A few months ago, in a video for Medscape, urologist Dr. Rachel Rubin said bluntly, “I’m here to tell you that vaginal dryness is killing women.” Rather than giving women a literal warning that they may drop dead on their way to the pharmacy to buy lubricant, Dr. Rubin sought to bring attention to certain menopause symptoms that are more serious than most people think. Specifically, vaginal dryness is a symptom of a condition known as genitourinary syndrome of menopause or GSM.
What is genitourinary syndrome of menopause (GSM)?
According to this review in the Journal of Menopausal Medicine, genitourinary syndrome of menopause is a relatively newer term that encompasses both genital and urinary symptoms related to menopause [1]. GSM replaces terms like vulvovaginal atrophy and atrophic vaginitis that only refer to genital symptoms but not urinary symptoms. These symptoms are very common and affect an estimated one-half or 50% of postmenopausal women.
Symptoms include:
- Genital discomfort such as dryness, burning, or irritation (which may make everyday activities like sitting and walking uncomfortable)
- Vaginal dryness
- Discomfort and pain with sex
- Difficulty with desire, arousal, and orgasm
- Frequent urge to pee (which may disrupt sleep)
- Pain with urination
- Recurring urinary tract infections (UTIs)
Unlike with hot flashes, these symptoms do not resolve on their own with time, and may become worse if untreated.
What causes GSM?
After menopause, the body has to adapt to life with (naturally) low estrogen. This change affects cells and tissue throughout the body, but especially in the genitourinary tract where there are lots of estrogen receptors. Without estrogen, the vagina experiences reduced collagen, hyaluronic acid (you’ve probably heard of this in skincare products), elastin, epithelium thickness (the outer layer of cells), and supporting blood vessels–all of which weaken the vagina. In the bladder, it’s thought that a lack of estrogen reduces the sensory threshold (meaning your bladder feels full even when it’s not) and how strongly the urethra can stay closed (this can let bacteria in and contribute to urinary tract infections, UTIs).
How can GSM be dangerous?
In her video, Dr. Rubin highlighted one symptom more than any other: UTIs.
UTIs are actually a massive problem, especially amongst older women. A 2021 article on Medicare spending estimated that UTIs cost the US healthcare system upwards of $1.6 billion each year, representing about seven million healthcare visits. According to the Mayo Clinic, complications can include repeated infections, kidney damage, and sepsis (bacteria in the bloodstream, which can be life-threatening). These complications are more likely if the UTI goes undiagnosed for long periods of time, which is more likely in menopause as UTI symptoms are similar to other GSM symptoms unrelated to infection.
What treatments are available for GSM?
Because GSM results from a lack of estrogen in the genitourinary tract, the main course of treatment involves local, low-dose hormone treatment. Dr. Rubin listed a number of treatment options that she found to be effective with her own patients: vaginal estrogen inserts, vaginal estrogen creams, DHEA, low-dose vaginal estrogen rings, and an oral pill called Osphena. Estrogen therapies have been found to significantly reduce recurrent UTIs, which may be a way to decrease antibiotic prescriptions for UTIs and thus reduce the risk of common UTI-causing bacteria becoming more antibiotic resistant [2].
John Hopkins also lists a number of non-hormonal treatments, but these treatments are more specific to genital symptoms than urinary symptoms. These include vaginal lubricants and moisturizers, creams that contain hyaluronic acid, and vaginal laser ablation.
Not every doctor is able to identify and treat GSM
As with many other issues in women’s health, it may take some time to find a doctor who can address your specific concerns with genitourinary syndrome of menopause. The John Hopkins article on GSM ends with the following quote, “Until recently, menopause symptom management has not been a part of the medical school or residency curriculum so there are many doctors who are unfamiliar or uncomfortable with it.”
Similar to using a fertility awareness method and seeking restorative reproductive medical treatment, getting the right help for menopausal symptoms may require you to be more heavily involved in your health journey in terms of noticing and tracking symptoms, researching options, and finding the right healthcare provider for you. By educating and empowering ourselves, our physicians, and one another, we can make effective treatments for common women’s health issues more accessible for everyone.
References:
[1] Kim HK, Kang SY, Chung YJ, Kim JH, Kim MR. The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 2015 Aug;21(2):65-71. doi: 10.6118/jmm.2015.21.2.65. Epub 2015 Aug 28. PMID: 26357643; PMCID: PMC4561742. [2] Tan-Kim, Jasmine et al. “Efficacy of vaginal estrogen for recurrent urinary tract infection prevention in hypoestrogenic women.” American journal of obstetrics and gynecology vol. 229,2 (2023): 143.e1-143.e9. doi:10.1016/j.ajog.2023.05.002Additional Reading:
Managing perimenopause naturally
The natural survival kit for perimenopause
