification
for Menopause Symptoms
When a woman goes through menopause, her estrogen levels
decrease along with the levels of other steroid hormones. These decreases can
lead to changes in certain areas of her body, like the vagina, vulva, and
bladder.
For example, estrogen helps keep the vagina moist and
flexible. But when estrogen levels decline, the vagina can become dry and
tight.
These hormonal drops can lead to a group of genital and
urinary symptoms that are called genitourinary syndrome of menopause (GSM).
GSM is thought to affect about half of postmenopausal
women. Symptoms include:
• Dryness, burning sensations, and irritation in the
genital area
• Poor vaginal lubrication during sex, discomfort or pain
with intercourse, and impaired sexual function
• An urgent need to urinate, painful urination, or
recurrent urinary tract infections (UTIs)
Women do not need to have all of the symptoms to be
diagnosed with GSM. But the symptoms are bothersome and are not caused by
another medical condition, such as an infection or allergy.
GSM is chronic and progressive. It does not get better
over time. However, symptoms can be managed with treatment.
Genitourinary syndrome of menopause is a fairly new term.
It was developed in 2014 by experts from the International Society for the
Study of Women’s Sexual Health (ISSWSH) and the North American Menopause
Society (NAMS). They felt that the term encompassed the genital, sexual, and
urinary symptoms related to estrogen decline in ways that previous terms did
not.
Neither of the previously used terms fail to describe the
menopausal symptoms is adequately, the panel and its consultants agreed.
Vulvovaginal atrophy refers to the appearance of the vulva and vagina
postmenopause, but it does not describe symptoms. Atrophic vaginitis suggests
inflammation or infection, which are pathological and not typically present.
Neither term covers urinary symptoms.
Older terms may also make patients feel uncomfortable.
"Atrophy" suggests wasting away, and many people will not say
"vagina." The authors compare use of GSM to the term erectile
dysfunction replacing the emotionally charged "impotence" and having
to say "penis."
GSM can include any or all signs and symptoms, which must
be attributed to menopause and not another cause, such as infection, allergy,
skin conditions, pelvic floor muscle dysfunction, cystitis, or pudendal
neuralgia.
So, GSM is now defined as a collection of symptoms and
signs associated with a decrease in estrogen and other sex steroids involving
the changes to the labia majora/minora, clitoris, vestibule/introitus, vagina,
urethra and bladder. These physical signs may include anatomic changes (ex/
thinning of the vulvar and/or vaginal tissue, a thin and smaller labia majora,
a narrowed introitus- vaginal opening). The physiological changes result in
reduced vaginal blood flow, diminished lubrication, decreased elasticity of the
vaginal wall, an increased vaginal pH and decreased vaginal flora with loss of
lactobacilli. The syndrome can include, but is not exclusively limited to
genital symptoms of dryness, burning and irritation, fissuring of vulvar
tissue, and bleeding after sex; sexual symptoms of decreased lubrication,
discomfort or pain with vulvovaginal touch/penetration, and impaired
arousal/orgasm functions; and urinary symptoms of urgency, dysuria and
recurrent urinary tract infections. Women with GSM can present with some or
even all of the signs and symptoms which must be bothersome to indicate the
diagnosis and without some other diagnosis that accounts for the symptoms.
The conference concluded that GSM is more accurate,
inclusive, and less embarrassing than the older terms. In addition to easing
conversations, the new term will be used to develop a tool to help standardize
physical examinations so that women can take advantage of treatments such as
vaginal moisturizers, vaginal estrogen, and estrogen mimics.
How Prevalent Is
GSM?
Approximately half of all postmenopausal women in the
United States report atrophy-related symptoms and a significant negative effect
on quality of life. However, very few women with these symptoms seek medical
attention.
The Vaginal Health: Insights, Views, and Attitudes (VIVA)
survey found that 80% of women with genital atrophy considered its impact on
their lives to be negative, 75% reported negative consequences in their sexual
life, 68% reported that it made them feel less sexual, 33% reported negative
effects on their marriage or relationship, and 26% reported a negative impact
on their self-esteem.
Another review of the impact of this condition by Nappi
and Palacios estimated that, by the year 2025, there will be 1.1 billion women
worldwide older than age 50 with specific needs related to GSM. Nappi and
Palacios cite 4 recent surveys that suggest that health care providers need to
be more proactive in helping patients disclose their symptoms. The same can be
said of other symptoms of the urinary tract, such as urinary frequency,
urgency, and incontinence, as well as pelvic floor relaxation.
A recently published international survey on vaginal
atrophy not only depicts the extremely high prevalence of the condition but
also describes fairly significant differences in attitudes toward symptoms
between countries in Europe and North America.9 Overall, 77% of respondents,
who included more than 4,000 menopausal women, believed that women were
uncomfortable discussing symptoms of vaginal atrophy.
Pastore and colleagues, using data from the Women’s
Health Initiative (WHI), found the most prevalent urogenital symptoms to be
vaginal dryness (27%), vaginal irritation or itching (18.6%), vaginal discharge
(11.1%), and dysuria (5.2%).4 Unlike vasomotor symptoms of menopause, which
tend to decrease over time, GSM does not spontaneously remit and commonly
recurs when hormone therapy—the dominant treatment—is withdrawn.
Treatment
Approaches
While not the full remedy, but nevertheless not-medicated
and not intrusive, lifestyle changes can help to minimize some of the
unpleasant symptoms, like vaginal irritation:
✓ Wear cotton underwear and avoid tight-fitting underwear
or garments that cause sweating
✓ Use fragrance-free or low-allergenic washing products
✓ Avoid products and activities that may irritate or dry
the skin
In 2013, the North American Menopause Society (NAMS)
issued a position statement noting that the choice of therapy for genitourinary
syndrome of menopause (GSM) depends on the severity of symptoms, the efficacy
and safety of therapy for the individual patient, and patient preference.
To date, estrogen therapy is the most effective treatment
for moderate to severe GSM, although a direct comparison of estrogen and
ospemifene is lacking. Nonhormonal therapies available without a prescription
provide sufficient relief for most women with mild symptoms. When low-dose
estrogen is administered locally, a progestin is not indicated for women
without a uterus—and generally is not indicated for women with an intact
uterus. However, endometrial safety has not been studied in clinical trials
beyond 1 year. Data are insufficient to confirm the safety of local estrogen in
women with breast cancer.
Ospemifene
This estrogen agonist and antagonist selectively stimulates
or inhibits estrogen receptors of different target tissues, making it a
selective estrogen receptor modulator (SERM). In a study involving 826
postmenopausal women randomly allocated to 30 mg or 60 mg of ospemifene, the
60-mg dose proved to be more effective for improving vulvovaginal atrophy.
Long-term safety studies revealed that ospemifene 60 mg given daily for 52
weeks was well tolerated and not associated with any endometrial- or
breast-related safety issues.13,14 Common adverse effects of ospemifene
reported during clinical trials included hot flashes, vaginal discharge, muscle
spasms, general discharge, and excessive sweating.
Vaginal lubricants
and moisturizers
Nonestrogen water- or silicone-based vaginal lubricants
and moisturizers may alleviate vaginal symptoms related to menopause. These
products may be particularly helpful for women who do not wish to use hormone
therapies.
Vaginal lubricants are intended to relieve friction and
dyspareunia related to vaginal dryness during intercourse, with the ultimate
goal of trapping moisture and providing long-term relief of vaginal dryness.
Although data are limited on the efficacy of these
products, prospective studies have demonstrated that vaginal moisturizers
improve vaginal dryness, pH balance, and elasticity and reduce vaginal itching,
irritation, and dyspareunia.
Data are insufficient to support the use of herbal
remedies or soy products for the treatment of vaginal symptoms.
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