The Genitourinary Syndrome of Menopause - changes that affect the vulva, vagina, bladder and pelvic floor
Many women find that as their oestrogen levels decline they start to experience vaginal, vulval, bladder and pelvic floor symptoms.
These are collectively referred to as the Genitourinary Syndrome of Menopause (GSM).
The GSM is very common with estimates that somewhere between 47-84% of women experience some or other symptoms of GSM.
These may include:
• vaginal dryness
• decreased sensation making sex less enjoyable
• painful sex
• bleeding after sex
• tearing or bleeding of skin around the vulva
• shrinkage of vulval tissue
• an increased discharge
• increased frequency of UTIs or bacterial vaginosis
• burning and itching in the vagina or around the vulva (external areas) often mistake for thrush
• changes to bladder function including urgency, leakage, the need to urinate more often and waking at night to urinate
• weakness of pelvic floor supports leading to vaginal wall or womb prolapse.
Sometimes these symptoms can start before menopause, but they can also start several years after the menopause (the last period) and because of that the dots aren’t always joined and it’s put down to aging rather than declining hormones.
This may mean the right treatment or advice may not be given.
What’s happening?
The decline in oestrogen leads to changes in the mucosal tissue of the vagina, the vulvar skin and the muscles in the pelvic floor.
These include:
• a thinning of the mucosa or tissue that lines the vagina as well as the external skin
• a shortening of the vagina
• a decline in production of lubrication
• a change in the vaginal pH which changes the microbiome leading to more infections
• shrinkage of the clitoral hood and clitoris, and the labia majora and minora (the external and internal lips)
• a decrease in elasticity of vaginal tissue
• changes to the pelvic floor muscles that can result in less support for the vagina, bladder and rectum resulting in bladder issues and prolapse.
These symptoms can have a profound impact on quality of life. It can be difficult to sit, walk, exercise and sleep. They can affect relationships. Bladder symptoms can see women planning trips out around public toilet locations or in severe cases avoiding going out altogether.
What helps?
Topical oestrogen is the recommended treatment. This usually involves a very low dose of oestrogen that is applied into the vagina or around the vulva. It is considered to be very safe and could even be used by many individuals with a history of breast cancer (always consult your healthcare specialist for more information related to your specific situation).
Many people may be on systemic hormone replacement therapy/menopause hormone therapy (HRT/MHT) or tibolone but may find they need topical oestrogen in addition.
Topical treatments can be used long term with an annual review as symptoms can return if it is stopped.
Topical HRT preparations come in a variety of forms including creams, gels, pessaries and a slow-release silicon ring. Some contain oestradiol and others contain oestriol which are different forms of oestrogen.
There are pessaries that contain an androgen too called dehydroepiandrosterone (DHEA). DHEA is converted into oestrogen and testosterone and can also be effective in treating vaginal symptoms and may also have a beneficial effect on tissues below the mucosal layer, boosting collagen production and increasing tissue strength.
You do not need to take a progestogen to protect your endometrium with topical HRT medications in licensed doses.
Ospemifene is another option. It is an oral tablet that is taken daily and is what’s known as a selective oestrogen receptor modulator (SERM). It works by binding to oestrogen receptors and acting like an oestrogen to reduce symptoms like dryness and painful sex. It is useful for individuals who wish to avoid vaginal medications, however may cause hot flushes as a side effect.
If you have persistent vaginal or vulvar symptoms (with or without use of topical oestrogen), it is important that a trained healthcare professional takes a look to make sure there are no other reasons for your discomfort.
Pelvic Floor physiotherapy
Pelvic floor physiotherapy can be helpful with bladder issues and painful sex due to muscle issues. A proper assessment can tell if your issues are due to the muscles being overly tight and not relaxing properly, or if they aren’t strong enough. Pelvic floor physiotherapists can also help with bladder retraining, teaching you how to reduce the need to urinate urgently.
Novel treatments
There are now several laser, radiofrequency or electro-magnetic treatments available for vaginal and/or bladder symptoms. They may provide an option for those who cannot take HRT/MHT but currently there is very little quality research to say how effective they really are. Many of the studies are done by the manufacturers and so far, independent studies on lasers have reported little if any improvement after 12 months. These treatments are mostly provided in the private sector and can be expensive.
If you consider one of these treatments it is important to see a qualified practitioner who can assess your vagina and pelvic floor thoroughly as these treatments may not be suitable for everyone.
Lifestyle
There are things you can do to make yourself more comfortable including:
• Wearing cotton underwear
• Avoid soap and intimate washes
• Try hypoallergenic laundry detergent
• Avoid perfumed products like panty liners with a fragrance
• Do not douche (the vagina is a self-cleaning unit)
• Do not smoke – it constricts blood vessels, reducing blood supply to the region.
Lubes and moisturisers
Lubricants to make sex easier and moisturisers to relieve dryness on a daily basis may help.
There are a multitude of products on the market but look for ones that have a pH between 3.8-4.5 and an osmolality below 380 mOsm/kg. To find this information you may need to contact the manufacturer.
Avoid those that have fragrances, warming substances as they may irritate and parabens.
Products containing glycols and glycerine should be avoided if you’re prone to thrush. If you are using condoms as a form of contraception, a water-based lube is preferred as oil-based lubricants may reduce their effectiveness.
Genitourinary Syndrome of Menopause symptoms are unlikely to improve if they are left untreated. They may be ‘common’ but they are not ‘normal’ and your healthcare professional can advise on the best treatment options for you.
Reviewed: Sept 2024