Patients with the genitourinary syndrome of menopause (GSM) often suffer in silence, said Melissa A. McNeil, MD, MPH, MACP.
“For so many of our patients, it's just perceived as ‘the way it is. This is what happens when you get older,’” she said during her talk at Internal Medicine Meeting 2023.
There are many symptoms of GSM (previously known as vulvovaginal atrophy), including vaginal dryness, painful sex, urinary burning and dysuria, urinary incontinence, and vaginal discharge. Unlike vasomotor symptoms, which tend to improve as women age, these symptoms become worse and worse with time from menopause, Dr. McNeil said.
As a clinical diagnosis with several effective treatments, GSM is within the internal medicine physician's broad domain, according to Dr. McNeil, who is a professor of medicine and clinician educator at the Warren Alpert Medical School of Brown University in Providence, R.I.
But too often, clinicians don't ask about GSM symptoms, she said. “We are seeing lots of vaginal complaints, but we may or may not hear about them,” Dr. McNeil said. “The symptoms are common, affecting anywhere between 27% and 84% of postmenopausal women, depending on what study you look at, and frankly, depending on whether you ask or not.”
While GSM is common, it's also undertreated, she noted. In a survey of about 4,250 women ages 55 to 65 years, 63% of those who had experienced vaginal atrophy had never been prescribed treatment for the condition, according to results published in September 2010 by Maturitas.
In addition, about one-third of women had never spoken with anyone about their symptoms, and one-third preferred that the clinician start the discussion of vaginal discomfort, noted Dr. McNeil, adding that some women may doubt the medical profession's ability to manage GSM.
“I can be standing in the checkout at my local grocery store, and I'll see a very nice, middle-aged woman having a conversation with the checkout clerk about what GNC products to buy for their menopausal symptoms,” she said. “And you'd think we can do better than this, right? We can literally do better than this.”
Dr. McNeil reviewed the history and physical exam for diagnosis of GSM and outlined safe and effective treatments within the scope of practice of internal medicine.
Making the diagnosis
Since women often do not report GSM symptoms, clinicians must ask about them, including urinary symptoms like itching and burning (frequently misdiagnosed as urinary tract infections) and sexual dysfunction, Dr. McNeil said. “For some of us, the vagina feels a little scary down there, but these are the complaints that women come in with,” she said.
This is a crucial task for internal medicine physicians because as women get older and enter menopause, they may no longer go to gynecology for routine care, Dr. McNeil noted. “Many of the patients we see don't have a gynecologist that helps them manage their symptoms, so these things actually really are presenting more and more commonly in primary care,” she said.
GSM symptoms are common, and “The older you get, the more likely you are to have the symptoms,” Dr. McNeil said. In one study that surveyed 3,500 postmenopausal women, 45% reported experiencing vaginal symptoms, according to results published in October 2013 by Menopause.
The symptoms also have significant effects on sexual health and quality of life. In 500 U.S. women in this study, those with symptoms reported a negative effect on their lives (80%), adverse effects on sexual intimacy (75%), feeling less sexual (68%), and feeling old (35%), “which is, you know, awful,” she said. One-quarter or more also reported negative consequences on their marriage/relationship, self-esteem, and quality of life.
Sexual difficulties in those with GSM are not surprising due to the anatomy and physiology of the vaginal environment after estrogen loss, Dr. McNeil said. The vagina narrows and shortens, fluid secretion during sexual activity decreases, vaginal elasticity decreases, the vaginal lining becomes thin and dry, and there is decreased blood flow to vaginal tissues, she explained.
But a diagnosis of GSM requires more than just the presence of symptoms. “It requires symptoms that are bothersome. … If it doesn't bother her, it's not going to bother me, no matter what the vagina looks like,” Dr. McNeil said.
For bothersome symptoms, treatments can target the specific concern (e.g., sex life, quality of life). But even if they're not bothersome enough to warrant treatment, Dr. McNeil said she warns the patient that the symptoms might worsen with age and that she should return if they become a burden.
The diagnosis also requires physical exam findings. “You have to look. … We've gotten to this place now where because we don't recommend the annual internal exam and because we stop doing Pap smears at 65, we're not looking,” Dr. McNeil said.
Often, a clinician doesn't have to look very hard to detect GSM, she added. “You may or may not need a speculum exam, although we would certainly recommend it, but you've got to look,” said Dr. McNeil, adding that she recommends using a small, well-lubricated speculum because “The exam itself can be very traumatic for women.”
Signs to look for include reduced soft tissue, such as the mons pubis, labia majora, and labia minora, she said. “The urethra … gets really prominent and red, because all the surrounding tissue around it just sort of atrophies,” said Dr. McNeil, adding that the vaginal surface will appear friable upon speculum exam. “You put the speculum in, and you see blood right away.”
Don't worry about ordering labs when making this clinical diagnosis. “I will, however, say that women remain sexually active and present with vaginal discharge, so you're in the differential of a more traditional infectious vaginitis versus atrophic vaginitis,” she said. “So the pH can be helpful. Women with GSM, the vaginal pH is generally greater than 5.0, and the reason is because they lose the Lactobacillus. The whole flora becomes abnormal.”
Other differential diagnoses include allergy/contact dermatitis, lichen sclerosis, erosive lichen planus, desquamative inflammatory vaginitis, and pelvic pain syndromes. An etiology other than GSM is more likely in patients with chronic or recurrent symptoms that presented before menopause, Dr. McNeil noted.
“If your symptoms came before your estrogen levels dropped, it is unlikely that these symptoms are going to be completely related to GSM,” she said. “They may be worse, but the best you can hope for is to get them back to where they were before the menopause.”
Safe, effective treatments
The primary goal of treatment is to relieve symptoms. Since GSM is, as Dr. McNeil put it, “a relentless progression to the Sahara in a woman's vagina,” treatments aim to restore moisture.
Clinicians can generally approach treatment in a stepwise fashion. First-line nonhormonal therapies for less severe symptoms include vulvar and vaginal lubricants for isolated dryness with sex and long-acting vaginal moisturizers, she said.
“The lubricants are just to make you slippery with sex,” Dr. McNeil said. “The moisturizers are like hand cream for the vagina: If you stop using hand cream, your hands get dry again, right? If you stop using your vaginal moisturizer, then your vagina gets dry again. So they have to be used multiple times a week.”
Vaginal lubricants are water-, oil-, or silicone-based and are used by one or both partners to decrease discomfort caused by friction during sexual intercourse, she noted. “Regular use has been studied, and it's associated with an increase in pleasure and ease of orgasm, and really decreased pain. … These can be very effective, especially for women early in the menopause whose vaginas are not super dry but are just not able to increase the lubrication during the act of sex,” Dr. McNeil said.
A 2020 position statement on GSM by the North American Menopause Society has a table of name-brand nonhormonal treatments for dyspareunia secondary to GSM, she noted. “But I want you to remember, there are a lot of homeopathic products that you can use: olive oil, coconut oil.”
Vaginal moisturizers, on the other hand, not only facilitate comfortable sexual activity but also help reduce daily symptoms when used two or three times per week, Dr. McNeil said. “I tend to use moisturizers for women either for whom lubricants don't work during sex, so they need to start with a better vagina and then add the lubricant—you can use them both together—or the woman who is just itchy down there all the time and kind of miserable,” she said.
While there aren't a lot of data available, one randomized controlled trial that looked at placebo versus moisturizer versus vaginal estrogen found that all arms (including placebo) had improvement, according to results published in May 2018 by JAMA Internal Medicine. “But the thought in this setting was that the placebo gel likely had lubricating properties,” Dr. McNeil said. “So again, moisturizers work, and they can work for a lot of women. … Vaginal estrogen is more powerful, but you don't necessarily have to go there first.”
To help treat the shrinking of the vagina after menopause, try counseling the patient to have more sex, she advised. “It's a ‘use it or lose it’ phenomenon, so you've got to keep that vagina active,” said Dr. McNeil, adding that vaginal stretching can occur in other ways if the patient is not sexually active or if intercourse is too painful. Regular, gentle vaginal stretching by inserting a finger or dilator can help, as can pelvic floor physical therapy, she noted.
Put together, these first-line treatments can ease GSM symptoms. “So it's multimodal: You make it more slippery, you make it more moist, and you stretch it out,” Dr. McNeil said.
Of the prescription vaginal therapies, low-dose vaginal estrogen is the safest option for women whose symptoms are limited to the vagina, she said. It's most often used to treat dyspareunia and vaginal dryness. “All of the approved products have proven efficacy compared to placebo. … The difference between the products is side effects and patient tolerance,” Dr. McNeil said.
Available formulations of vaginal estrogen products include creams, inserts, and a vaginal ring. Dr. McNeil said her preferred preparation is the ring because it lasts for 90 days and controls the dosing, although it can be expensive. “It can be up to $300, depending on your insurance,” she said, adding that the insert also allows for controlled dosing (in contrast to creams, which have a higher likelihood of overdose).
Vaginal estrogen can also improve urge incontinence, Dr. McNeil noted. “The relative risk of symptoms, it goes down by 25%,” she said. Systemic estrogen, on the other hand, may worsen urinary incontinence, Dr. McNeil said, “So incontinence is never an indication for systemic hormone therapy.”
As for the safety of vaginal estrogen therapy, rates of cardiovascular disease, endometrial cancer, and breast cancer were no different than in controls in several trials with one-year follow-up, she noted. “Vaginal estrogen is so safe and so effective for so many things,” Dr. McNeil said, adding that there are virtually no contraindications except for in patients with undiagnosed vaginal bleeding and those with estrogen-dependent cancers.
However, all estrogen products (including vaginal estrogen) have a package insert stating they can cause cardiovascular disease, endometrial cancer, and breast cancer, she noted. “So [when] I prescribe it, I tell them, ‘This is what the package insert's going to say,’ and I tell them the package insert's wrong. … You absolutely should lead with that, because without counseling, the boxed warning will scare them off,” Dr. McNeil said.
Systemic estrogen therapy is most helpful in GSM treatment when vasomotor symptoms like hot flashes are also present, she noted, although it can take a while for it to work on the vagina. “If I have women who are really uncomfortable with their hot flashes and vaginal symptoms, I will start both [vaginal and systemic estrogen] at the same time,” Dr. McNeil said. “Sometimes we can back off of it, sometimes not, but they each have their place in the treatment of the menopausal woman.”
Finally, therapy should continue with appropriate clinical follow-up for as long as bothersome symptoms are present, Dr. McNeil said. Patients generally see improvement in symptoms within a couple of weeks and take up to 12 weeks to see maximum benefit, she said.
GSM treatment may well last a lifetime, Dr. McNeil noted. “Some women, if they stop being sexually active, they decide they don't need it or they don't want it,” she said. “But again, if you stop it, the symptoms will come back.”