Here at Lakeview, we’re focusing on an important yet often overlooked aspect of menopause: Genitourinary Syndrome of Menopause (GSM) and the use of estrogen therapy.
Menopause has become a major topic of discussion this year, and for good reasons. With October recognized as World Menopause Month, it's the perfect time to raise awareness about this life transition, its symptoms, and the range of care and support options available. Here at Lakeview, we’re focusing on an important yet often overlooked aspect of menopause: Genitourinary Syndrome of Menopause (GSM) and the use of estrogen therapy.
The Role of Estrogen in Menopause: Why It Matters
Many people assume that treating menopausal symptoms is as simple as using estrogen or hormone therapy. However, that advice alone can be oversimplified. It is essential to understand why estrogen is helpful and how it works, empowering individuals to make informed decisions about their care. Without this knowledge, people might hesitate to start treatment or prematurely stop, feeling it’s ineffective.
On the other hand, not every menopausal symptom requires hormone therapy. Estrogen replacement is the primary treatment for managing vasomotor symptoms like hot flashes and night sweats, and it’s also effective for GSM, primary ovarian insufficiency, and preventing bone loss. However, not all symptoms call for hormone replacement.
Estrogen’s Impact on the Body
As estrogen levels decline during menopause, the body undergoes various changes. While most are familiar with changes in the menstrual cycle, estrogen also affects other systems, including:
Reproductive and urinary tracts
Cardiovascular system
Bones
Skin and hair
Pelvic muscles and mucous membranes
Brain and breasts
In this post, we will focus on how estrogen decline affects the vulva and vaginal area, leading to GSM.
How Declining Estrogen Impacts Vaginal Anatomy
As estrogen decreases, several notable changes occur in the vaginal area:
Reduced blood flow to the vagina
Thinning and paling of the vaginal walls
Narrowing of the introitus (vaginal opening)
Loss of vaginal rugal folds (ridges on the vaginal walls)
Decreased lubrication and vaginal secretions
Altered vaginal pH, increasing the risk of urinary tract infections (UTIs)
These anatomical changes lead to a collection of symptoms known as Genitourinary Syndrome of Menopause (GSM).
What Is Genitourinary Syndrome of Menopause?
GSM encompasses a range of symptoms resulting from the physical changes in the vaginal and urinary tissues. Some of the most common symptoms include:
Vaginal irritation, itching, and burning
Pain during intercourse, sitting, or activities like biking
Vaginal discharge with changes in quantity, color, or odor
A persistent feeling of needing to urinate, discomfort during urination, or urinary urgency
Frequent nighttime urination and urinary incontinence
Unlike hot flashes, which often improve with time, GSM symptoms typically worsen without treatment. Women who experience surgical menopause (due to the removal of ovaries) or undergo cancer treatments such as chemotherapy or aromatase inhibitors may notice more severe symptoms.
Treatment Options for Genitourinary Syndrome of Menopause (GSM)
The good news is that there are several effective treatments for GSM, both hormonal and non-hormonal. Let’s explore these options:
Non-Hormonal Treatments:some text
Pelvic Floor Physical Therapy: Often the first line of treatment, it helps address urinary and vaginal symptoms.
Vaginal Moisturizers: Used regularly to maintain moisture and reduce GSM symptoms.
Vaginal Lubricants: Used during sexual activity to decrease discomfort and enhance pleasure by reducing friction. Options include water-, silicone-, and oil-based products.
Sexual Stimulation: Regular sexual activity, either alone, with a partner, or using a device (such as a vibrator), can improve vaginal health by promoting blood flow and secretions. Broadening the concept of sexual intimacy to include outercourse, such as extended caressing and massage, can also be beneficial.
Local Vaginal Hormone Therapy: Low-dose estrogen applied directly to the vaginal tissues has been shown to safely and effectively treat GSM symptoms. This treatment works locally on the vagina, urethra, and parts of the vulva. It’s available in creams, suppositories, rings, and pills. However, it’s essential to be patient, as it takes 8–12 weeks of regular use to see the full benefits.
Dehydroepiandrosterone (DHEA; prasterone): This hormone-containing vaginal insert is used nightly to reduce dryness and discomfort during sexual activity.
Systemic Estrogen Therapy: For those dealing with more widespread menopausal symptoms like hot flashes, systemic estrogen (in oral pill form) can also help with vaginal dryness. However, many women benefit from additional low-dose local vaginal hormone treatment if vaginal symptoms persist.
Other Therapies:
Ospemifene: A selective estrogen receptor modulator (SERM) taken orally, this daily medication is used to treat vaginal dryness and sexual pain. It’s particularly useful for individuals who can’t use hormone therapy or for whom hormone therapy is contraindicated.
Take Control of Your Menopausal Health
While GSM can significantly impact your quality of life and intimate relationships, effective treatments are available. Whether you opt for non-hormonal or hormonal therapy, there’s no reason to suffer in silence. By understanding your options and working with your healthcare provider, you can find a treatment plan that works for you.
Illustration from The Vagina Bible to show some of these changes at the cellular level:
Articles used for reference:
2022 and 2020 Position statements by the Menopause Society.
Wasnik VB, Acharya N, Mohammad S. Genitourinary Syndrome of Menopause: A Narrative Review Focusing on Its Effects on the Sexual Health and Quality of Life of Women. Cureus. 2023 Nov 2;15(11):e48143. doi: 10.7759/cureus.48143. PMID: 38046779; PMCID: PMC10692865.
Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle. Yuksel, Nese et al. Journal of Obstetrics and Gynaecology Canada , Volume 43, Issue 10, 1188 - 1204.e1
