What is the Genitourinary Syndrome of the Menopause?
The genitourinary syndrome of menopause is a condition that can go on for years, there is a belief that this is a normal part of ageing for women. Sensitive questioning can encourage a woman to admit that she suffers from these symptoms, that it may be affecting her relationship. Careful explanations can explain to her why it is happening, inform her that treatment is safe for almost every woman and is long-term and effective. Genitourinary syndrome of menopause is experienced by 60% of postmenopausal women who do not use hormone replacement therapy (HRT), and 25% of women who do use systemic HRT. As other symptoms of menopause can settle, this does not unless it is treated appropriately.
What might the symptoms be?
The genitourinary symptoms:
Pain or discomfort during sexual intercourse
Decreased arousal, orgasm
How do women describe this?
‘It’s so itchy, I can’t stop scratching’
‘I cannot wear underwear it is so uncomfortable’
‘It feels prickly, dry and sore’
‘It feels like I have cuts down there’
‘I bleed after sex’
‘Sex is so uncomfortable’
‘I need to pass urine far more often’
‘I’m getting urine infections’
‘It feels like razor blades’
‘It stings to pass urine’
‘I keep getting candida infections’
‘It’s so painful to have my smear test’
Many women feel that they only become dry during sex, which can be painful, while others feel dry, sore, prickly, and itchy all the time. They may have pain in the vagina, and they may bleed after sex. It is associated with sexual dysfunction and arousal disorder for some women.
The lower urinary tract is also affected by the genitourinary syndrome of menopause, and a woman can be affected by recurrent urinary tract infections, the urge to pass urine, frequency of passing urine, and dysuria, which means it stings for her to pass urine. These genitourinary symptoms are not usually significant until around 10 years after menopause but can present in 3-5 years as oestrogen levels start to fall. While vaginal symptoms of urogenital atrophy become more common with age, they can occur at any stage of perimenopause and menopause.
Why does it occur?
Oestrogen is needed to keep tissues well-lubricated, healthy, and supple. Loss of oestrogen in perimenopause and menopause results in the tissues becoming dry and more delicate. The usual vaginal and vulval elasticity can be lost, which can mean sex becomes painful. The vagina can become shorter and loose its normal folds, especially if a woman stops having sex. All these changes are called urogenital atrophy. Oestrogen also stimulates the presence of good bacteria, lactobacillus, in the Vaginome of vagina, to protect a woman against vaginal infections.
What happens physically?
The vulva may appear paler. The labia may be thinner and smaller. The clitoral hood may be less obvious. A urethral mucosal prolapse can occur which many women notice as a red swelling. The vulval skin may look thin and dry, with tiny blood vessels under it resulting in patchy redness. Stretching the vulva may cause splitting at the skin at the bottom of the vagina or around the anus.
How does the vagina change after menopause?
The vagina before menopause: The lining is thick and moist. There is good blood flow to the vaginal tissue. The vaginal walls are flexible. The vagina after menopause: The vagina becomes thin and dry. There is less blood flow to the vaginal tissue. Vaginal flexibility is reduced.
How can this condition affect relationships?
Led to loss of intimacy in 80% Interfered with the relationship in 45% Negatively affected sleep in 30% Adversely affected general enjoyment of life in 2.7% Detracted from the enjoyment of sex in 59%
What advice and treatment can help?
A non-soap cleanser can be used or advised to gently wash with warm water alone, a maximum of twice daily.
Advising not to douche or use harsh products which may affect the vaginal pH. The premenopausal vaginal pH is around 4.5 and the post-menopausal vaginal pH naturally rises, due to falling oestrogen levels, which affects the microbiome in the vagina, called the vaginome. The main effect of this is a reduction in lactobacillus. Lactobacillus has an important role in protecting the vagina from bacterial, viral and candida infection and keeps the vagina healthy, by making it more acidic. It achieves a lower vaginal pH by producing lactic acid when it ferments glycogen in the body. If levels of lactobacillus are low, as they can be after menopause, it can be easier to suffer from candida, BV and other infections. If candida is allowed to multiply this is called vaginosis, it can produce an unpleasant fishy odour due to the production of a substance called trimethylamine.
An emollient cream or petroleum gel can be used if the vulva is dry and itchy. Emollients can be considered, for example Cetreban, Dermol, Diprobase, Doublebase and Epaderm. Aqueous cream is best avoided as this can irritate.
A hormone free lubricant can be used for sexual intercourse. Sometimes this can cause stinging so she may need to use an alternative brand or use petroleum gel. Oil-based lubricants can be more effective, though they can affect the efficacy of condoms, so if condoms are used she should use a water-based lubricant. The key thing is finding one she likes and is comfortable with. Examples are YES OB or YES WB. It’s important to use a recommended brand. She should avoid the lubricants with added extras (like a tingle, or heat) as they can cause irritation. Shop-bought products can also irritate, so care is needed. Jo Divine has a website which is a good source of information when looking for products.
A trial of vaginal moisturisers, using a reputable brand is also really helpful. They can be used throughout the day and be applied when necessary. YES VM and Sutil Luxe and Rich are examples. It is best to avoid products that contain glycerine or glycerol, as these may exacerbate thrush. Care may be needed with Ovestin local oestrogen cream, as it contains glycerin.
A medication review with a Dr. is important. Anticholinergic medications, antihistamines, decongestants or antidepressant medication may contribute to dryness.
It may be necessary to use short-term topical steroids, for dermatitis caused by irritants such as urine, panty liner or tight clothing.
Local vaginal oestrogen may be used as this is safely used in most women.
Why is vaginal oestrogen used?
There are more oestrogen receptors in the vagina than in the vulva so this explains why the local oestrogen is inserted into the vagina. Vaginal oestrogen use will help by increasing the vaginal lactobacillus, and subsequently lowering the vaginal pH again, which will be having a beneficial effect on the vaginome. It will improve the quality of the skin on the vulva and vagina and help with improving prolapse and bladder symptoms. Urinary contact with the vulva and pads causes the most challenging symptoms topical steroids may also be needed to help if things are severe. Even if they take systemic HRT, topical or vaginal oestrogens can be prescribed in the form of Estradiol (E2) or Estriol (E3) safely in almost every woman. These can be given as a cream, a gel, a pessary or vaginal ring, inserted into the vagina with a finger or a small applicator. A loading dose is given over 2-3 weeks, and this is followed by a maintenance dose for most preparations. It is best if treatment is started early, when symptoms are mild, as it is much easier to keep tissues healthy than it is to try to reverse the changes in the skin that have been there for years, but it is never too late to start. It usually takes three to four months for improvement to be felt. Vaginal oestrogen is used long-term with an annual review. There is no evidence one vaginal oestrogen is better than another. It’s reassuring for women to know that when they put oestrogen directly into the vagina, their body only absorbs a tiny amount. So, they can use it without the risk of breast cancer, blood clots, stroke or heart disease. They do not need to use progesterone treatment to provide endometrial protection if they only use local oestrogen. There are different options available for vaginal oestrogens, as shown in the table below. The dosing varies for all of them and will be confirmed on their prescription. If the symptoms do not improve using one product, then two products can be combined together, one estriol and one estradiol, as this may help. Systemic HRT may need to be added, too. These are the products available:
Ovestin cream TM – Estriol 0.1% cream. This comes with a washable applicator, but you could measure out the applicator dose and use your finger instead.
Imvaggis TM – Estriol 30mcg pessary. This is a slightly bigger pessary. There is no applicator, it is inserted using the woman’s finger to push it into the vagina. It melts and some women find it moisturising.
Estriol 0.01% cream. This is a cream, and it comes with a washable applicator, but you could measure out the applicator dose and use your finger instead.
Blissel TM – Estriol 50mcg. This is the lowest dose of vaginal oestrogen; it comes in a tube and is drawn up into an applicator.
Vagifem TM or Vagirux – Estradiol 100mcg vaginal tablet. These are tiny pessaries with an applicator which can be reused and washed.
Estring TM – Estradiol 7.5mcg/24h. This is a small flexible plastic ring that is fitted into the vagina, by the doctor or by the woman, and it releases oestrogen slowly daily for three months. It needs to be changed every 3 months, but it can be taken out and washed during this time if necessary. She can continue to have sex with this fit.
There are two other medications used to treat vaginal symptoms related to urogenital atrophy of menopause. They are usually prescribed by specialists.
Prasterone (Intrarosa TM) is a 6.5mg pessary containing DHEA delivered vaginally daily. It’s identical to a hormone called dehydroepiandrosterone (DHEA) in the adrenal gland. The adrenal glands (80%) and ovaries (20%) secrete DHEA. It is converted into oestrogens and androgens by enzymes within the epithelial cells of the vagina, but not the endometrium. It causes maturation of the parabasal cells into superficial cells, with an associated increase in mucosal thickness and secretions. It increases collagen density in the lamina propria. This has been shown to be effective in treating menopausal vaginal and vulval atrophy (thinning) that is moderate too severe.
Ospemifene is an oral tablet administered at a dose of 60mg once daily. It is a selective oestrogen receptor modulator that has an oestrogen-like receptor effect on the vagina, increasing cellular maturation of the vaginal epithelium and lowering the vagina pH and improving the vaginal maturation index (VMI). It reduces symptoms including vaginal dryness and pain during sexual intercourse. There is an antagonist effect on the endometrium and breast tissue. Hot flushes are most frequently reported as a side effect of this medication. NICE guidance recommends its use for women who are not candidates for local oestrogen therapy. 52-week extended studies showed long-term benefits from long-term use.
Vaginal dryness can make women prone to vaginal candida infections and discharge can decrease or increase as the balance of bacteria that are naturally found in the vagina changes. Women may also be more prone to bacterial vaginosis, where there is an imbalance of the normal bacteria that usually live happily in the vagina. Excessive vaginal discharge can sometimes cause further irritation.
Low-dose vaginal oestrogen can be used safely and continued for as long as required. Symptoms of vaginal atrophy can come back when the treatment is stopped, adverse effects are very rare, and any unscheduled bleeding should be reported to a doctor. Vaginal laser therapy is a technique that can help the symptoms of vaginal atrophy. Laser energy is used to treat vaginal tissue and increase collagen production. Results from small studies have shown that this treatment can be effective, but it is not yet widely available. Chronic vulval irritation is extremely debilitating and has a significant effect on mood, well-being, and relationships. A doctor should examine the vulva and assess for inflammatory skin disorders or malignancy.
It is so important that every woman is counselled about the genitourinary syndrome of menopause early so that they can start treatment for the genitourinary syndrome of menopause before symptoms cause a problem for her and her relationship.