What are the symptoms and treatment options for Genitourinary Syndrome of Menopause (GSM)?

Symptoms and Treatment Options for Genitourinary Syndrome of Menopause (GSM)

Symptoms of GSM

Genitourinary Syndrome of Menopause (GSM) is characterized by vaginal dryness, discomfort, burning, itching, dyspareunia, urinary tract infections, urgency, and other urogenital symptoms that progressively worsen over time without treatment. 1, 2

Vaginal Symptoms

• Vaginal dryness affects approximately 50% of postmenopausal women 1, 3
• Burning and itching sensations in the vaginal area 1, 4
• Discomfort and pain during sexual intercourse (dyspareunia) 1, 2
• Vaginal discharge 1
• Decreased vaginal lubrication during sexual activity 3
• Unlike vasomotor symptoms which tend to resolve over time, GSM symptoms persist indefinitely and often worsen without treatment 1

Urinary Symptoms

• Increased susceptibility to urinary tract infections 1, 3
• Urinary urgency and frequency 1, 4
• Dysuria (painful urination) 4
• Nocturia (frequent urination at night) 5
• Urinary incontinence 5

Sexual Function Impact

• Decreased libido and sexual desire 3
• Pain during sexual activity (dyspareunia) 1, 2
• Difficulty achieving orgasm 3
• Reduced sexual satisfaction 3

Treatment Options for GSM

Non-Hormonal Treatments (First-Line)

• Regular use of vaginal moisturizers is recommended as first-line therapy for daily maintenance of vaginal health and symptom relief. 1, 2
• Water-based or silicone-based lubricants should be used during sexual activity to reduce friction and discomfort 1, 3
• Hyaluronic acid preparations can help prevent vaginal mucosal inflammation, dryness, and fibrosis 1, 2
• Topical vitamin D or E may provide some symptom relief 1
• Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, and satisfaction 1, 3
• Vaginal dilators may benefit women with pain during intercourse or vaginal stenosis 1

Hormonal Treatments (Second-Line)

• Low-dose vaginal estrogen therapy is the most effective treatment for GSM when non-hormonal options fail, available in creams, tablets, and rings with minimal systemic absorption. 1, 2
• DHEA (prasterone) is FDA-approved for vaginal dryness and pain with sexual activity, improving sexual desire, arousal, and overall sexual function 1, 2
• Ospemifene (a selective estrogen receptor modulator) is indicated for moderate to severe dyspareunia in postmenopausal women without a history of breast cancer 1, 2

Special Considerations for Cancer Survivors

• For breast cancer survivors, non-hormonal options should be tried first 1, 3
• Women on aromatase inhibitors experience more severe vaginal atrophy (18%) compared to those on tamoxifen (8%) 1, 3
• If vaginal estrogen is needed for breast cancer survivors, estriol-containing preparations may be preferable as estriol is a weaker estrogen that cannot be converted to estradiol 1
• Small retrospective studies suggest vaginal estrogens do not adversely affect breast cancer outcomes, but caution is still warranted 1

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of symptoms (vaginal dryness, dyspareunia, urinary symptoms) 2
   • Review medical history for contraindications to hormonal therapy 2

2. First-Line Treatment:

   • Begin with non-hormonal therapies: vaginal moisturizers for daily use and lubricants for sexual activity 1, 2
   • Consider hyaluronic acid preparations and topical vitamins D or E 1
   • Implement pelvic floor physical therapy if pain or muscle tension is present 1, 3

3. Second-Line Treatment (if symptoms persist):

   • For women without contraindications: Low-dose vaginal estrogen (creams, tablets, or rings) 1, 2
   • For women with contraindications to estrogen: Consider prasterone (DHEA) or ospemifene (except in women with history of estrogen-dependent cancers) 1, 2

4. Monitoring and Follow-up:

   • Assess symptom improvement after 2-3 months of treatment 2
   • Adjust treatment based on response and tolerability 2
   • Continue treatment indefinitely as symptoms typically worsen without ongoing management 1

Common Pitfalls and Caveats

• GSM is often underdiagnosed and undertreated, with many women not seeking help despite significant impact on quality of life 6
• Unlike vasomotor symptoms, GSM does not resolve over time and requires ongoing management 1
• Systemic hormone replacement therapy may not adequately address vaginal symptoms, and local therapy is often needed 2
• The FDA has not cleared or approved energy-based devices (laser therapy) for treatment of GSM symptoms despite some promising preliminary data 7
• Women with a history of breast cancer require special consideration, with non-hormonal options as first-line treatment 1, 3