By Dr. Nathalie Leroux
Genitourinary syndrome of menopause (GUSM)
There are many estrogen receptors in the vaginal mucosa (wall), vulva, bladder, urethra and pelvic floor. During menopause, the hypoestrogenic state (a decline in estrogen) leads to harmful changes within the tissues. The term vulvovaginal atrophy is used when describing many urogenital tissue changes. On the other hand, the term atrophy has been abandoned because it could negatively affect patients. But more importantly, the term does not adequately describe symptoms and changes within the urogenital tissues.
The presence of estrogens in the urogenital tissues leads to a vaginal mucosa with a thick, well-vascularized epithelium (surface) which allows adequate lubrication in most pre-menopausal women. The drop in estrogen that occurs with the onset of menopause leads to atrophic changes and, consequently, a thinner mucous membrane, a shorter and narrower vagina and a loss of elasticity. The vaginal entrance can retract, especially in women who are not sexually active. The thin vaginal mucosa becomes friable, lubricates less well and is likely to bleed easily at the slightest trauma.
Changes in the vaginal mucosa can sometimes occur very early from the onset of pre-menopause. Some patients are still having menstrual cycles and already experiencing GUSM symptoms. It is essential to speak with a healthcare professional at the start of the first symptoms because treatment initiated quickly will allow you to avoid changes in the formation of the vagina and vulva.
GUSM is present in approximately 50% of postmenopausal women. Unlike hot flashes, which tend to get better over time, GUSM does not improve and will even worsen if left untreated. Vaginal dryness and pain during intercourse (dyspareunia) are two symptoms frequently reported by women. Despite a high prevalence of these symptoms, few women seek medical advice. It is, therefore, our role as doctors to question patients regarding dyspareunia and vaginal dryness.
Although the symptomatology is typical, a targeted physical examination is necessary to rule out conditions such as skin irritations, chronic infections or even pre-cancerous cells. Your healthcare professional should do a speculum examination to assess the calibre of the vagina and the vaginal canal entrance and the quality of the vaginal mucosa. In some cases, a pediatric speculum can be used to minimize discomfort.
A laboratory test isn’t necessary to make an GUSM diagnosis. On the other hand, a vaginal PH, as well as a maturation index (looking at the cells of the vagina obtained with a cotton swab under the microscope), can be informative for the clinician. Doctors can easily use these tools during a speculum examination.
Many patients experiencing the symptoms of GUSM decide to self-medicate. However, remember that GUSM can get worse over time if not explicitly treated. On the other hand, for patients in whom the symptoms are not severe, the first step is to seek an over-the-counter treatment available at pharmacies. Lubricants can be used during intimate relations to improve natural lubrication or during the day to reduce the discomfort of vaginal dryness. The vast majority contain hyaluronic acid in various concentrations and help moisturize the vaginal mucosa.
Local hormone therapy treatment
Despite the above, lubricants may become insufficient when treating GUSM adequately. That is why women should consider local hormonal treatment, that is to say, at the level of the vaginal mucosa only. Local hormone therapy (HT) is not comparable to systemic HT (oral or transcutaneous treatment). The hormone level needed to treat vaginal atrophy is far lower than in systemic HT. On the other hand, some patients already on systemic (standard dose) HT have GSM symptoms. Many doctors must fully understand this situation because their patient is already undergoing hormonal treatment. Women should note that systemic estrogens do not adequately reach the urogenital tissues. Therefore, it is imperative to treat these particular cases locally and systemically.
Estrogen treatments come in three formats: cream (Prémarin cream, Estragyn), tablets (Vagifem) or vaginal rings (Estring).
The cream comes in a tube with an applicator. The advantage is that women can apply it both at the vaginal and vulvar levels (with the finger). Some patients may prefer the tablet treatment, as this is less messy. This method uses a single-use plastic applicator. Both treatments are applied in the evening at bedtime twice a week. The last option is the vaginal ring which delivers estrogens locally to the vaginal mucosa continuously for three months. The ring is removed and replaced by the patient herself. The procedure is relatively easy in itself. Still, it requires a specific skill, and a woman must be comfortable removing and replacing the ring in the vagina. Some patients are not comfortable with this responsibility.
The amount of hormones used for the local treatment of GUSM is meagre. Some drug labels contain warnings about the risk of breast cancer, thromboembolic disease (heart attack, pulmonary embolism), endometrial cancer and dementia. These warnings are derived from concerns about the safety of hormone therapy obtained in studies of systemic hormone therapy (which has a much higher amount of hormones). The quantity of hormone in the local vaginal treatment is much lower, and no clinical study has suggested any adverse effects at the dosage used.
The treatment based on Dehydroepiandrosterone (DHEA) or Prasterone (Intrarosa) transforms the vaginal cells into various estrogens, including estradiol and androgens testosterone. It is formulated as a cream with a vaginal applicator and is applied every night. Currently, there is no conclusive knowledge of its safety in patients with breast cancer.
Ospemifene (Osphena) comes in a 60 mg oral tablet and is approved for treating dyspareunia in GUSM. It is a drug of the SERM (selective estrogen receptor modulator) class. A small percentage of women treated with Osphena report vasomotor symptoms compared to placebo.
Two types of lasers (Mona Lisa Touch and Diva) exist to treat GUSM, either the carbon dioxide (CO2) laser or the yttrium-aluminum-garnet (YAG) laser. Fractional lasers are minimally invasive technologies that activate tissue repair and tissue regeneration. Its effect suggests a vascularization which causes the collagen to increase and, thus, a thickening of the vaginal mucosa. Small studies have shown that CO2 fractional lasers reduce symptoms of GUSM and that YAG laser treatments improve GSM and stress urinary incontinence.
Radio Frequency Treatment
Another technology also acts on the vaginal mucosa to treat GUSM. This is radiofrequency (Emfemme 360). The radio frequency used in the vagina is an advanced technology that regulates energy flow by continuously measuring impedance for even heating and optimal therapeutic results. The device helps maintain uniform and constant heating within the tissues, making it possible to activate the factors that help regenerate the vaginal mucosa without burning it. Blood perfusion in the tissues increases during treatment. Small studies have shown an improvement in the cell maturation index (cell quality) and PH and vaginal flora. Many women unable to have sex due to severe pain have been able to resume sex without pain.
GUSM and urogynecology
In addition to causing unpleasant symptoms for women and affecting the quality of sexual relations, GSM can also impact the urinary tract. The following symptoms may be caused or exacerbated by a lack of estrogen in the urogenital tissues: pain during urination, urgency, and recurrent UTIs. Local estrogen therapy, laser or radiofrequency treatment also improves this aspect of GUSM.