What is genitourinary syndrome of menopause?

Menopause is a natural part of the aging process that signals the end of a woman’s reproductive years.

Because of declining hormone levels, women can experience a host of symptoms, such as hot flashes, mood swings, sleep issues and brain fog.

Other symptoms experienced in menopause — such as vaginal dryness, urinary urgency and painful intercourse — are part of a condition called genitourinary syndrome of menopause.

We spoke to Leanne Zilar, CNM, ARNP, with MultiCare Rockwood Clinic; Terry Silvestrin, ARNP, with MultiCare Women’s Health in Tacoma; and Catherine Hunter, DO, with MultiCare Virtual Women’s Health Services, to understand this condition and the most effective treatments that can help with symptoms.

What causes genitourinary syndrome of menopause?

Zilar: Genitourinary syndrome of menopause (GSM) is a chronic condition that used to be known as vaginal atrophy; however, the term was expanded to be more encompassing and cover both vaginal and urinary symptoms.

When you go through menopause, your ovaries stop making estrogen. The vagina, urethra and bladder are all made up of estrogen-dependent tissue that gets thin, dry and more fragile when estrogen is no longer present.

Silvestrin: Symptoms may include vaginal dryness, pain with intercourse, burning, difficulty getting lubricated, as well as urinary urgency, pain with urinating and urinary retention. It can be itchy and uncomfortable at the opening to the vagina or in the vagina. It can cause avoidance of sex and lack of desire because it’s painful.

As the bladder becomes less elastic, it can retain urine, become irritated and lead to urinary tract infections. It’s important to continue doing Kegel and pelvic floor exercises during menopause to keep these muscles in shape and help prevent urine from leaking or being retained.

Zilar: Because of the urinary frequency, some women believe drinking less water will alleviate their symptoms since they would be peeing less, but it actually makes the condition worse.

And, unfortunately, it’s common for women to be overtreated with antibiotics for recurring bladder or urinary tract infections when these infections are not the underlying cause.

Tips for good bladder health

• Drink plenty of water
• Use the bathroom often (don’t hold it)
• Give yourself time to relax when using the toilet
• Take deep breaths
• Make sure you’re sitting, not hovering — you can’t relax your muscles when engaging legs
• Wipe front to back
• Use baby wipes to help clean the entire area
• Urinate after sex
• Wear loose-fitting clothes and cotton underwear
• Keep a healthy weight
• Quit smoking — it increases risk of bladder cancer
• Avoid constipation — it puts stress on the pelvic floor, increases UTI symptoms and can lead to UTIs
• If you get up to urinate in the night, stop drinking water by 6pm (except to take medications)

What treatments are available?

Silvestrin: Over-the-counter solutions for vaginal dryness include moisturizers like Replens or vaginal lubricants like KY or Slippery Stuff (made in Puyallup, Washington).

But if moisturizers or lubricants aren’t working to alleviate symptoms, a prescription for vaginal estrogen may be a solution.

Zilar: The most common type of vaginal estrogen we prescribe is an ultra-low-dose cream that’s applied topically.

When women hear “estrogen,” they are worried about the risk of breast cancer, heart attack or stroke. Topical estrogen, however, is not absorbed systemically (through the bloodstream), so there is no increased risk of these conditions.

This treatment is very safe and increases stretchability of the tissues that help keep women from getting yeast, vaginal and urinary tract infections. It helps decrease the frequency of urinating and improves dryness.

Dr. Hunter: The tissues that make up the genitourinary anatomy are estrogen-receptor-rich and respond best to estrogen therapy. Estrogen also preserves the three layers of the vagina and can decrease inflammatory markers.

Estrogen also preserves the vaginal biome (organisms that keep the vagina healthy) and the proper pH, decreasing vaginal and urinary tract infection rates, which are more common in untreated menopausal women.

Are there different types of vaginal estrogen?

Silvestrin: Yes, there are several types of vaginal estrogens available:

• Cream: Estrogen cream is applied topically twice a week. It’s most valuable in the first three months of having symptoms. It helps build up tissue and provides lubrication/moisture to alleviate pain and return tissue flexibility.
• Tablet: A small estrogen tablet is deposited with a pen dispenser into the vagina twice a week.
• Ring: Estrogen is delivered in pulses via a plastic ring in the vagina over a 90-day period. The ring is not recommended if your pelvic floor muscles are weak.
• Suppository: Estrogen is delivered in the form of a vaginal suppository. It’s a weaker estrogen, so it requires daily use.

Is it necessary to be seen by a provider for genitourinary syndrome of menopause?

Silvestrin: I know it can be difficult to talk about these types of symptoms, but it shouldn’t be something you’re embarrassed about. If you’re experiencing any of the symptoms discussed here, I encourage you to have an open dialogue with your women’s health care provider. If symptoms persist or get worse, they may refer you to see a urogynecologist (physicians who specialize in pelvic floor disorders).

Dr. Hunter: Only about one-third of women report the symptoms of GSM or talk with their provider regarding these problems. GSM affects 27-84 percent of postmenopausal women, so the impact is extensive.

GSM symptoms create adverse effects on quality of life, including sexual interest or performance, difficulties in relationships or marriage, and lower self-esteem, which leads to a loss of intimacy and detracts from enjoyment of sex and other activities.

It will be important for both patients and doctors to facilitate a better discussion regarding these issues. These are common symptoms and women should be encouraged to discuss them, as there are clear improvements with multiple therapies.

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