Menopause Matters upcoming columns will review what happens to lower genitourinary tissues like the vagina and bladder when a woman’s circulating estrogen goes away. In prior column’s I reviewed the time frames for the menopausal transition and defined menopause as starting 12 months after a woman’s final menstrual period (FMP). Hot flashes, typically the most common symptom that women associate with the menopausal transition, go away in over 90% of women within 5-7 years. What many women don’t associate with their FMP are the changes that occur in the vagina and bladder that may not be noticed until 5 years after the FMP. Unlike hot flashes which often go away, bothersome changes in the vagina and bladder don’t get better with time.
Anatomic and physiologic changes in the vagina associated with menopause are directly related to reduced circulating estrogen levels and aging. The high concentration of estrogen receptors in the vagina and the opening of the vagina modulates tissue health. Low levels of circulating estrogen after menopause results in physiologic, biologic, and clinical changes in the vagina and bladder. Anatomic changes include reduced collagen and elastin and thinning of the tissues which can cause altered appearance and function. The smaller/inner labial lips can become thin and regress, causing the opening of the vagina to retract and become narrow all which can result in pain with intimacy. Physiologic changes can result in fewer blood vessels and reduced vaginal blood flow, diminished lubrication, leading to decreased flexibility and elasticity. These anatomic and physiologic changes can lead to decreased strength and increased fragility which can lead to daily discomfort or pain with intimacy.
Approximately 20-50% of US women experience symptoms such as vaginal dryness, itching, burning, or UTI like symptoms from the anatomic and physiologic changes mentioned above. These symptoms can occur during the peri-menopausal transition when menses are spacing out or may not be noticed until several years after the final menstrual period. Women at high risk for breast cancer or those who have already had breast cancer, are often prescribed medicines (to reduce future risk) which can have negative effects on vaginal mucosa. The old term to describe these symptoms was vulvovaginal atrophy, or VVA. The term VVA has recently been abandoned because of negative connotation with the word atrophy and that bladder symptoms were not mentioned. The current term accepted the North American Menopause Society (menopause.org) is the Genitourinary Syndrome of Menopause, or GSM.
Treatment of GSM should be made available to all symptomatic women who are bothered by these symptoms and are interested in treatment. Sexual difficulties and chronic irritating symptoms may result in ongoing discomfort and/or personal or interpersonal distress. Some women may complain of interruption of activities of daily living because of severe vaginal dryness, whereas others only complain of pain with intimacy. First line treatments include nonhormonal over-the-counter (OTC) products such as vaginal moisturizers (like placing moisturizers on your skin) and personal lubricants. A company out of Luxembourg, Pjur, (https://au.pjurmed.com) has a complete line of water and silicone based products for daily use. If non-hormonal interventions are not successful in ameliorating symptoms, minimally absorbed vaginal low-dose estrogen can be considered in women who have no medical contraindication to its use. Another helpful internet resource I share with patients is (https://middlesexmd.com). This professional website created by a gynecologist is devoted to genitourinary health in peri-menopausal/menopausal women. Next month’s column will go into more specifics about medical management of GSM.