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Genitourinary Syndrome of Menopause (GSM) IUGA Workshop

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Genitourinary Syndrome of Menopause (GSM) IUGA Workshop Genitourinary Syndrome of Menopause (GSM) IUGA Workshop Linda Cardozo Professor of Urogynaecology King’s College Hospital, London Genitourinary Syndrome of Menopause (GSM) Linda Cardozo Disclosures: Atlantic Therapeutics, Boston Scientific, DEKA, Fotona, Merck GSM • Genitourinary Syndrome of Menopause (GSM) - Previously known as vulvovaginal / urogenital atrophy • Collection of signs and symptoms associated with a decrease in oestrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder • Symptoms include - Dryness - Burning - Irritation - Sexual symptoms of lack of lubrication, discomfort or pain, and impaired function - LUTS: urgency, dysuria and recurrent urinary tract infections Consensus on Vaginal Atrophy Terminology Portman & Gass 2014 Ageing Population • Life expectancy for women in Europe is 84yrs and natural age of menopause is 51yrs – 40% of life postmenopausal • In Jan 2019 there were 3800 million women worldwide of which 266 million were over 65 years United Nations Department of Economic and Social Affairs: Population Division • The proportion of >65 yrs will double from 7.8% to 14.7% between 2010 and 2040 • The number of older people will increase from 530 million in 2010 to 1.3 billion in 2040 US Census Bureau, 2010 Prevalence Postmenopausal women • 40% have symptoms of urogenital atrophy Bachmann 2000 • Vaginal dryness in 27 - 85% • Dyspareunia in 32 - 41% • Urinary tract infection (UTI) in 4 - 15% • 40% on systemic HRT have persistent vaginal dryness • Only a third seek help Johnston 2004 Nappi et al 2017 Views and Attitudes Towards Vaginal Health (VIVA) 3520 postmenopausal women, 55-65 yrs • 1578 (45%) experienced vaginal discomfort Of these: • 83% experienced vaginal dryness • 42% had pain during intercourse • 30% had involuntary urination • 27% experienced soreness • 26% suffered from itching • 14% described burning • 11% had pain when touching the vagina Nappi et al 2011 Prevalence • 747 women aged 40-55 • Vaginal atrophy was diagnosed in 36.8% • 19.2% of 40-45 year olds, 53.8% of 52-55 year olds • 64% reported vaginal dryness • 54.5% reported dyspareunia • Other common symptoms reported were itching, burning and dysuria • Most signs and symptoms showed an age related increase in frequency and intensity Cagnacci 2019 GSM: REVIVE Study European REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs 3768 Women • 50% suffered vaginal dryness in last month with an overall prevalence of 75 - 80% • 75% of women say that GSM interferes with their enjoyment of sexual intercourse • Despite this only 25% of British women are receiving treatment • Most common treatment was topical OTC preparations • Primary reason for not starting treatment was that their symptoms were not bothersome enough • Thoughts around the disadvantages of treatment differed from side effects to how messy preparations were and how much they cost Nappi et al 2017 Pathophysiology • Vagina and lower urinary tract have common embryological origin • Hypoestrogenism has both vulvovaginal and urological effects • Urogenital tissue receptors are dependent on endogenous oestrogen levels to maintain normal physiology • Number of receptors decrease in postmenopausal women but never disappear • In presence of exogenous oestrogen receptors can be replenished Gandhi et al 2016 Urogenital Ageing • Late manifestation of the menopause (>10 years after last menstrual period) • Incidence increases with age • Under recognised, inappropriately treated • May take long term replacement therapy (>1 year) to reverse the changes Urogenital changes after menopause Physiological changes Anatomical changes • Fewer blood vessels • Labia minora thin & • Reduced vaginal blood regress flow • Introitus retracts • Reduced collagen content • Hymenal carunculae • Decreased elastin involute • Decreased flexibility • Urethral meatus appears • Decreased vaginal tissue prominent relative to strength introitus • Diminished lubrication • Increased vaginal pH • Change in vaginal flora • Loss of lactobacilli Portman 2014 Genitourinary Syndrome of Menopause Symptoms Signs • Genital dryness • Decreased moisture • Decreased lubrication with sexual • Decreased elasticity activity • Labia minora resorption • Discomfort or pain with sexual • Pallor/erythema activity • Loss of vaginal rugae • Post-coital bleeding • Tissue fragility/fissures/petechiae • Decreased arousal, orgasm, • Urethral eversion or prolapse desire • Loss of hymenal remnants • Irritation /burning /itching of vulva • Prominence of urethral meatus or vagina • Introital retraction • Dysuria • Recurrent urinary tract infections • Urinary frequency/urgency Portman 2014 GSM Risk factors • Menopause (decreased ovarian function) • Premature menopause / ovarian failure • Surgical menopause - bilateral oophorectomy • Postpartum loss of placental oestrogen • Elevated prolactin level during lactation • Absence vaginal childbirth • Decreased frequency and abstinence sexual intercourse • Radiation • Chemotherapy • Autoimmune disorder • Cigarette smoking • Alcohol abuse • Lack of exercise Medication • Selective Oestrogen Re-uptake Modulators (SERMS) • Tamoxifen.. • Aromotase Inhibitors • Letrazole.. • Danazol • Medroxyprogesterone • GnRH analogues • Zoladex • Prostap LUT: Effect of Ageing Postmenopausal bladder changes • Capacity decreases • Compliance decreases • Post void residual increases • Glycosaminoglycan layer thins • Ability to initiate or suppress detrusor contractility impaired LUT: Effect of Ageing Postmenopausal urethral changes • Epithelium thins • Blood flow and vascular pulsations decrease • Total collagen reduced • α adrenergic receptors decrease • Slowing of nerve conduction time • Urethral support impaired by degenerative changes in elastic connective tissue Effect of ageing Vaginal Cytology Pre-menopausal Post-menopausal LUT: Effect of Ageing Postmenopausal physiological changes • Cardiac function impaired (nocturia) • Neurological disorders (incontinence) • Diabetes (frequency) • Mobility impaired (incontinence) • Drugs which affect lower urinary tract function Urogenital Ageing Conclusions • GSM replaces the old terminology of vulvovaginal or urogenital atrophy • GSM is common in postmenopausal women but can occur in peri-menopausal and post-partum women, the prevalence increases with age • The most common presenting symptom is vaginal dryness followed by vaginal discomfort and then LUTS • Symptom aetiology is multifactorial but is associated with decreased oestrogen and change in vaginal microbiome • GSM has a hugely negative impact on womens health related quality of life UKCS 2019.
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