Genitourinary syndrome of the menopause

Genitourinary syndrome of the menopause, GSM, is a term used to describe the vaginal and bladder symptoms experienced by about 60% women in menopause. Your bladder and vagina are rich in estrogen receptors, so when estrogen levels fall in your perimenopause and remain low in menopause, your vulva, vagina, bladder and pelvic floor muscles change, which can lead to these symptoms. The symptoms don’t get better without treatment, but treatment is usually highly effective and is easy to use. 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. At Rowena Health Menopause Clinic we are passionate about helping treat this condition.

What changes happen in the bladder, vulva, vagina and pelvic floor when estrogen declines?

Estrogen is needed to keep tissues well-lubricated, healthy, and supple, so loss of estrogen in perimenopause and menopause results in the tissues becoming dry and more delicate and these changes can occur:

• Loss of fat from the outer lips of the vulva, your labia majora
• The tissues of your vulva and vagina may become dry and delicate, not seem moist and well lubricated, healthy, elastic and supple as they once were
• Elastin and collagen reduce so that your vagina loses its natural folds and can become shorter, especially if you are not having sex
• The tissues of your vulva can shrink so your urethra, which is the entrance to your bladder, is exposed and you may be prone to urinary tract infections
• Your vagina and vulva may become pale and thin, and might tear more easily especially when having sex
• Your clitoral hood can overgrow, which can lead to reduced sensitivity or over sensitivity when you or your partner touch that area. This can affect arousal and desire and your ability to have an orgasm
• Tissues may sag in the pelvis leading to prolapse, you might feel a dragging feeling between your legs
• Estrogen also stimulates the presence of good bacteria, lactobacillus, in the vaginome of vagina, to protect you against vaginal infections.
• Vaginal dryness can make you prone to vaginal candida infections and discharge can decrease or increase as the balance of bacteria that are naturally found in the vagina changes. You 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.

What do women say about this?

• ‘It’s so itchy, I can’t stop scratching’ or ‘I cannot wear underwear it is so uncomfortable’
• ‘It feels prickly, dry and sore’ or ‘It feels like I have cuts down there’
• ‘I bleed after sex’ or ‘Sex is so uncomfortable’
• ‘I need to pass urine far more often in the day’ or ‘I’m always getting urine infections’
• ‘I have to get up at night to pass urine’ or ‘I leak on the way to the loo’ and ‘I leak when I cough and sneeze
• ‘It feels like razor blades’ or ‘It stings to pass urine’
• ‘I keep thinking I’m getting candida infections’ or ‘It’s so painful to have my smear test’
• ‘I find it hard to orgasm as everything seems to have shrunk away’
• ‘My vagina bleeds after sex’ and ‘It is sore to insert a tampon’

What can help with these symptoms? Caring for your bladder and vagina is important and using local vaginal estrogen treatment can also help.

Bladder care

To care for the bladder, you should:

• Drink lots of water to keep well hydrated, especially when it is hot. Your urine should be pale yellow in colour
• Limit bladder irritants like caffeine, chocolate and alcohol as these can make your bladder problems worse
• Avoid becoming constipated as this can put pressure on your bladder and straining to open the bowels can weaken your pelvic floor
• Stop smoking as bladder problems are more common in smokers
• Pass urine straight after after you have sex. Sex can transfer bacteria from your bowel or vagina to your urethra, which is the opening into your bladder. Passing urine after sex helps to flush these bacteria away.
• Wipe from front to back after using the toilet to avoid the transfer of bacteria from the bowel to the urethra
• Exercise your pelvic floor. Download the NHS Squeezy App to help in you. Pilates is helpful and it helps to strengthen your pelvic floor muscles
• Learn how to relax the pelvic floor. Breathing exercises can help with this. Relaxation helps to ensure the bowel and bladder empty correctly
• Fill out a bladder chart over a couple of days and make an appointment with your GP if you are having increasing frequency passing urine, stinging, you are up at night or are leaking either on the way to the loo (urge incontinence) or on coughing, sneezing or jumping (stress incontinence). You need a full assessment.

Vagina care

To care for your vulva and vagina, you should:

• Avoid using any thing other than water to wash the vulva and never douche. Using soap, bath bombs, shower gel, bubble bath, talcum powder, cleansing or feminine wipes or washed, perfumes, fragranced washing powders or fabric conditioners and panty liners can irritate the tissues of the vulva which are very sensitive. Avoid wearing tight clothing.
• You are supposed to have some vaginal discharge, don’t wash it away, if you are concerned please see your doctor
• Use dermol or emulsifying ointment instead to soap, if you prefer to use something only on the vulva, not inside the vagina
• Avoid washing too often, once daily is usually enough
• Wash gently usually with your hands is best to avoid scratching the skin
• Gently pat dry with a soft towel, do not rub your vulva as you may tear the tissues
• After washing, you can use a product called dermol to the lips or a moisturiser like YES VM
• Use a lubricant when you have sex like YES OM (oil based) and YES WB (water based), these can be used together for a slip and slide feeling. Oil based lubricants should be avoided if condoms are being used for contraception
• A medication review with a Dr. is important. Anticholinergic medications, antihistamines, decongestants or antidepressant medication may contribute to dryness.

Vaginal oestrogen

• This can be taken if you are on HRT, or if you choose or are not able to take HRT. 20% of women who take HRT will need the addition of local vaginal oestrogen to help these symptoms.
• It is a very effective treatment and relives the symptoms of GSM within about 3 months.
• Local estrogen can be used as a tablet, pessary, cream, gel or ring.
• A loading dose is given over 2-3 weeks, and this is followed by a maintenance dose for most preparations. 
• There are two types of estrogen, estradiol and estriol, and several methods of using it so you can choose the one that you prefer.
• 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 is a long term treatment, if it is stopped the tissues will again become thin and dry.

Different vaginal oestrogens

• Ovestin cream TM is an estriol 0.1% cream. This comes with a washable applicator, but you could measure out the applicator dose and use your finger instead to use it inside the vagina and on the vulva
• Imvaggis TM is an estriol 30mcg pessary. There is no applicator, it is inserted using your finger to push it into your vagina. It melts and some women find it moisturising.
• Estriol 0.01% cream and comes with a washable applicator, but you could measure out the applicator dose and use your finger instead.
• Blissel TM is an estriol 50mcg gel. This is the lowest dose of vaginal oestrogen; it comes in a tube and is drawn up into an applicator.
• Vagifem TM or Vagirux are estradiol 100mcg vaginal tablets. These are tiny pessaries which come with with an applicator which can be reused and washed.
• Estring TM is an estradiol 7.5mcg/24h small flexible plastic ring. It is fitted into the vagina, by the doctor or by you, 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. You can continue to have sex with this in place.

There are two other medications used to treat vaginal symptoms related to urogenital atrophy of menopause.

• 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. It is easy to use but can damage latex condoms.

• 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 laser therapy

Laser therapy using CO2 or Erbium Yag laser are both recently developed treatments for GSM and can be helpful for women who have not shown adequate response to the treatments above, or in women where other treatments are contraindicated. Early studies have shown improvements in women, but long-term study results reporting safety and effectiveness are still awaited. This treatment is not available on the NHS.

What if things are not getting better on treatment?

Chronic vulval irritation is extremely debilitating and can have a significant effect on your mood, your well-being, and your relationship. Please see your doctor so they can examine you to check that the GSM diagnosis is right, as other common conditions can affect the vulva and vagina, and these need different treatment.

Last updated September 2023 Dr Carys Sonnenberg

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