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Lovers Embrace
Education and treatment options for genitourinary syndrome of menopause, including hormone replacement therapy.

Genitourinary Syndrome of Menopause

“Hormone therapy remains the most effective treatment option available for the management of menopausal vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM).”

 

Endocrine Review, Vol. 42, 2021

What is Genitourinary Syndrome of Menopause (GSM)?

The genitourinary syndrome of menopause (GSM) is a relatively new term, first introduced in 2014 by a consensus of the International Society for the Study of Women's Sexual Health and the North American Menopause Society. GSM, previously known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy, is a term that describes the spectrum of changes caused by the lack of estrogens during menopause.

1) Angelou, K., Grigoriadis, T., Diakosavvas, M., Zacharakis, D., & Athanasiou, S. (2020). The genitourinary syndrome of menopause: an overview of the recent data. Cureus, 12(4).

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What causes GSM?

1) Maseroli, E., & Vignozzi, L. (2020). Testosterone and vaginal function. Sexual medicine reviews, 8(3), 379-392. 2) Traish, A. M., Vignozzi, L., Simon, J. A., Goldstein, I., & Kim, N. N. (2018). Role of androgens in female genitourinary tissue structure and function: implications in the genitourinary syndrome of menopause. Sexual Medicine Reviews, 6(4), 558-571. 3) Simon, J. A., Goldstein, I., Kim, N. N., Davis, S. R., Kellogg-Spadt, S., Lowenstein, L., ... & Vignozzi, L. (2018). The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review. Menopause, 25(7), 837-847.

Most of the symptoms of GSM are attributed to the lack of estrogen that characterizes menopause.  Low testosterone in women is emerging as an important contributing factor that should not be overlooked when considering how to best address GSM. “Preclinical and clinical data consistently suggest that testosterone plays an important role in maintaining vaginal health and genital sexual function.”1

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How common is GSM?

1) Angelou, K., Grigoriadis, T., Diakosavvas, M., Zacharakis, D., & Athanasiou, S. (2020). The genitourinary syndrome of menopause: an overview of the recent data. Cureus, 12(4). 2) Manson, MD, DrPH, professor, Harvard Medical School; chief, Division of Preventive Medicine, Brigham and Women’s Hospital, Boston. (https://endocrinenews.endocrine.org/underdiagnosed-undertreated-mysteries-genitourinary-syndrome-menopause/) 3) Marino, J. M. (2021). Genitourinary syndrome of menopause. Journal of Midwifery & Women's Health, 66(6), 729-739.

As the name implies, genitourinary syndrome of menopause (GSM) tends to affect perimenopausal and postmenopausal women as a result of declining hormone levels.  50-70% of postmenopausal women report symptoms related to GSM. 

However, "GSM remains extremely underdiagnosed despite its high prevalence, mostly because of the reluctance among women to seek help due to embarrassment, or as a result of a tendency among many women to consider it as a normal feature of natural aging."1

“Women may just not be comfortable talking about the fact that sexual activities are painful for them. People are often embarrassed to bring up subjects like that.”2

We strive to provide a safe, confidential, and unrushed environment where you feel safe to discuss any of your concerns.

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Can GSM affect premenopausal women?

Yes.

 

"GSM-like symptoms [are] present in 15% of premenopausal women due to the hypoestrogenic state."

1) Gandhi, J., Chen, A., Dagur, G., Suh, Y., Smith, N., Cali, B., & Khan, S. A. (2016). Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. American journal of obstetrics and gynecology, 215(6), 704-711.

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Will GSM improve on its own with time?

Unfortunately, no.  

"Symptoms … are typically progressive and unlikely to resolve spontaneously, [and] may include, but are not limited to, vulvovaginal dryness, burning or irritation, dyspareunia (painful intercourse), or urinary symptoms of urgency, dysuria (painful urination) or recurrent urinary tract infection."

1) Phillips, N. A., & Bachmann, G. A. (2021). The genitourinary syndrome of menopause. Menopause, 28(5), 579-588.

How do you diagnose GSM?

1) Sachdev, P. (2022, April 28). Diagnosing Menopause. WebMD. https://www.webmd.com/menopause/diagnosing-menopause

While GSM is caused largely by low estrogen and testosterone, the diagnosis is made by considering your signs and symptoms.  Blood hormone levels may play a role at times, but there is no recommendation that treatment of GSM and menopausal symptoms be based on chasing a specific hormone level.  Treatment is tailored and adjusted based on addressing your symptoms.  We do our best to avoid costly and unnecessary hormone tests. 

"There is currently no proven role for blood testing regarding menopause except for tests to exclude medical causes of erratic menstrual periods other than menopause. Menopause is diagnosed based on the lack of menstrual periods for 12 months. The average age women in the U.S. stop having their periods is 51."1

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Signs and symptoms of GSM?

Genital                 

  • Vaginal dryness

  • Irritation/burning/itching

  • Leukorrhea

  • Thinning/graying pubic hair

  • Vaginal/pelvic pain and pressure

  • Vaginal vault prolapse

Sexual

  • Pain during intercourse

  • Reduced lubrication

  • Post-intercourse bleeding

  • Decreased arousal, orgasm, desire

  • Loss of libido, arousal

  • Problems with orgasm

Urinary                 

  • Dysuria

  • Urgency

  • Stress/urgency incontinence

  • Recurrent urinary tract infections

  • Urethral prolapse

  • Decrease blood flow to bladder

1) Angelou, K., Grigoriadis, T., Diakosavvas, M., Zacharakis, D., & Athanasiou, S. (2020). The genitourinary syndrome of menopause: an overview of the recent data. Cureus, 12(4).

Anatomical & Physiologic Changes

  • Loss of labial and vulval thickness

  • Decreased collagen, elasticity, and blood flow

  • Reduced vaginal discharge

  • Reduced pubic hair, subcutaneous fat of labia majora

  • Reduced labia minora and hymenal remnants

  • Decreased vaginal cells glucogen => change vaginal microbiome => increased pH          

  • Decreased pelvic floor strength and control

  • Dry and thin epithelium

  • Short and narrow vagina

  • Prolapse (vaginal vault, pelvic organs, urethral)

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How do you treat GSM?

1) Angelou, K., Grigoriadis, T., Diakosavvas, M., Zacharakis, D., & Athanasiou, S. (2020). The genitourinary syndrome of menopause: an overview of the recent data. Cureus, 12(4). 2) Flores, V. A., Pal, L., & Manson, J. E. (2021). Hormone therapy in menopause: concepts, controversies, and approach to treatment. Endocrine reviews, 42(6), 720-752. 3) Marino, J. M. (2021). Genitourinary syndrome of menopause. Journal of Midwifery & Women's Health, 66(6), 729-739.

Treatment options include:

"Hormonal therapy with estrogen products is generally considered the 'gold standard'."1

"HT remains the most effective treatment option available for the management of menopausal vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM)."2

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Why treat GSM?

1) JFaubion, S. S., Kingsberg, S. A., Clark, A. L., Kaunitz, A. M., Spadt, S. K., Larkin, L. C., ... & McClung, M. R. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 27(9), 976-992.

Symptoms of GSM can have a negative impact on quality of life.

 

The Vaginal Health: Insights, Views & Attitudes (VIVA) study surveyed 3,520 postmenopausal women.  They reported that GSM affected them in the following way:

  • Negative effect on their lives (80%)

  • Adverse effects on sexual intimacy (75%)

  • Feeling less sexual (68%)

  • Feeling old (36%)

  • Negative consequences on marriage/relationship (33%)

  • Negative effect on self-esteem (26%)

  • Lower quality of life (25%)

 

The Real Women’s Views of Treatment Options for Menopausal Vaginal Changes (REVIVE) study surveyed 3,046 women.  They reported that their vulvovaginal atrophy symptoms had the following effect:

  • Led to some loss of intimacy (85%)

  • Detracted from enjoyment of sex (59%)

  • Interfered with their relationship (47%)

  • Negatively affected sleep (29%)

  • Adversely affected general enjoyment of life (27%)

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