The Genitourinary Syndrome of Menopause (GSM) is defined as a collection of symptoms and signs associated with estrogen deficiency that can involve the labia, introitus, vagina, clitoris, bladder, and urethra. 

In 2014, the term “genitourinary syndrome of menopause” (GSM) was introduced to describe the genital, sexual, and urinary symptoms that accompany the loss of estrogen and other hormones after menopause.

GSM replaced the less inclusive terms of vaginal atrophy, atrophic vaginitis, or vulvovaginal atrophy. 

Although the most common reason for vulvar and vaginal complaints in post-menopausal women is GSM, there can be other conditions responsible for the symptoms. Therefore, a careful history and examination is essential to making the correct diagnosis. 

How many women does vaginal atrophy affect?

Regardless of the term used, vaginal atrophy remains highly prevalent, affecting approximately 20-84% of menopausal women and despite the availability of many safe and effective treatments for GSM, most menopausal women remain untreated. 

Data from the VIVA (Vaginal health: insights, views and attitudes) survey showed that most women were not aware that vaginal atrophy is a medical condition. Therefore, do not report symptoms to their healthcare provider. This survey also showed 48% of menopausal women experienced vaginal discomfort – most commonly, vaginal dryness (85%) and pain during intercourse (52%)

For most women, vaginal discomfort negatively affects their lives, especially with regard to sexual intimacy and quality of life. 

Bothersome VVA (vaginal-vulvo atrophy) symptoms have a significant adverse impact on women’s lives. In one study, women with sexual dysfunction were approximately four times more likely to have VVA symptoms. 

What are the treatment options?

It is important for women to know that although vasomotor symptoms (hot flashes and night sweats) typically improve over time, signs and symptoms of GSM typically worsen with prolonged estrogen deficiency beyond menopause. 

Non-hormonal GSM treatment options 

  1. Pelvic physiotherapy: Either as a stand alone or in conjunction with local therapy. May include the use of vaginal dilators, especially in the treatment of pelvic floor hypertonus
  2. Vaginal moisturisers: Designed to adhere to the vaginal mucosa, allowing cells to retain moisture. They are longer acting and applied to the vagina and vulva on a regular basis.
  3. Vaginal lubricants: Intended for use during sexual activity, and effects are short acting. They reduce friction  and increase lubrication and comfort

Hormonal GSM treatment options

  1. Low dose vaginal estrogen therapy: Estrogen restores vaginal blood flow, decreases vaginal pH (and therefore aids in the prevention of recurrent UTI’s) and improves thickness and elasticity of vulvovaginal tissues. This is minimally absorbed, and so an option for most women with GSM
    • Different formulations are present: Vaginal creams, tablets and rings
    • Improvements can be expected within a few weeks, though maximum effect may not be achieved until 2-3 months Estradiol ring (self-inserted slow hormone releaser) has been FDA approved for urinary urgency as well as VVA
    • Tablets and rings are preferred for those where systemic estrogen is contraindicated: They are fixed-dosing and there is a well-documented lack of significant systemic absorption 
  2. Intravaginal DHEA: Approved for treatment of moderate to severe dysparunea (pain during sexual intercourse) secondary to VVA in menopausal women 

Sometimes one of these treatment options is sufficient and sometimes it may be a blend. With my own patients we have seen results that lead to life-changing relief of symptoms. And of course, this leads to more confidence that as we age, life remains as enjoyable (if not more enjoyable!) in spite of the usual physiological changes.

Dr. Rav James is one of a handful of medical doctors in South Africa with an Advanced Fellowship in Nutritional, Metabolic and Functional Medicine through the American Academy of Anti-Aging Medicine. She is also a member of the North American Menopause Society. As a Functional Medicine specialist, Dr. Rav is interested in “root causes” and her most recent research focuses on peri-menopause and menopause, food as medicine, insulin resistance, metabolic health, integrative oncology, cardiovascular health, and holistic, whole-being approaches to mental health. Dr. Rav offers Functional Medicine consultations, DNA and gut microbiome testing, and various forms of IV therapy treatments. To get in touch, email admin@hanya.house.