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.
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.
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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