GSM - What Should You Know About It?

Vaginal atrophy or atrophic vaginitis is a condition in which vaginal walls become dry, thin and inflamed. It happens in response to persistently low levels of estrogen, usually after menopause. Vaginal atrophy not only leads to painful sex and other vaginal symptoms but also induces a wide variety of disturbing urinary symptoms, due to which experts have agreed to a more appropriate term for vaginal atrophy i.e. “genitourinary syndrome of menopause (GSM)." It has been estimated that approximately 50% women experience GSM after menopause but not all the women go for treatment because of embracement in discussing their symptoms.

Symptoms Of GSM

Following symptoms are usually experienced in moderate to severe GSM:

• Dry vagina
• Burning pain
• Vaginal discharge
• Itching in genitals
• Urination with burning sensation
• Frequent urinary tract infections
• Urinary urgency
• Urinary incontinence
• Discomfort during sex
• Slight bleeding after sex
• Reduced vaginal lubrication during sexual act
• Shrinkage and tightening of vaginal canal

Causes Of Genitourinary Syndrome Of Menopause

As discussed earlier, genitourinary syndrome of menopause (GSM) happens due to significant drop in the estrogen levels which reduces elasticity and lubrication of vagina and makes it more vulnerable to inflammation. In some women, the symptoms begin at a much younger age (long before the actual menopause), whereas some women will not suffer major change in the vaginal lubrication even after menopause.

Estrogen level are decreased due to:

• Post menopause
• Surgical menopause (menopause due to surgical removal of ovaries)
• Perimenopause
• Chemotherapy
• Radiotherapy of pelvic cancer
• Side effect of hormonal treatment of breast cancer

Risk Factors That Makes You More Susceptible To GSM?

Following are the factors that increases your risk of developing GSM:

• Minimum or no sexual activity: Engaging into sexual activities improves blood circulation and increases elasticity of vagina.
• Not having vaginal delivery: As per latest medical research, women who never gave vaginal births are more likely to develop GSM.
• Cigarette smoking: Smoking impairs the blood flow due to which vaginal tissues do not get sufficient oxygen. Besides this, smoking also reduces the effects of natural estrogens.

Complications Of GSM

Poorly managed GSM is associated with following complications:

• Urinary problems: Women with GSM experience urinary problems such as urinary urgency, urination with burning pain, urinary incontinence, and frequent urinary tract infections.
• Infections: GSM alters the acidic medium of vagina which makes it more vulnerable to develop infections i.e. vaginitis.

How To Diagnose GSM

• Pelvic examination

It involves physical examination of vagina, cervix, and external genitals. Doctor will also look for bulging in vaginal walls, an indication of pelvic organ prolapses.

• Acid balance test

It is done to detect the acid balance of vagina either by inserting a paper indicator strip or taking sample of vaginal fluids.

• Urine analysis

In case any urinary symptoms are experienced, a urine sample is taken for evaluation.

Treatment Of GSM

OTC Products:

Initially your doctor may suggest OTC products such as vaginal moisturizers (Vagisil Feminine Moisturizer, Replens) or water based lubricants (glycerin free K-Y Touch, Astroglide). If using condoms, avoid use of petroleum based products as it can break down the latex condoms.

Topical Estrogen:

When OTC products do not work, doctor may recommend topical estrogens, including:

• Vaginal estrogen ring

A flexible ring placed on upper part of vagina which releases uniform dose of estrogen and is replaced after every 3 months.

• Vaginal estrogen cream

It is directly applied inside vagina via applicator.

• Vaginal estrogen tablet

A tablet is inserted inside vagina via disposable applicator.

Systemic Estrogen:

It includes estrogen gels, patches, pills, and high dose rings. If uterus is not removed, progestin is given along with estrogen. Usually oral progesterone is preferred but combination of estrogen-progestin patches may also be given.

Those with breast cancer will have different treatment approach.

Self-management

Ask doctor before using herbal supplements as it is not approved by FDA and may lead to severe interactions with your medications. Frequent sexual activities will keep vagina healthy.

References

• Portman, D. J., & Gass, M. L. (2014). 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. Climacteric, 17(5), 557-563.
• Rahn, D. D., Carberry, C., Sanses, T. V., Mamik, M. M., Ward, R. M., Meriwether, K. V., ... & Murphy, M. (2014). Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstetrics and gynecology, 124(6), 1147.
• Palacios, S., Castelo-Branco, C., Currie, H., Mijatovic, V., Nappi, R. E., Simon, J., & Rees, M. (2015). Update on management of genitourinary syndrome of menopause: a practical guide. Maturitas, 82(3), 308-313.