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Genitourinary Syndrome of Menopause

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Genitourinary Syndrome of Menopause CLINICAL Genitourinary syndrome of menopause Elizabeth Farrell AM Background enitourinary syndrome of oestrogen receptor alpha almost solely Genitourinary syndrome of menopause menopause (GSM) is a more active postmenopause. Testosterone (GSM) is the new term for vulvovaginal G accurate and inclusive term that receptors are concentrated mainly in atrophy (VVA). Oestrogen deficiency describes the multiple changes occurring the vulval tissues and less in the vagina, symptoms in the genitourinary tract in the external genitalia, pelvic floor whereas progesterone receptors are are bothersome in more than 50% of tissues, bladder and urethra, and the found only in the vagina and at the women, having an adverse impact sexual sequelae of loss of sexual function vulvovaginal epithelial junction. on quality of life, social activity and and libido, caused by hypoestrogenism The loss of oestrogen causes sexual relationships. GSM is a chronic during the menopause transition and anatomical and functional changes, and progressive syndrome that is postmenopause.1 These genitourinary leading to physical symptoms in all of underdiagnosed and undertreated. changes primarily occur in response to the genitourinary tissues (Box 1). The reduced oestrogen levels and ageing, and tissues lose collagen and elastin; have Objective do not settle with time. altered smooth muscle cell function; The aim of this article is to increase have a reduction in the number of blood Pathophysiology and vessels and increased connective tissue, knowledge and understanding of GSM, anatomical changes improving the ability of healthcare leading to thinning of the epithelium; professionals to discuss and obtain an Oestrogen receptors are present in the diminished blood flow; and reduced appropriate history sensitively, and treat vagina, vestibule of the vulva, urethra and elasticity. Thinning is also related to the accordingly. trigone of the bladder, and on autonomic change in the vaginal epithelial cells. and sensory neurons in the vagina and Premenopausally, the predominant cells Discussion vulva. The highest concentration of are intermediate and superficial, and there oestrogen receptors is in the vagina, with are few parabasal cells, whereas after GSM includes conditions of the vagina, vulva, pelvic floor tissues, urinary tract, and sexual dysfunction and loss of libido. Box 1. Anatomical and functional changes in the genitourinary tissues Many women are reluctant to report these symptoms to their healthcare professional • Loss of labial and vulval fullness for many reasons. • Contraction of labia majora and clitoral hood • Narrowing and stenosis of the introitus • Loss of hymenal remnants or reduced elasticity • Vaginal shortening and narrowing • Prolapse • Pelvic floor weakening • Vaginal epithelium dry and thin with petechiae • Loss of superficial cells and increase in parabasal cells • Loss of vaginal rugae • Inflamed vaginal tissues • Alkaline pH changes the vaginal microbiome with loss of Lactobacilli (vaginal pH >4.5) • Persistent or recurrent discharge with odour (not Candida in postmenopause) • Urethral meatal prominence and prolapse with thinning of the urethral epithelium • Touch perception altered either hypersensitive or decreased feeling • Loss of clitoral stimulation © The Royal Australian College of General Practitioners 2017 REPRINTED FROM AFP VOL.46, NO.7, JULY 2017 481 CLINICAL GENITOURINARY SYNDROME OF MENOPAUSE menopause, the number of parabasal their symptoms with loss of oestrogen at Second, the healthcare professional cells increase, and sometimes there is an menopause.4 may be embarrassed or reluctant to ask increase in intermediate cells and loss of The most bothersome symptoms appropriate questions (especially about superficial cells.2 reported were vaginal dryness and sexual function), dismiss the symptoms dyspareunia; some women have as part of normal ageing, or feel pressured Symptoms multiple symptoms, whereas others are for time. Healthcare professionals may GSM symptoms are manifestations asymptomatic. In the Women’s Health also be unaware of available treatments or of the changes that occur during Initiative Study, 60% of participants had their recommended doses, and may treat menopause and lead to complaints physical evidence of vaginal atrophy, but inadequately and in the short term.7 of vaginal dryness, loss of lubrication, only 10% declared they had symptoms. dyspareunia, vaginal wall prolapse, vaginal Estimations suggest that only 7% of Assessment bleeding and discharge. Vulval burning, women are treated.5 Many women were A careful history and examination should dryness, irritation or itching, and entry unaware that there were treatments be performed to identify bothersome dyspareunia with fissuring are some of available.6 Symptoms after surgical symptoms, their impact on quality of life the vulval symptoms. Urinary symptoms menopause, treatment for breast cancer and sexual function. Acknowledging that include recurrent urinary tract infections, and premature menopause are often more GSM symptoms are common is a useful urgency and urge incontinence, stress severe and debilitating. strategy to start the discussion. Being incontinence, dysuria, and voiding issues. Societal views about women’s sexuality proactive by asking questions specifically There may be loss of libido, dyspareunia at older ages are essentially negative, and or as part of a systematic review in on entry, within the vagina or deep in the sexual problems are often considered a sensitive, respectful and culturally pelvis, and sexual dysfunction of arousal to be part of normal ageing leading to appropriate manner, and asking open- and orgasm. Bleeding or spotting may many women not seeking help for their ended questions, may assist in gaining occur during or after intercourse. Risk symptoms. the woman’s trust to inform you of her factors for GSM are listed in Box 2. There is a disparity between the concerns and symptoms. number of women who experience The woman’s past history may Frequency of symptoms bothersome symptoms and those who are reveal risk factors predisposing her to Many studies have surveyed the treated. First, women are unwilling, shy or GSM. Her medical, surgical, menstrual, frequency, type of symptoms, and their embarrassed to discuss their symptoms gynaecological and obstetric histories may impact on health and quality of life. In the with their healthcare professional, be relevant to development of particular Melbourne Women’s Midlife Study, the especially if: symptoms and subsequent management. prevalence of vaginal dryness increased • the healthcare professional is young and Ask about vulval hygiene and the use of with age – 4% in early perimenopause, male possible irritants such as soap, bath gels, rising to 25% at one year postmenopause • the patient has had a previous powders, lubricants, condoms, panty and 47% three years after the negative experience with a healthcare liners or pads that could cause symptoms. menopause. The symptoms range from professional Identify and document the onset of mild, moderate to debilitating.3 Other • the patient regards her symptoms as a symptoms, their description, duration, studies have found that 50% of women natural part of ageing that she should how bothersome or distressing the aged 50–60 years report symptoms, ‘put up with’. symptoms are, and their impact on quality increasing to 72% in women aged older Women often wait for their healthcare of life. The patient’s psychosocial and than 70 years, but only 4% associated professional to ask the questions. sexual history should include the presence of a long-term or new partner, partner relationship, frequency of sexual activity, Box 2. Risk factors for genitourinary syndrome of menopause history of sexually transmissible infections • Menopause (STIs) and the effect of her symptoms on • Bilateral oophorectomy her sexual intimacy. • Premature ovarian failure Ask the woman’s permission and explain • Smoking how you will conduct the examination. • Alcohol abuse Some conditions of the vulva and vagina • Decreased sexual frequency or abstinence may be identified or excluded by the • Lack of a vaginal birth examination. Using Box 1 as a checklist will • Other causes of low oestrogen (eg postpartum period, hypothalamic amenorrhoea) help healthcare professionals to determine • Cancer treatments, including pelvic irradiation, chemotherapy and endocrine therapy the extent and severity of the changes. 482 REPRINTED FROM AFP VOL.46, NO.7, JULY 2017 © The Royal Australian College of General Practitioners 2017 GENITOURINARY SYNDROME OF MENOPAUSE CLINICAL Where there is introital narrowing, Personal lubricants and vaginal Box 3. Differential diagnosis visualisation of the vagina, cervix or vaginal moisturisers • Dermatological conditions of the vulva vault may require a very small or paediatric Lubricants and vaginal moisturisers are (eg lichen sclerosus or planus, eczema, speculum. Digital examination may elicit effective in relieving discomfort, friction and dermatitis, chronic vulvovaginitis) a narrowed introitus, especially of the pain with penetrative sex. Lubricants are • Vulvodynia, vaginismus posterior fourchette with reduced elasticity. used at the time of intercourse, whereas • Autoimmune disorders The pelvic floor muscles may be relaxed, vaginal moisturisers provide longer term • Malignancy tense and painful or in severe spasm relief. Lubricants can be water-based or • Chronic pelvic pain (vaginismus). The vaginal epithelium may silicone-based. Water-based
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