Understanding GSM: What Every Woman Needs to Know About Genitourinary Syndrome of Menopause

 In this episode, I'm talking about something I see all the time in my practice but that too many women still suffer through in silence: Genitourinary Syndrome of Menopause (GSM). This condition shows up in women as estrogen levels decline, most commonly during and after menopause.

If you've been dealing with vaginal dryness, itching, pain with intercourse, or repeated urinary tract infections, you're not alone, and it may be GSM.

I walk you through the updated guidelines from the American Urologic Association (AUA) and the American Urogynecologic Society (AUGS) for diagnosing and treating GSM. We talk about what symptoms to look for and the full range of treatment options, including hormonal and non-hormonal therapies, so you can make informed decisions that work for you.

In this episode, I also cover:

• Why follow-up care is just as important as starting treatment
• How shared decision-making with your provider changes outcomes
• What research still needs to catch up when it comes to cost and access

If you've ever wondered if your symptoms are "just aging" or felt unsure about what's normal after menopause, this episode is for you. My goal is to empower you with information and make sure you know you're not alone.

For more information on this study: https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause

Timeline:

00:30 Introduction to Genital Urinary Syndrome of Menopause 

01:25 Understanding the Symptoms and Diagnosis 

03:15 Guidelines for Treatment 

06:09 Hormonal Treatments and Recommendations 

07:43 Non-Hormonal Treatments and Considerations 

08:49 Energy-Based Treatments and Their Efficacy 

10:36 Cancer Concerns and Hormonal Treatments 

13:14 Follow-Up and Long-Term Management 

14:04 Conclusion and Future Research

Transcript

Hi there. I've had a lot of episodes where I've talked about vaginal estrogen, but today I wanna take a step back and talk about genital urinary syndrome of menopause. This is a term that we've had medically since 2014 before we called it atrophy, and it really describes the spectrum of bladder and vaginal symptoms that happen.

When there's less estrogen or no estrogen in the body, this most frequently happens at the time of menopause. But there are other times where this can happen, like when you're breastfeeding or with certain medications, there's no consensus about how many symptoms or how severe the symptoms have to be for this diagnosis.

And there are no specific things that need to be seen on physical exam. The most common symptoms in this syndrome are vaginal dryness, itching, burning, pain with intercourse and bladder frequency, bladder urgency, bladder burning, and recurrent urinary tract infection. Recently, the American Urologic Association, the Society of Urodynamics and Female Pelvic Medicine and Urogenital Reconstruction, and S, which is the American Urogynecologic Society, got together and created guidelines on how to treat.

Genital urinary syndrome of menopause. So these are the big three guiding bodies in in what I do, and it's not really that common that they all get together to provide guidelines, but these guidelines are what we use to treat. They reviewed all of the studies with a systematic review, and then they provided recommendations as well as grading to show how good a recommendation is.

They focused on eight patient-centered outcomes, and these outcomes were felt to be the most important to patients and to clinicians. So these outcomes were one, painless sex, two vaginal dryness, three vaginal discomfort and irritation. Four, pain with peeing. Five. Change in the most bothersome symptom.

Six. Bother of genital urinary symptoms. Seven. Satisfaction in treatment, and eight side effects with the diagnosis. These guidelines are endorsed by the Menopause Society and the International Society on Women's Sexual Health as well. So the guidelines start by saying that there should always be shared clinical decision making.

So this only makes sense that the decision should be made with the physician and with the patient as well, and that the decision should weigh evidence as well as the patient's values, preferences, and goals. So this means that you will pick different treatments for different patients depending on what they want to do and what is acceptable to them.

So the next thing they said was that clinicians should screen all patients at risk for general urinary syndrome of medicine. And this is really screening all women who are around 50 plus or minus 10 years, as well as younger women who are having symptoms. And that the screening should take place with a history, right, where you're really just talking to someone about their symptoms.

27 to 84% of women who are after menopause have this syndrome. I. If you have symptoms, then you should have a pelvic exam to examine you to look for other things that might be causing these symptoms. Right? These symptoms are somewhat vague. There's a lot of overlap with other syndromes, with infections, vaginal infections, bladder infections, stones.

There are, there are different things that can cause these similar symptoms. So you should have a pelvic exam. And then clinicians should spend time educating patients on how the symptoms are because of a decrease in hormones. This isn't something that people think about a lot. A lot of times we just assume that during menopause you have, um, hot flashes and we don't realize that there are all of these other symptoms and how estrogen very profoundly affects the bladder and the va.

In all of this, clinicians should also evaluate for other coexisting genital urinary conditions, so urinary incontinence, prolapse, infections, et cetera. And that is because of what I just said, that there is a big overlap between different conditions and so you wanna make sure that you have the diagnosis correct.

Then if there are psychosocial concerns, you should refer to a counselor or a therapist. You should also consider referring to a pelvic floor therapist if there are concerns about the pelvic floor muscles being either too weak or too tight. So those guidelines are general guidelines. They're considered best practice.

They make complete sense. They're not controversial at all. The next set of recommendations. They categorized with a strong recommendation, moderate, conditional, or expert opinion, and then they graded the evidence level as A, B, or C with a being the best level of evidence. So when it comes to hormonal treatment, symptoms of vul, vaginal discomfort and irritation, dryness and pain with intercourse should be treated or can be treated with vaginal estrogen.

And this is a strong recommendation, but the evidence level is c. And there have been significant improvements seen with these symptoms on vaginal estrogen. There isn't enough data to compare the different forms of estrogen, and so this includes all types of vaginal estrogen, whether it's a cream, a pill, a suppository, or the ring.

If, if you have these symptoms and you have recurrent urinary tract infections. Low dose vaginal estrogen reduces urinary tract infections, and so it should be used in this situation as well. And this is a moderate recommendation, and the level of evidence is B, but we think that when you use vaginal estrogen, it decreases your chance of a urinary tract infection by about 50%.

So there are other medications that can be used besides vaginal estrogen, and so if you're someone that's having vaginal dryness or pain with sex, you can also use vaginal DHEA, which is a precursor to testosterone and estrogen. Or you can use Emine, which is a selective estrogen receptor modulator. It mimics estrogen in the vaginal tissues, but not in other tissues.

These are both moderate recommendations with an evidence level of C. So there are non-hormonal treatments as well, and you can use vaginal moisturizers or lubricants, and this is a moderate recommendation level evidence C as well. There's no evidence that alternative supplements work and. Things that irritate the tissues.

I mean, I think this only makes sense, should be avoided. So you should avoid v vaginal irritants, cleaners, anything that makes the symptoms worse. So for some people this can be sweat, it can be urine, it can be stool. There are certain soaps and cleansers that can make things better. There are spermicides.

Pads, liners, douches, all kinds of things. And these are frequently things that people use thinking that they're improving their symptoms, but they actually make it worse. So this requires a little bit of a homework on your part, seeing what you're doing, and seeing if it's actually making it better or making it worse.

There are energy-based treatments that have been recommended to improve these symptoms to improve the health of both the vulva and the vagina. The energy-based treatments that we've looked at include laser treatments as well as radio frequency treatments, and there is no evidence that these treatments help with dryness, discomfort.

Pain with urination, quality of life change and bothersome symptoms, pain with intercourse or satisfaction with treatment. And this is actually a, a moderate recommendation with level evidence. C. These treatments have also been shown to be really low in side effects. I mean, they are really safe, but there isn't evidence that they have been helpful.

There is an expert opinion showing that using shared decision making, right? So as a clinician, I'm talking to a, a patient. There may be times when someone is not a candidate for other treatments that you could consider using these, these treatments. So using radio frequency, using the laser. Even if it's not as part of a clinical trial.

So there's some thought that these treatments may work in specific situations, and so they are still being studied to see if there are certain situations or certain patients that these treatments can help. But if it's something that someone wants to try, they're not a candidate for other treatments, they need to know about this evidence.

So that they can make an informed decision because these treatments are frequently very expensive and they should know that it may not help, but it, it should not hurt either. So in these guidelines, they also addressed breast cancer and endometrial cancer. So we put a lot of patients on vaginal estrogen, and this is always a concern that people have.

So their, their first recommendation is that clinicians should inform patients that there is no evidence linking low dose vaginal estrogen to developing breast cancer. This is an expert opinion recommendation, but there is evidence to back it up, and this is also true for DHEA or the AINE patients who are afraid of developing breast cancer.

It is completely fine. It does not increase your risk of breast cancer if you use vaginal estrogen or these other hormonal treatments. Patients who have had a breast cancer, right? So you, you personally have had a breast cancer, not a family history of breast cancer. You can also recommend vaginal estrogen, so that very low dose vaginal estrogen does not change the risk.

In someone who has had breast cancer. So it's not gonna make you have a recurrence, it's just not gonna affect your breast cancer treatment. So this is something that requires a big discussion. Patients have to be comfortable with this. Even if you understand this information, you may not be comfortable using vaginal estrogen.

So this is something that requires a lot of shared decision making, and this too is expert opinion. Low dose vaginal estrogen, DHEA, asperine do not increase the risk of endometrial hyperplasia or atypia or endometrial cancer. So these are all cancers and pre-cancerous of the uterus. Uterine cancer is frequently.

Modulated by estrogen, but when we use the low dose vaginal estrogen, it, it does not increase the risk of the cancer or pre-cancer. And this is a moderate level recommendation with grade C level of evidence. You also don't have to do routine surveillance for endometrial cancer, right? So this would be, um, routine biopsies or routine ultrasounds, but if someone has symptoms, and the most common symptom would be vaginal bleeding after menopause, that absolutely has to be evaluated.

It has to be evaluated in everyone. But if you're on vaginal estrogen, it should be evaluated as well. Then the, the last recommendation that came about was that patients need to come back. There needs to be follow up, so you need to reassess to see if the treatment is working, and so you cannot just put someone on vaginal estrogen and then not double check on their symptoms and see if something needs to be adjusted or addressed.

Some patients may need to be on estrogen long term, and then they need to continue to follow up. So some patients will be on vaginal estrogen for the rest of their lives. Some patients stop the vaginal estrogen and that's fine. And then if they develop symptoms again, they can always restart it. But it is important to know how this medication can impact your system so that you can make decisions that work for you.

So that is a synopsis of the current recommendations for genital urinary syndrome of menopause. And again, these guidelines were created by three medical groups, AOGs, SUFU, and a UA. So there's big consensus in the medical community. I think a lot of these recommendations are common sense. You should know that this is what the medical bodies are endorsing at this point in time.

There's also a lot of work that needs to be done. They acknowledge this in their guidelines, so we still need to do additional research to determine if one treatment works better than others for specific symptoms. We need to determine optimal dosing and scheduling. We frequently recommend estrogen, vaginal, estrogen twice weekly.

Is that the best? Is that the best for all conditions? We need to determine exactly how these treatments impact bladder symptoms versus vaginal symptoms. Then the other thing is cost to patients. So some of these treatments can be very expensive. Even the vaginal estrogen can be very expensive. So there's a lot of additional work that needs to be done.

But if you're someone who is having these symptoms, burning, itching, pain with intercourse, pain with urination. Those are definitely things that should be evaluated. There are lots of medical conditions that can cause this, but a drop in estrogen can absolutely cause these symptoms as well. So just some additional education and things for you to think about.