Genitourinary Syndrome of Menopause

We know how hard it is to figure out what is going on with your body in perimenopause. We’ve had little to no education, and unfortunately most of us don’t have a menopause expert as part of our healthcare team. So we’ve created ‘what you need to know’ posts to help you better understand the symptoms and medical conditions associated with the menopause experience. Our first post is about genitourinary syndrome of menopause.

Genitourinary Syndrome of Menopause

Genitourinary Syndrome of Menopause (GSM) is a medical condition associated with menopause, both pre and post. Formerly known as vaginal atrophy, or atrophic vaginitis, GSM is a collection of symptoms influenced by declining levels of estrogen in the vulva, vagina, urethra, and bladder.

GSM is a relatively new term that better describes all of the tissues that can be affected by a loss of estrogen as opposed to the term vaginal atrophy, which implies only the vagina is affected.

Why Do You Need to know?

It’s hard to sleep, work, have sex, be present and enjoy life when your vagina, vulva, urethra and/or bladder are ‘on fire’, in pain, and/or just not working as they once did and should. Most doctors will not proactively ask about these types of symptoms. And while this can be an uncomfortable topic to broach with your medical provider, it is important to do so as there are solutions to alleviate the symptoms associated with GSM.

Treatment of GSM Symptoms is Important

Living with pain and discomfort and withdrawing from life’s pleasures, like sex, is not normal and wholly unnecessary. These symptoms can appear early in perimenopause and unlike some of the other symptoms associated with achieving menopause, these do not get better over time without treatment.

The more proactive you are, the better.

Reversing these changes is a lot harder than preventing them from happening in the first place, especially if they are ignored for a long time.

The more proactive you are, the better.

GSM Symptoms Can Include:

  • Vaginal dryness
  • Vaginal itching
  • Vaginal burning
  • Vaginal discharge
  • Change in vaginal odor
  • Vaginal infections
  • Thinning of the vaginal lining (vaginal atrophy)
  • Pain with sex
  • Decreased lubrication with sexual activity
  • Light bleeding with intercourse
  • Vulvar dryness
  • Vulvar itching
  • Vulvar burning
  • Vulvar skin changes or thinning
  • Urinary tract infections (UTIs)
  • Burning with urination
  • Urinary urgency and/or frequency
  • Urinary incontinence (or leakage)

While urinary incontinence is included in most GSU symptom lists, it’s important to mention that symptoms like leaking urine are also related to aging and other factors than menopause.

Similarly, some people can experience changes in the size and shape of their vaginal and vulvar tissues, including a reduction of erectile tissue in the clitoris making it harder for some to achieve orgasm. Whether these tissue changes are due to aging or decreased estrogen is still not properly understood.

Not Just Bothersome Symptoms

There are other conditions, like lichen sclerosus, that can mirror the symptoms of GSM. It is important to see a knowledgeable practitioner as this kind of autoimmune skin condition increases the risk of vulvar cancer and requires different treatment. A tell-tale sign of lichen sclerosus that is not part of GSM is patches of skin on the vulva turn white and become fragile.

Vaginal and vulvar symptoms can be harmful to sexual health and relationships, and can impact your long-term vaginal and vulvar health. They can also impact your quality of life and well-being. It is estimated that 85% of women will experience GSM symptoms.

Symptom Relief

Most of us don’t get the care we need. The reasons are many and range from being uncomfortable talking with your doctor about sex or trying to explain what part of your vulva feels like it’s on fire, to having your doctor misdiagnose or dismiss your concerns.

Let’s be very clear: you do not need to just ‘put up’ with these symptoms, particularly as they won’t just resolve on their own. There are treatments that can help.

Treatment Options

Depending on the severity of your symptoms your doctor may suggest over-the-counter options like vaginal/vulvar moisturizers or lubricants, or perhaps changing up your care routine and using a gentle facial cleanser instead of soap for cleaning.

It is really important to be honest about the level of pain and discomfort you are experiencing. A physical exam may not make apparent what you are experiencing. You need to be direct. If your symptoms are keeping you up at night, tell your doctor. Becoming anxious about peeing? Tell your doctor. If the thought of sex makes you wince, tell your doctor.

Hormonal Therapy

For more severe symptoms your doctor may recommend hormonal therapy. Topical or vaginal estrogen is considered one of the best ways to improve symptoms of GSM. Your doctor can provide recommendations regarding dosage and method of application as there are several options available.

DHEA is also a hormonal option and comes as a daily suppository.

If you are experiencing other symptoms like hot flashes, your doctor may recommend oral or systemic estrogen, provided your medical history does not preclude you from this type of treatment. Some people end up on both systemic and vaginal/local estrogen to treat their symptoms.

Non-hormonal Medication

Ospemifene (Osphena) is a daily medication taken by mouth. It is a selective estrogen receptor modulator (SERM).  These drugs activate or block the estrogen receptors in certain areas of the body and not others, which can make them safer than estrogen options depending on the patient.

Lasers and Radio Frequency Devices

These have been around for some time, but there still isn’t conclusive evidence on their effectiveness. We are keeping an eye on these, and hope that research is undertaken to determine if these machines can in fact increase blood flow and improve tissue health.

Call to Action

See your doctor at least once a year to set a baseline and be able to monitor any changes to your health. It is always important to discuss symptoms with your doctor, not only to get the appropriate support and solutions, but also to rule out other medical conditions that can mirror the signs and symptoms of perimenopause and postmenopause.

Don't be a boiling frog.Some information we’ve read implies that GSM generally occurs postmenopause. While the data available show that most will experience symptoms postmenopause, you can indeed experience GSM in perimenopause. This is important as your doctor may rule out GSM due to your age. Particularly if your periods are regular and you aren’t experiencing hot flashes.

Symptoms can come on suddenly or build gradually. The latter can make a person less likely to seek treatment as they continually and slowly adjust to symptoms that become increasingly uncomfortable and painful.  Don’t be a boiling frog.

The Hero Bit

If talking about your vulva and vagina feels embarrassing, write down your symptoms and share your notes with your doctor. Providing your doctor with the diagram below and indicating the areas where you are having trouble by circling in red or just pointing to the diagram can also be helpful.

If you need some additional motivation, check out this post: Dear, Vulva. An Apology.

Vulva Diagram