Dr Louise Newson provides 10 top tips on managing vaginal dryness and genitourinary syndrome of the menopause in primary care
Read this article to learn more about:
- why practitioners should consider using the term genitourinary syndrome of the menopause (GSM) to describe all the symptoms that result from a decrease in oestrogen levels
- asking the right questions during a consultation with a patient with vaginal dryness symptoms
- which treatments are best suited to managing the symptoms of GSM.
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V aginal dryness is a common condition, more so than most people realise. Although vaginal dryness can affect women of all ages, it is particularly common in menopausal and postmenopausal women, and can have a very negative impact on a woman's quality of life as well as her sexuality.1 This article will primarily focus on vaginal dryness as a symptom of the menopause. NICE Guideline (NG) 23 on Menopause: diagnosis and management gives clear recommendations as to the optimal treatment for vaginal dryness in menopausal and postmenopausal women, which will be covered in this article.2
1 Get the terminology right
For both clinicians and women, the many terms used to describe the symptoms and conditions associated with the menopause can be confusing. Many people use the term vaginal dryness, but this is not adequate in defining all the different symptoms that can occur from reduced levels of oestrogen. The term vulvovaginal atrophy (VVA) (or atrophic vaginitis) has been used for many years to describe the collection of symptoms that can arise due to vaginal dryness, but it does not encompass the urinary symptoms that frequently occur in people with VVA. Following a terminology consensus conference involving the International Society for the Study of Women's Sexual Health and the North American Menopause Society, it was concluded that the term genitourinary syndrome of the menopause (GSM) is: 'a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy.' It is defined as a 'collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder'; see Box 1 below.3
Box 1: Terminology
- Genitourinary syndrome of the menopause (GSM)—encompasses all menopausal symptoms related to the urinary tract in addition to the genital tract
- Atrophic vaginitis and vulvovaginal atrophy (VVA)—both terms are commonly used (often interchangably) to describe the symptoms and signs associated with decreased oestrogenisation of the vulvovaginal tissues; however, VVA usually relates to the signs found on clinical examination
- Vaginal dryness—the most common symptom caused by GSM.
Because GSM is a relatively new term, it is not yet widely used in general practice; however, this article will use the term GSM.
2 Know the changes in the genital and urinary tracts caused by GSM
Genitourinary syndrome of the menopause is caused by the reduction in oestrogen production that occurs during the menopause.4 The female genital and urinary tracts both arise from the urogenital sinus and are both sensitive to the effects of female sex steroid hormones.
Oestrogen receptors are present in the vagina, urethra, bladder trigone, and pelvic floor—clearly oestrogen has an important role in these areas. As oestrogen levels decrease:
- the vaginal mucosa becomes drier, thinner, less elastic, and more fragile
- there is a reduction in the volume of vaginal secretions
- there is a decrease in production of glycogen from the vaginal epithelium—this is associated with an increase in vaginal pH,5 which consequently increases the risk of infections such as bacterial vaginosis and thrush.
Interestingly, one study demonstrated that less than half (40%) of postmenopausal women consider their symptoms of vaginal dryness to be related to their menopause.6 Women receiving treatment for breast cancer, such as aromatase inhibitors, and women who have received chemotherapy, surgery and/or radiotherapy for certain types of malignancies are at high risk of developing GSM.7,8
Practitioners should be aware that not all women with signs of GSM are symptomatic; a study in the United States demonstrated that only around 10% of women with physical evidence of vulvovaginal atrophy on clinical examination exhibit moderate to severe symptoms. Symptoms of discomfort or pain do not arise in all women with signs of vulvovaginal atrophy.9
3 Don't underestimate the prevalence of vaginal dryness
Vaginal dryness and GSM are extremely common, with some studies showing prevalence figures as high as 80% in postmenopausal women;10 however, figures are generally estimates as many women do not present with, or talk openly about, their symptoms so the actual true prevalence is likely to be even higher. Genitourinary syndrome of the menopause can also occur in young women; around 15% of premenopausal women experience symptoms of the condition.11 Although many other menopausal symptoms (e.g. hot flushes, tiredness, and low mood) improve with time, symptoms of GSM get worse with age for many women.12
4 Understand why GSM is under diagnosed and under treated
Genitourinary syndrome of the menopause is under diagnosed and under treated. There are many reasons for this, but embarrassment, lack of understanding, reluctance to seek medical advice, and poor communication between healthcare professionals and women are all likely to be major factors.13,14 Due to the sensitive nature of GSM, many women are embarrassed to talk openly about their symptoms and often delay seeking medical advice.8 An Italian study showed that the vast majority of women (81%) admitted to never having voluntarily disclosed their symptoms to their healthcare professional.10 Too often women simply accept that their symptoms are attributable to the ageing process and do not realise that simple and effective treatments are available.15 Some women attempt to self-medicate, which can lead to them using products that cause irritation or worsening of their symptoms. In the author's experience, many women do not realise that effective hormonal and non-hormonal treatments, many of which can be acquired without prescription, are available to them. Women who are aware of hormonal treatments are often unnecessarily worried about their use.7
If GSM is not optimally managed, then the symptoms will typically either persist or worsen with time. Compliance with treatment is often an issue; some women think that the treatments are too messy or inconvenient to use, whereas other women needlessly worry about a perceived increase in the risk of cancer when using topical oestrogen.6
5 Ask the right questions
A correct diagnosis of GSM is not being made for a huge proportion of women because they are not being asked appropriate questions during consultations with their practitioner.15,16 It is inadequate to only ask the patient if she is having difficulties during sexual intercourse, as there are many women who are not sexually active but have symptoms of vaginal dryness that adversely affect the quality of their lives. It is important to ask sensitive, but direct questions about any vaginal symptoms women might be experiencing, including itching, soreness, irritation, and any burning sensations; see Box 2, below. Women who present with urinary symptoms such as increased urinary frequency should also be asked if they have any local vaginal symptoms. If the right questions are asked, in the right clinical setting, then women are more likely to be open about their symptoms.
Box 2: Questions to consider asking during a consultation
- Have you noticed any vaginal dryness or less vaginal discharge than you used to have?
- Have you experienced any vaginal soreness, burning, or irritation?
- Do you have any itching around your vagina or vulval area?
- Is sexual intercourse painful or uncomfortable?
- Have you noticed changes in any vaginal discharge (either increased or reduced)?
- Have you noticed any urinary symptoms such as increased urinary frequency or being less able to hold on to urine?
- Do you have any discomfort on passing urine?
6 Recognise the main symptoms of GSM
The most common symptom of GSM is usually vaginal dryness, which can lead to dyspareunia. Other symptoms can include vaginal irritation and itching, which can interfere with sleep, general enjoyment of life, and mood. Symptoms can be worse in women who smoke17 and those who do not have frequent sexual intercourse.18
Symptomatic vaginal atrophy can occur in younger women due to hypothalamic amenorrhoea, hyperprolactinaemia, and lactation. Conditions such as chronic heart failure, diabetes, inflammatory bowel disease, and multiple sclerosis can also be a cause of vaginal dryness. In addition, stress can reduce the amount of moisture in the vagina.
Some medications, such as antihistamines, decongestants, and some anti-depressants, can cause vaginal dryness as a side-effect.
7 Explain the safety of treatment with topical oestrogen
Topical oestrogens are very safe and can be used by most women with GSM.19 As highlighted in NG23, topical oestrogens are effective at improving both short-term and long-term outcomes in most women with GSM, and adverse effects are very rare.2 The only absolute contraindications are active breast cancer and undiagnosed vaginal bleeding. Since the systemic absorption of oestrogen from recommended doses of topical oestrogens is very small (i.e. approximately 1 year's supply of topical therapy contains the same dose as taking a single tablet of oral hormone replacement therapy [HRT]), it is unlikely to be associated with the adverse effects reported with the use of systemic HRT.2 Therefore, menopause experts advise that women should be reassured about the content of the patient information leaflets of topical oestrogen, as these highlight safety issues related to the use of systemic HRT. In addition, as studies show there is unlikely to be an effect on the endometrium when using topical oestrogens, additional progestogens are not necessary for these women.2,20
Maximum benefit with these products is usually achieved after around 1–3 months but it can take up to 1 year in some women. Treatment with topical oestrogen should be continued for as long as needed to relieve symptoms as symptoms will often return after treatment is stopped.2 NICE NG23 recommends that if vaginal oestrogen does not relieve symptoms then the dose can be increased after seeking advice from a healthcare professional with expertise in menopause.2
8 Systemic HRT improves GSM symptoms in the majority of women with other menopausal symptoms
Systemic HRT can be very effective when given to women with other symptoms of the menopause (or perimenopause) in addition to symptoms of GSM.21 Systemic oestrogen restores normal vaginal pH levels, thickens and revascularises the epithelium, and also increases vaginal lubrication;22 however, around 10–25% of women who take systemic HRT will have urogenital symptoms that persist.23 These women can safely be given vaginal local oestrogen in addition to taking HRT.2
9 Recommend use of moisturisers and lubricants
There are many different vaginal moisturisers and lubricants available for women, and these are effective at improving local symptoms. For women who cannot, or choose not to use topical oestrogens, both of these products can make a significant positive difference to the quality of their lives. The pH and osmolality of moisturisers and lubricants should be taken into consideration, as some products can have a high pH, which can increase the risk of vaginal infections such as bacterial vaginosis and thrush. Some products with a high osmolality can actually make vaginal dryness worse. Moisturisers need to be used regularly, either alone or in conjunction with topical oestrogens. Lubricants are recommended prior to sexual intercourse and do not need to be used on a regular basis. Women should be advised to choose a product that is balanced in terms of both osmolality and pH, and that is physiologically most similar to natural vaginal secretions.15 Various moisturisers and lubricants are available as a prescription; over-the-counter medication is also available from chemists or the Internet.
10 Consider alternative treatments
There are some alternative treatments for women who cannot, or choose not to use hormones. Specialised physiotherapy involving vaginal dilators can be of benefit for some women. Treating GSM symptoms with a fractional CO2 laser is both effective and safe; the laser is well tolerated and has been shown to increase thickness of the squamous epithelium and improve vascularity of the vagina.24 There is increasing evidence that shows the benefits of the oral medication ospemifene, an oestrogen agonist/antagonist.25 Ospemifene does not appear to have any negative effects on the endometrium or any association with an increased risk of thromboembolism.26
|Now Test and Reflect: view our multiple choice questions|
written by Dr David Jenner, GP, Cullompton, Devon
- Genitourinary syndrome of the menopause is a common problem in older women, but is often inadequately diagnosed and managed
- In most cases, GSM can easily be managed in primary care and local management guidelines published on a website and/or app would help support this. These guidelines could include:
- a printable information sheet for patients
- a list of recommended, local formulary-approved treatments
- clear contraindications to topical oestrogens
- indications for onward referral to specialists services
- Specialist community-based nurse advisors should be considered to help support patients and practices. These nurse advisors could be recruited from any pre-existing bladder and bowel services.
GSM=genitourinary syndrome of the menopause
- Nappi R, Lachowsky M. Menopause and sexuality: prevalence of symptoms and impact on quality of life. Maturitas 2009; 63: 138–141.
- NICE. Menopause: diagnosis and management. NICE Guideline 23. NICE, 2015. Available at: www.nice.org.uk/ng23
- Portman D, Gass M, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause 2014; 21 (10): 1063–1068.
- Calleja-Agius J, Brincat M. Urogenital atrophy. Climacteric 2009; 12: 279–285.
- MacBride M, Rhodes D, Shuster L. Vulvovaginal atrophy. Mayo Clin Proc 2010; 85: 87–94.
- Nappi R, Palacios S, Panay N et al. Vulvar and vaginal atrophy in four European countries: evidence from the European REVIVE Survey. Climacteric 2016; 19 (2): 188–197.
- Sadovsky R, Basson R, Krychman M et al. Cancer and sexual problems. J Sex Med 2010; 7: 349–373.
- Lester J, Pahouja G, Andersen B, Lustberg M. Atrophic vaginitis in breast cancer survivors: a difficult survivorship issue. J Pers Med 2015; 5 (2): 50–66.
- Gass M, Cochrane B, Larson J et al. Patterns and predictors of sexual activity among women in the hormone therapy trials of the Women’s Health Initiative. Menopause 2011; 18: 1160–1171.
- Palma F, Della Vecchia E, Cagnacci A; as the Writing Group of the AGATA study. Medical and patient attitude towards vaginal atrophy: the AGATA study. Climacteric 2016; 13: 1–5.
- Palacios S. Managing urogenital atrophy.Maturitas 2009; 63 (4): 315–318.
- Cagnacci A, Carbone M, Palma F; AGATA study. Prevalence and association between objective signs and subjective symptoms of vaginal atrophy: the AGATA study. Menopause 2016; 23 (10): 1139–1145.
- Kingsberg S, Wysocki S, Magnus L, Krychman M. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med 2013; 10: 1790–1799.
- Gandhi J, Chen A, Dagur G et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynecol 2016; 215 (6): 704–711.
- Edwards D, Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? Climacteric 2016; 19 (2): 151–161.
- Nappi R, Kokot-Kierepa M. Vaginal health: insights, views & attitudes (VIVA)—results from an international survey. Climacteric 2012; 15 (1): 36–44.
- Milsom I, Arvidsson L, Ekelund P et al. Factors influencing vaginal cytology, pH and bacterial flora in elderly women. Acta Obstet Gynecol Scand 1993; 72 (4): 286–291.
- Bachmann G, Leiblum S. Sexuality in sexagenarian women. Maturitas 1991; 13: 43–50
- Baber R, Panay N, Fenton A; IMS Writing Group. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016; 19 (2): 109–150.
- Rahn D, Carberry C, Sanses T et al. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol 2014; 124 (6): 1147–1156.
- North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013; 20: 888–902.
- Sturdee D, Panay N. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric 2010; 13: 509–522.
- Barnabei V, Cochrane B, Aragaki A et al. Menopausal symptoms and treatmentrelated effects of estrogen and progestin in the Women’s Health Initiative. Obstet Gynecol 2005; 105 (5 Pt 1): 1063–1073.
- Sokol E, Karram M. An assessment of the safety and efficacy of a fractional CO2 laser system for the treatment of vulvovaginal atrophy. Menopause 2016; 23 (10): 1102–1107.
- McLendon A, Clinard V, Woodis C. Ospemifene for the treatment of vulvovaginal atrophy and dyspareunia in postmenopausal women. Pharmacotherapy 2014; 34 (10): 1050–1060.
- Del Pup L. Ospemifene: a safe treatment of vaginal atrophy. Eur Rev Med Pharmacol Sci 2016; 20 (18): 3934–3944. G