Genitourinary Syndrome

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Introduction

Genitourinary syndrome of menopause GSM a new alternative terminology for vulvovaginal atrophy was first introduced in 2014 by consensus between the International Society for the Study of Women’s Sexual Health and the North American Menopause Society, it is a chronic condition affect women after menopause.

It is a chronic progressive conditions that describes the changes result from the decrease in estrogen level after menopause on  vulvovaginal and lower urinary tract. The majority of women may be affected after menopause but about 15%of  women may have symptoms pre-menopause, and may women consider it a normal process with aging process and they do not seek help or consider it a condition that need help so it remains underdiagnosed and they need medical awareness of their conditions. GSM symptoms may progress overtime if it left untreated.

Mechanism of Injury / Pathological Process

The vagina, vestibule, urethra, trigone of bladder contain receptors a and b for estrogen. However both receptors can be found in premenopausal women but during menopause only b receptors can be found. So the level of estrogen at urogenital tract will be decreased and will affect on the contractility and elasticity of organs. The stratified squamous vaginal epithelium is estrogen responsive, there will be changes in the vaginal epithelium thickness, blood flow, atrophy of smooth cells of vagina, loss of tissue elasticity, and the vaginal mucosa will be fragile and pallor. The labia minora consists of elastic fibers, dense connective tissue, and erectile tissue, there will be loss in the size of labia minora, decrease in the subcutaneous fat of labia majora, reduction in pubic hair, in addition, there will be a change in microbial environment of the vagina and an increase in vaginal PH.

That cause trauma and irritation during sex. Plus changes at the level of genital system the contractile ability of ureteral sphincter, and contractile coordination of pelvic floor muscle will be decreased.

Clinical Presentation

More than 45% of post menopausal women report some types of GSM, those with dryness and painful intercourse are the most common. In about 50% of post-menopausal women  the manifestations are mild and non specific and it is not necessary for all GSM symptoms to occur. Irritation, burning, itching of vulva or vagina are common symptoms of  GSM, and they are reported in 63.3% of the women with GSM. Symptoms of GSM appear to have a greater impact on the quality of life (QOL) specially in sexually active women, confidence and intimacy with their partner. Other signs and symptoms includes:

• Vaginal dryness.
• Dyspareunia (20% to 59%).
• Decrease or loss of arousal, orgasm, or desire.
• Vaginal vault prolapse.
• Post coital bleeding.
• Incontinence (stress or urge).
• Recurrent urinary tract infection UTI (8%-11%).
• Dysuria (7%- 13%).
• Urethral prolapse.
• Idiopathic overactive bladder.
• Interstitial cystitis.

Diagnostic Procedures

There is not specific or necessary diagnostic procedures to diagnose GSM and it depends on exclusion of other causes with similar symptoms such as chronic pelvic pain, vulvodynia, or dermatological conditions, but the measurement of vaginal pH, and assessment of vaginal maturation index (VMI) by taking a vaginal smear there will be an increase in parabasal cells and reduction in superficial cells are the most objective evaluation methods for GSM.

Outcome Measures

Vulvovaginal Symptoms Questionnaire.

Day-to-Day Impact of Vaginal Aging (DIVA) Questionnaire.

Management / Interventions

The management of genitourinary syndrome of menopause will depend on symptomatic relief and it is important first to exclude any other possible causes specially if there is vaginal bleeding it will be important to exclude cancer.

Medical management

Non- hormonal therapy:

• Vaginal lubricants
• Vaginal moisturisers
• Oral ospemifene (Selective Estrogen Receptor Modulator (SERM).
• Small dose of DHEA intravaginally (prasterone).

Hormonal therapy:

• Estrogen it will be delivered in to forms;

Systemic delivered oral, transdermal (patch or gel) or subcutaneous.

Vaginal systemically delivered estrogen with low dose to have a beneficial effect on the genital tissues.

Physical Therapy Management

Laser therapy

Its mechanism depends on the absorption of waves by lamina propria of vagina that is made mainly  of water, the absorbed energy allows the affected tissues to be covered by another healthy one (proliferation)  that will prevent pain,, and help in rapid recovery this stage  lasts for about 30 days. This absorbed and transmitted heat to water will help to stimulate collagen-producing fibroblasts (remodeling) and it lasts for 30–40 days. However it is effect foe women with GSM there is low data support its long term efficacy . any laser device with FDA approved can be used. the recommended sessions from previous studies for microablative fractional carbon dioxide (CO₂) laser, is usually used for  three sessions at five- to six-week intervals, but sessions can be up to 5 session for more benefits. A recent prospective cohort study found it was effective for treating symptoms associated with GSM; vaginal burning, dryness, and dyspareunia and these improvement lasts for 6-12 month after treatment.

Pelvic Floor Muscle Training (PFMT)

There are recent studies about effect of PFMT on GSM symptoms in case other options of treatment can not be available. In this study by Mercier in 2019 an intensive PFMT program, divided into three phases to help with gradual progression was used, the session was for 1 hour/ week and they had to do a home exercise program for 5 times/ week. It was conducted for 12 week, After termination of the study the outcomes showed PFMT can be effective for symptoms with GSM and  UI. In 2020, Mercier published a study on the mechanism of action of PFMT on symptoms of GSM. In this study color doppler ultrasound used to measure the pulsatility index of the internal pudendal and dorsal clitoral arteries before and after pelvic floor muscle (PFM) contraction task, a dynamometer used to assess PFM function, and Vaginal Atrophy Index for assessment of vaginal elasticity all was measure before and after termination. At the end of the study there was an improvement in the parameters of blood flow in both arteries, improvement in  PFM contraction, decrease in the tone of muscles in addition to improvement in skin elasticity.

Differential Diagnosis

Dermatological conditions related to vulva; vaginitis, lichen sclerosus, chronic vulvovaginitis, or eczema.

Vulvodynia

Chronic pelvic pain