Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM) is a chronic, progressive collection of symptoms and signs due to oestrogen deficiency affecting the vulva, vagina, urethra and bladder.

It affects 50 to 70% of postmenopausal women (and women with premature ovarian insufficiency, breast cancer on aromatase inhibitors, oophorectomy, or lactation), yet fewer than 25% seek treatment.

Oestrogen deficiency reduces vaginal epithelial thickness and glycogen content, decreasing lactobacilli, raising vaginal pH above 5, reducing blood flow, collagen and elasticity, and thinning the urethral and trigonal mucosa.

• Genital: dryness, burning, irritation, decreased lubrication, pruritus, and discharge
• Sexual: dyspareunia, post-coital bleeding, reduced arousal, and avoidance of intimacy
• Urinary: urgency, frequency, dysuria, nocturia, recurrent urinary tract infections, and stress incontinence
• Signs: pale, thin, dry vaginal epithelium with loss of rugae, petechiae, fissures, reduced labial fullness, shrinkage of the introitus, urethral caruncle or prolapse, and increased vaginal pH (above 5.0 to 5.5)
• Symptoms are progressive and do not resolve spontaneously (unlike vasomotor symptoms)

• Clinical diagnosis from symptoms and examination
• Vaginal pH (above 5.0), vaginal maturation index (decrease in superficial cells and increase in parabasal cells; maturation value below 55), and wet mount for exclusion of infection
• Exclude other causes: infection (bacterial vaginosis, candidiasis, trichomonas), dermatoses (lichen sclerosus, lichen planus), malignancy (biopsy suspicious lesions; unexplained postmenopausal bleeding needs endometrial assessment), contact dermatitis, vulvodynia
• Most bothersome symptom is used to guide therapy

• First line: non-hormonal vaginal moisturisers (hyaluronic acid based, polycarbophil gel applied 2 to 3 times weekly) and water based or silicone lubricants for intercourse; regular sexual activity and pelvic floor exercises.
• Low dose vaginal oestrogen (the most effective therapy; minimal systemic absorption): estradiol 10 microgram vaginal tablet or insert daily for 2 weeks then twice weekly; estradiol 4 or 10 microgram softgel capsule similar; conjugated oestrogen cream 0.5 to 1 g (0.625 mg/g) twice weekly; estradiol cream 0.01% 0.5 to 1 g daily for 2 weeks then 1 to 3 times weekly; estradiol vaginal ring 7.5 micrograms/day every 90 days; estriol 0.5 mg pessary or 0.1% cream (EU). Endometrial protection with a progestogen is not routinely required at these doses; long term safety beyond 1 year is reassuring in observational studies.
• Prasterone (DHEA) vaginal insert 6.5 mg nightly (intravaginal dehydroepiandrosterone converting to local oestrogen and androgen), for dyspareunia.
• Ospemifene 60 mg orally once daily (selective oestrogen receptor modulator) for moderate to severe dyspareunia and vaginal dryness (contraindicated with undiagnosed uterine bleeding, VTE history; hot flushes common).
• Systemic hormone therapy (oestrogen with or without progestogen) when vasomotor symptoms coexist (systemic doses may not fully resolve GSM, and local oestrogen can be added).
• Breast cancer survivors: non-hormonal measures first; local oestrogen (lowest dose) may be considered after multidisciplinary discussion, with caution in women on aromatase inhibitors (estriol 0.03 mg, or prasterone); vaginal CO2 or erbium laser and radiofrequency are investigational and not recommended outside trials.
• Pelvic floor physiotherapy, vaginal dilators for stenosis, and topical lidocaine before intercourse.
• Recurrent UTIs: vaginal oestrogen reduces recurrence (about 50 to 60%), plus standard prophylaxis measures.
• Review at 3 months for response, then annually; continue long term because symptoms recur on stopping.