Genito Urinary Syndrome of Menopause (GSM) or Vulvo-vaginal Atrophy (VVA) an Unspoken Sorrow
American Journal of Internal Medicine
Volume 7, Issue 6, November 2019, Pages: 154-162
Received: Aug. 19, 2019;
Accepted: Sep. 26, 2019;
Published: Dec. 2, 2019
Views 521 Downloads 180
Shaikh Zinnat Ara Nasreen, Obs/Gyne Department, Z. H. Sikder Women’s Medical College & Hospital, Dhaka, Bangladesh
Safinaz Shahreen, Obst/Gyne Department, Watford General Hospital, London, UK
Saleheen Huq, Internal Medicine Department, Peterborough General Hospital, Peterborough, UK
Sabereen Huq, Urology Department, Uclh Hospital, Euston Road, London, UK
GSM includes wide spectrum of vulvovaginal Symptoms and urinary troubles replacing the term vulvovaginal atrophy (VVA). It is a silent epidemic condition affecting 50-60% postmenopausal women. Estrogen withdrawal causes thinning, narrowing, tissue loss & reduced blood supply in vulvo-vaginal area, which results GSM. GSM causes burning in vagina, dyspareunia, urinary urgency, repeated UTI. Dyspareunia affects all the domain of sexual function and deteriorates the quality of life. Irony is, women are oblivious to share and doctors are reluctant to discuss. So women keep continue suffering without knowing the restorative treatment. Repercussion of GSM/VVA intensifies the sorrows, distress and sufferings. It has profound effect on relationship and psychology and quality of life of women. Good history taking and clinical examination do diagnosis. Investigations are done to exclude other causes. Treatment is challenging. Maintenance of optimum body weight, exercise, regular coitus, quitting smoking & excessive alcohol intake are the key factors. Vaginal moisturizers are recommended as 1st line therapy for mild to moderate VVA or women who can’t take estrogen. Ideal moisturizers should have similarity with vaginal secretion of osmolality, pH and composition. Meta analysis shows local estrogen therapy is effective. It restores vaginal pH and maturation index. Systemic absorption is minimal so progesterone needs not to be added. Testosterone improves dyspareunia, sexual desire, lubrication and satisfaction. DHEA (Prasterone) penetrates vaginal wall better. It increases elasticity and vascularity of vagina. RCTs have not shown benefits of it’s systemic therapy. But local daily administration of DHEA reduces dyspareunia and GSM so improves the quality of life. Ospemifene is well tolerated. It’s agonist effect on vaginal mucosa and antagonist effect on endometrium and breast, makes it promising. Lasofoxifene, third generation SERM, is also very effective but it needs FDA approval. Laser is widely being used and very effective. It is simple, faster, painless procedure. It activates dominant fibroblasts, proteoglycans, hyaluronic acid, thereby improves GSM & sexuality. Black cohosh, Botox, G-shot, probiotics, gabapentin are not yet evidence based. Still there is significant unmet need for medical treatment. Women reports GSM but that is only tip of iceberg. Good communication and optimum treatment only can break the sorrows GSM/VVA.
Shaikh Zinnat Ara Nasreen,
Genito Urinary Syndrome of Menopause (GSM) or Vulvo-vaginal Atrophy (VVA) an Unspoken Sorrow, American Journal of Internal Medicine.
Vol. 7, No. 6,
2019, pp. 154-162.
Labrie F, Belanger A, Pelletier G, et al. Science of intracrinology in postmenopausal women. Menopause 2017; 24: 702–12.
Davis SR, Davison SL, Donath S, et al. Circulating androgen levels and self-reported sexual function in women. JAMA 2005; 294: 91–6.
Krychman M, Graham S, Bernick B, Mirkin S, Kingsburg SA. The women’s EMPOWER survey; women’s knowledge and awarness of treatment options for vulvar and vaginal atrophy remains inadequate Sex Med 2017; 14; 425-33.
Erekson EA, Li FY, Martin DK, et al. Vulvovaginal symptoms prevalence in postmenopausal women and relationship to other menopausal symptoms and pelvic floor disorders. Menopause 2016; 23: 363–75.
Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric 2014; 17: 3-9
Calleja-Agius J, Brincat MP. Urogenital atrophy. Climacteric 2009; 12: 279–85.
Lara LA, Useche B, Ferriani RA, et al. The effects of hyopoestrigenism on the vaginal wal: interference with the normal sexual response: J Sex Med 2009; 6: 30-9
Wysoki S, Kingsberg S, Krychman M. Management of vaginal atrophy: implications from the REVIVE Survey. Clin Med Insights Reprod Health 2014; 8: 23–30.
Santoro N, Komi. Prevalence and impact of vaginalsymptoms among postmenopausal women. J Sex Med 2009; 6: 2133-42.
Santoro N, Sherman S. New interventions for Menopausal symptoms. Bethesda MD: National institute ofs of health, UD Dept of Health and Huma Services, 2006.
Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary Syndrome of menopause: New Terminology For Vulvovaginal Atrophy From The International Society for the Study of Women’ Sexual Health and The North American Menopause Society. Climacteric 2014; 17; 557-63.
M. Shaprio; What should guide our patient management of vulvovaginal atrophy?; CILMACTERIC, 2019; volume 22; number 1; 38-43.
Baber RJ, Panay n, Fenton A; IMS Writing u group. 2016 ims Recommendation on women’s midlife health and menopause hormone therapy Climacteric 2016; 19; 109-50.
Freedman MA. Perceptions of dyspareunia in postmenopausal women with vulvar and vaginal atrophy: findings from the REVIVE survey. Womens Health (Lond Engl) 2014; 10: 445–54.
Barton DL, Shuster LT, Dockter T, et al. Systemic and local effects of vaginal dehydroepiandrosterone (DHEA): NCCTG N10C1 (Alliance). Support Care Cancer 2018; 26: 1335–43.
Willhite LA, O'Connell MB. Urogenital atrophy: prevention and treatment. Pharmacotherapy 2001; 21: 464–80.
Meisels A. The menopause: a cytohormonal study. Acta Cytol 1966; 10: 59-55.
Nappi RE, Cucinella L, Martella S, Female sexual dysfunction (FSD); prevalence and impact on quality of life. Maturitas 2016; 94: 87-91.
Worsley R Bell RJ, Gartoulla P, Davis SR, Prevalence and predictors of low sexual desire, sexuality related personal distress and hypoactive sexual desire dysfunction in a community based sample of midlife women. J Sex Med 2007; 14: 675-86.
Sidi H, Puteh SE, Abdullah N, Midin M, The prevalence of sexual dysfunction and potential risk factors that may impair sexual function in Malaysian women. J Sex Med 2007; 4: 311-21.
Johnston S. Urological concerns J Obstet Gynecol Can 2006; 28: 533-542.
North American Menopause Society. The role of local vaginal estrogen for the treatment of vaginal atrophy in post menopausal women.2007 position statemen of the North American Society of Menopause2007; 14: 355-69.
Mac Bride MB, Rhodes DJ, Shuster LT. Vulvovaginal atrophy. Mayo Clin Proc 2010;85: 87-94.
Nappi RE, Lachowsky M. Menopause and sexuality; prevalence of symptoms and impact on quality of life. Maturitas; 2009: 63; 138-41.
Palma F, Volpe P, Cagnacci A; as the writing Gropu of the AGATA STUDY. Vaginal atrophy of women in postmenopause. Results from multicentric observational study: The AGATA study. Maturitas 2016; 83: 40-4.
Kingsberg SA, Wysocki S, Magnus L, Vulvar and vaginal atrophy in postmenoausal women; findings from REVIVE survey, J Sex Med 2013; 10: 1790-9.
Simon JA, Komi J, Postmenopausal women’s attitude: Vulvovaginal atrophy and it’s symptoms. (NAMS Abstract LB-10) Menopause 2007; 14: 1107.
Goldstein I, Recognizing and treating urogenital atrophy in postmenopausal women. J Women’s health (Larchmt) 2010; 19: 425-32.
Nappi RE, NRd demelo, M Martiso, C Celis, Gonzaliz. VIVA study, Climacteric 2018, vol 21. No 4, page 397-403.
Kingsberg SA, Wysocki S, Magnus L, et al. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med 2013; 10: 1790–9.
27Kingsberg SA, Krychman M, Graham S, et al. The women’s EMPOWER survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment. J Sex Med 2017; 14: 413–24.
Kingsberg SA, Krychman ML. Resistance and barriers to local estrogen therapy in women with atrophic vaginitis. J Sex Med 2013; 10: 1567–74.
Chua Y, Lympaphayom KK, Cheng B, et al. Genitourinary syndrome of menopause in five Asian countries; results from the Pan Asian REVIVE survey, Climacteric 2017; 20: 73.
Simon JA, Nappi RE, Kingsberg SA, Maamari R, Brown V. Clarifying vaginal Atrophy’s impact on sex and relationship (CLOSER) survey; emotional and physical impact of vaginal discomfort on North America postmenopausal women their partners. Menopause 2014; 21: 137-42.
The North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013; 20: 888–902.
Kingsberg S, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med 2013; 10: 1790–9.
Hutcherson HY, Kingsberg SA, Krychman ML, et al. A positive approach to female sexual health: a summary report. Female Patient 2009; (Suppl April): 1–4.
Crandall CJ, Hovey KM, Andrews CA, et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s health initiative Observational study. Menopause 2018; 25: 11-20..
The North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause 2007; 14: 357–69.
Bachmann G, Lobo RA, Gut R, Nachtigall L, Notelovitz M. Efficacy of low-dose estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Obstet Gynecol 2008; 111: 67–76.
Lethaby A, Ayeleke R, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev 2016; 8: CD001500.
Rahn DD, Carberry C, Sanses TV. Vaginal estrogen for genitourinary syndrome of menopause. Obstet Gynecol 2014; 124: 1147–56.
Archer DF. Efficacy and tolerability of local estrogen therapy for urogenital atrophy. Menopause 2010; 17: 194–203.
Zeleke BM, Bell RJ, Billah B, Davis SR. Vasomotor and sexual symptoms in older Australian women: a cross-sectional study. Fertil Steril 2016; 105: 149–55. e1 41.
Santoro N, Worsley R, Miller KK, Parish SJ, Davis SR. Role of estrogens and estrogen-like compounds in female sexual function and dysfunction. J Sex Med 2016; 13: 305–16.
Labrie F, Archer DF, Kolitun W, et al. Efficacy of intra vaginal dehydroepiadrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause 2016; 23: 243-56.
Simio JA, Goldstein I, Kim NN, et al. The role of androgen in the treatment of genitourinary syndrome of menopause (GSM); International society for study of women’s Sexual health, expert consensus panel review. Menopause; 2018; 25; 837-47.
Constantine G, Graham S, Portman DJ, Rosen RC, Kingsberg SA Female sexual function improved with ospemifene in postmenopausal women with vulvar and vaginal atrophy: results of a randomized, placebo-controlled trial. Climacteric 2015; 18: 226–32.
Kozma B, et al. Orv Hetil. 2019; 160: (41): 1617-1622.
Nappi RE, Palacios S, Panay N, et al. Vulvar and vaginal atrophy in four European countries: Evidence from the European REVIVE survey. Climacteric 2016; 19: 188–97.
Giarenis I, Cardozo L. Managing urinary incontinence: Whay works? Climacteric 2014; 17 (suppl 2) 26-33.
Salvatore S, Nappi RE, Parma M, et al. Sexual function after fractional microablative CO2 laser in women with vulvovaginal atrophy. Climacteric 2015; 18: 219–25.
Salvator S, Nappi RE, Zerbinati N, et-al. A 12 week treatment with fractional CO2 laser for vulvo-vaginal atrophy: a pilot study. Climacteric 2014; 17: 363-9.
Pitsouni E, Grigoriadis T, Falagas ME, et al. Laser therapy for genitourianry syndrome of menopause. A systematic review and meta-analysis. Maturitas 2017; 103: 78–88.
Muhleisen AL, Herbst Kralovertz MM. Menopause and the vaginal microbiom. M aturitas 2016; 91: 422.
Carter J, Goldfrank D, Schover LR. Simple straties for vaginal health promotion in cancer survivors. J Sex Med 2011; 8; 549.