madman
Super Moderator
Genitourinary syndrome of menopause (GSM) occurs in approximately 50% of menopausal women but is both underrecognized and undertreated despite numerous treatment options. Vaginal dryness, irritation, dyspareunia, urinary frequency, and urinary urgency are some of the more common symptoms that can have a negative effect on women’s lives and relationships. Treatment options can include over-the-counter moisturizers and lubricants that can be composed of water or silicone or have an oil base. However, women and health care providers need to be aware of the effects of excipients in these products so that the therapy does not cause vaginal irritation. US Food and Drug Administration (FDA)–approved treatment options include vaginally administered estrogen products as well as dehydroepiandrosterone (prasterone) and the selective estrogen receptor modulator ospemifene. The prescription options have proven efficacy and safety and can be considered for use by women with a history of cancer following collaboration with the oncologist. Despite the FDA warning that recommends vaginal lasers not be used for vaginal rejuvenation, vaginal lasers have also been used as a treatment for GSM, but studies on their safety are limited. This article reviews GSM, including its impact, diagnosis, and treatment.
INTRODUCTION
Menopause is the natural progression in a woman’s reproductive life when she outlives ovarian production of estrogen. The significant reduction in circulating estrogen has far-reaching effects throughout the body, including the brain, skin, hair, joints, and the genitourinary system. Vulvovaginal atrophy (VVA) refers to the changes in the genitals associated with a hypoestrogenic state but does not include the coinciding changes to the urinary system. Therefore, menopausal symptoms that affect the genitourinary tract are now referred to as the genitourinary syndrome of menopause (GSM). Symptoms include vulvovaginal dryness, burning, and irritation, which can lead to painful intercourse and difficulty reaching arousal and orgasm. In addition, women may also develop dysuria and urinary urgency and be at risk for recurrent urinary tract infections, vaginitis, and sexually transmitted infections.1 Unlike other bothersome symptoms of menopause such as hot flashes or mood changes, which usually lessen or resolve with time, GSM is progressive without treatment. Symptoms of GSM are common, affecting 27% to 84% of postmenopausal women, yet may be significantly undertreated with approximately 7% of those affected reporting use of prescribed therapies.1,2 This article reviews the etiology and treatment options for women with GSM, including over-the-counter options, prescriptions, and energy-based therapy.
*PATHOPHYSIOLOGY OF GSM
Most likely, the pathophysiology of GSM is due to a decrease in both estrogen and androgens. In addition to estrogen receptors, women have androgen receptors in the vulva and vagina, with a higher density of estrogen receptors in the vagina and more androgen receptors in the vulva.2 Not only are androgens necessary for the biosynthesis of estrogen but both estrogen and testosterone are necessary for vascular responsiveness and signaling pathways during sexual arousal.5
*HOW GSM AFFECTS WOMEN
*ASSESSMENT AND DIAGNOSIS OF GSM
*DIFFERENTIAL DIAGNOSES OF GENITOURINARY SYNDROME OF MENOPAUSE
OVER-THE-COUNTER TREATMENT OPTIONS
*Moisturizers and Lubricants
*Vitamins E and D
*Probiotics and the Vaginal Microbiome
PRESCRIPTION TREATMENTS FOR GENITOURINARY SYNDROME OF MENOPAUSE
*Vaginal Estrogen
*Safety of Vaginal Estrogen Products
*Dehydroepiandrosterone (Prasterone)
Dehydroepiandrosterone (DHEA), also known as prasterone (Intrarosa), is another medication available by prescription for the treatment of GSM. Prasterone is formulated as a daily vaginal insert and has been approved by the FDA for the treatment of moderate to severe dyspareunia in women. The metabolism of DHEA is unique in that it is metabolized by enzymes inside the vaginal mucosal cells into both estrogen and testosterone, a process that is referred to as intracrinology.28 The cell-specific small amounts of estrogen and testosterone are then able to act locally as paracrine agents in the vagina.5 Approximately 95% of the produced estrogen and androgen is then inactivated inside the cells and released in the blood for elimination, thereby avoiding hormone exposure to other tissues.29 Prasterone is also distinctive because it replaces not only vaginal estrogen but also testosterone.29 Studies have shown prasterone to be effective in treating dyspareunia and improving sexual dysfunction scores. The improvement in sexual dysfunction score is most likely due to the increased sensitivity of vaginal nerve fibers to the androgenic action.29 The effect of prasterone on the urinary system has not been studied, but it is suggested that because the effects are similar to estrogen, it may be helpful for the treatment of dysuria and recurrent urinary tract infections.30
*Testosterone
Currently, there are no FDA-approved testosterone formulations for women, and the only country that does regulate and authorize the use of testosterone for women is Australia. Although systemically administered testosterone is prescribed off-label for hypoactive sexual desire disorder in women, there are limited studies that have evaluated the use of systemic testosterone for the treatment of GSM. Androgens regulate the epithelium of the vagina and mucin production, which is important for lubrication and sexual response.32 However, there are limited data that address the safety and efficacy of testosterone cream for the treatment of GSM. A review of 6 clinical trials examined the safety of intravaginal testosterone used to treat VVA.33 The studies had between 10 and 80 participants.33 The review was unable to determine the effectiveness or safety of intravaginal testosterone because of the poor research study designs.33 Further research is needed to determine the role of testosterone in the treatment of GSM.
*SERM: Ospemifene
*Lidocaine
*Vaginal Laser Treatment
*ADDITIONAL TREATMENT OPTIONS
CONCLUSION
GSM is a common condition that can adversely affect the quality of life following menopause and is frequently undertreated. Following treatment, women report improved quality of life, comfort, and pain-free sexual play. These are attainable goals that health care providers can help women achieve. GSM diagnosis, treatment, and education can require a great deal of the health care provider’s time, but it is also rewarding to make such an important impact on a woman’s life.
INTRODUCTION
Menopause is the natural progression in a woman’s reproductive life when she outlives ovarian production of estrogen. The significant reduction in circulating estrogen has far-reaching effects throughout the body, including the brain, skin, hair, joints, and the genitourinary system. Vulvovaginal atrophy (VVA) refers to the changes in the genitals associated with a hypoestrogenic state but does not include the coinciding changes to the urinary system. Therefore, menopausal symptoms that affect the genitourinary tract are now referred to as the genitourinary syndrome of menopause (GSM). Symptoms include vulvovaginal dryness, burning, and irritation, which can lead to painful intercourse and difficulty reaching arousal and orgasm. In addition, women may also develop dysuria and urinary urgency and be at risk for recurrent urinary tract infections, vaginitis, and sexually transmitted infections.1 Unlike other bothersome symptoms of menopause such as hot flashes or mood changes, which usually lessen or resolve with time, GSM is progressive without treatment. Symptoms of GSM are common, affecting 27% to 84% of postmenopausal women, yet may be significantly undertreated with approximately 7% of those affected reporting use of prescribed therapies.1,2 This article reviews the etiology and treatment options for women with GSM, including over-the-counter options, prescriptions, and energy-based therapy.
*PATHOPHYSIOLOGY OF GSM
Most likely, the pathophysiology of GSM is due to a decrease in both estrogen and androgens. In addition to estrogen receptors, women have androgen receptors in the vulva and vagina, with a higher density of estrogen receptors in the vagina and more androgen receptors in the vulva.2 Not only are androgens necessary for the biosynthesis of estrogen but both estrogen and testosterone are necessary for vascular responsiveness and signaling pathways during sexual arousal.5
*HOW GSM AFFECTS WOMEN
*ASSESSMENT AND DIAGNOSIS OF GSM
*DIFFERENTIAL DIAGNOSES OF GENITOURINARY SYNDROME OF MENOPAUSE
OVER-THE-COUNTER TREATMENT OPTIONS
*Moisturizers and Lubricants
*Vitamins E and D
*Probiotics and the Vaginal Microbiome
PRESCRIPTION TREATMENTS FOR GENITOURINARY SYNDROME OF MENOPAUSE
*Vaginal Estrogen
*Safety of Vaginal Estrogen Products
*Dehydroepiandrosterone (Prasterone)
Dehydroepiandrosterone (DHEA), also known as prasterone (Intrarosa), is another medication available by prescription for the treatment of GSM. Prasterone is formulated as a daily vaginal insert and has been approved by the FDA for the treatment of moderate to severe dyspareunia in women. The metabolism of DHEA is unique in that it is metabolized by enzymes inside the vaginal mucosal cells into both estrogen and testosterone, a process that is referred to as intracrinology.28 The cell-specific small amounts of estrogen and testosterone are then able to act locally as paracrine agents in the vagina.5 Approximately 95% of the produced estrogen and androgen is then inactivated inside the cells and released in the blood for elimination, thereby avoiding hormone exposure to other tissues.29 Prasterone is also distinctive because it replaces not only vaginal estrogen but also testosterone.29 Studies have shown prasterone to be effective in treating dyspareunia and improving sexual dysfunction scores. The improvement in sexual dysfunction score is most likely due to the increased sensitivity of vaginal nerve fibers to the androgenic action.29 The effect of prasterone on the urinary system has not been studied, but it is suggested that because the effects are similar to estrogen, it may be helpful for the treatment of dysuria and recurrent urinary tract infections.30
*Testosterone
Currently, there are no FDA-approved testosterone formulations for women, and the only country that does regulate and authorize the use of testosterone for women is Australia. Although systemically administered testosterone is prescribed off-label for hypoactive sexual desire disorder in women, there are limited studies that have evaluated the use of systemic testosterone for the treatment of GSM. Androgens regulate the epithelium of the vagina and mucin production, which is important for lubrication and sexual response.32 However, there are limited data that address the safety and efficacy of testosterone cream for the treatment of GSM. A review of 6 clinical trials examined the safety of intravaginal testosterone used to treat VVA.33 The studies had between 10 and 80 participants.33 The review was unable to determine the effectiveness or safety of intravaginal testosterone because of the poor research study designs.33 Further research is needed to determine the role of testosterone in the treatment of GSM.
*SERM: Ospemifene
*Lidocaine
*Vaginal Laser Treatment
*ADDITIONAL TREATMENT OPTIONS
CONCLUSION
GSM is a common condition that can adversely affect the quality of life following menopause and is frequently undertreated. Following treatment, women report improved quality of life, comfort, and pain-free sexual play. These are attainable goals that health care providers can help women achieve. GSM diagnosis, treatment, and education can require a great deal of the health care provider’s time, but it is also rewarding to make such an important impact on a woman’s life.
