GSM is defined as a constellation of genital, sexual, and urinary signs and symptoms associated with the decline of estrogen during menopause. This decline in estrogen causes significant changes to the labia, introitus, vagina, clitoris, bladder and urethra. When our ovaries stop making estrogen, the skin of these areas is affected. The skin gets thin, dry, irritated, and can tear easily. It loses its elasticity. The normal vaginal pH is 4.0 to 4.5 which is acidic; this acidic environment is protective. But with GSM, the vaginal microbiome changes as the vaginal pH changes, and you can be at an increased risk of developing infections. There is a decrease of lubrication and pain with intercourse.

These changes in microbiome affect the urethra and the bladder and can cause urinary symptoms of urgency, frequency, incontinence (leaking), and increase risk of complicated urinary tract infections (UTIs). A small percentage of postmenopausal women experience recurrent lower UTIs. The bacteria causing the bladder infection can go up the urinary tract and reach your kidneys. An elderly person who gets a UTI could present differently than a younger person with UTI (fever, pain and urgency). They can present with mental status changes and the infection can take time to be recognized. This infection can turn into sepsis, which can be fatal. Treating recurrent UTIs can lead to antibiotic resistance, which can also be serious. The goal after initial antibiotic treatment is to prevent recurring infections. Prevention, prevention, prevention — that is the key word!

Vulvovaginal atrophy is a component of GSM. The skin of the vulva, vagina and urethra gets thin, loses its color, its elasticity. The vaginal opening gets smaller and vaginal exams and intercourse can be painful. Patients can experience symptoms of dryness (not only during intercourse), itchiness, irritation. These symptoms are chronic, progressive, but can be reversed with the continuous use of topical vaginal estradiol. More on that below.

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Up to 50% of women are affected by GSM. These symptoms can take many years to develop, but there are some women that can develop the symptoms in perimenopause.

The term GSM is not perfect, it really refers to a low estrogen state. It can also be present in pre-menopausal states, when there is hormonal changes, like after childbirth, in lactating women, when using oral contraceptives, etc.

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Unlike vasomotor symptoms that may resolve over time, GSM symptoms are typically progressive, worsen over time, and persist indefinitely without treatment. So what can we do to prevent all of this?

Non prescription therapies: There are non-hormonal options that help with dryness and pain with intercourse: (1) Avoidance of triggers, (2) Over the counter vaginal moisturizers and vaginal lubricants. Their effects are short acting and won’t produce changes in the vaginal and vulvar skin. Long-lasting vaginal moisturizers create a barrier that traps moisture, but don’t promote permanent changes in the skin.

Prescription therapies: Low-dose vaginal estrogen has the most robust evidence base. It improves vulvovaginal dryness, dyspareunia (pain with intercourse, the most bothersome symptom), and reduces UTIs up to 50%. Estrogen restores vaginal blood flow, decreases vaginal pH, improves the thickness and elasticity of vulvovaginal tissues, and promotes good bacteria. It might take time for full efficacy, 2 or 3 months, so be patient. Consistency is key!

There are various formulations (tablets, creams, rings). They appear equally effective. Most frequently prescribed intravaginally 2-3 times per week.

Use of topical vaginal estrogens is very safe. They support the vaginal microbiome. The dose of topical estrogen is very low and it is not absorbed systemically. Even women using systemic (full body) estrogen therapy can use topical vaginal estrogen. They don’t add up. It is safe to use even in women who had had breast cancer because it does not absorb systemically. Topical vaginal estrogen is a lifelong treatment and should be non negotiable!

Vaginal dehydroepiandrosterone (DHEA/Prasterone): DHEA is a precursor of both estrogen and androgen. It has been approved as a daily vaginal suppository for the treatment of moderate to severe dyspareunia (pain with intercourse) due to vulvar atrophy and dryness and genitourinary symptom distress by 40-80%. 

Oral Ospemifene (Osphena): An oral agent to treat GSM. It is a SERM (an estrogen receptor agonist/antagonist) approved for the treatment of moderate to severe dyspareunia associated with vulvovaginal atrophy.  This is good for women who prefer oral treatment. It is taken daily.

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Sorry for the long post, but I am very passionate about this. This is such an important issue that can have a serious impact in women’s health and wellbeing.

Happy Bloom!