Genitourinary Syndrome of “Menopause”: how and why to treat it
As most of you know, menopause marks a significant shift in our health, driven by the natural decline in estrogen and other hormones. One of the most affected systems is the genitourinary system—which encompasses our vagina, vulva (labia majora & minora), vestibule, clitoris (genito-), bladder, and urethra (-urinary).
The decline in hormones, mainly estrogen but also testosterone, leads to a condition known as Genitourinary Syndrome of Menopause (GSM).
Research shows as many as 84% of menopausal women are affected by GSM, and unlike other symptoms of menopause, which, for the most part, do tend to improve over time, GSM is a chronic and progressive condition, and it is essential to treat this condition proactively because if left untreated can lead to medical complications such as urosepsis.
It's important to note that this condition can also affect women at other stages of life when estrogen levels are low, such as during long-term use of oral contraceptives, lactation, and breastfeeding, premature menopause, or while taking medications that reduce estrogen levels—hence why in the title, I put menopause in quotations.
Hormonal Changes and Their Impact on the Genitourinary System
As estrogen levels decline during menopause, a cascade of changes affects the vulva, vagina, bladder, and urethra:
Vaginal Epithelium (“skin”):
With menopause, the epithelium becomes thinner, less elastic, and more prone to microtrauma.Loss of Elasticity and Moisture:
The decline in estrogen reduces collagen and elastin within vaginal tissues. This leads to a loss of elasticity and hydration, manifesting as vaginal dryness, which can cause discomfort during everyday activities and significantly impact sexual health, causing dyspareunia (painful intercourse).Changes in Vaginal Microbiota:
A healthy vaginal microbiome relies on estrogen-driven glycogen production, which nourishes lactobacilli. These bacteria produce lactic acid, maintaining a protective acidic pH. When estrogen declines, glycogen production decreases, disrupting lactic acid levels and raising vaginal pH (often above 5.0), increasing the risk of infections, irritation, and discomfort.Vulvar Changes:
Estrogen withdrawal can cause atrophy of the labia majora and minora. The vulvar skin becomes thinner, more fragile, and prone to irritation. Loss of subcutaneous fat in this area may also contribute to discomfort and an altered appearance.Urinary Tract Effects:
Estrogen receptors are abundant in the bladder and urethra, where they contribute to maintaining tissue integrity and function. Estrogen loss can weaken the urethral sphincter and diminish the mucosal barrier, leading to symptoms such as:Urgency and frequency (overactive bladder symptoms)
Stress urinary incontinence (involuntary leakage with coughing or sneezing)
Recurrent urinary tract infections due to the loss of protective barriers and changes in microbiota.
Blood Flow and Tissue Health:
Estrogen increases blood flow to genitourinary tissues. In its absence, diminished vascularity leads to decreased oxygen and nutrient delivery, further contributing to atrophy and thinning of vaginal and urethral tissues.
Treatment Options for Genitourinary Changes
The good news is that many effective treatment options exist to address these changes and alleviate symptoms. The goal of therapy is to restore tissue health, relieve symptoms, and improve quality of life.
The GOLD STANDARD treatment for GSM is estrogen therapy.
Estrogen directly addresses the root cause of GSM by restoring the health and function of estrogen-dependent tissues. It:
Promotes the proliferation of vaginal epithelial cells, reversing atrophy.
Stimulates blood flow and collagen production, improving tissue elasticity and hydration.
Enhances the vaginal microbiota, restoring a protective acidic environment.
Supports the urethral sphincter and bladder mucosa, reducing urinary symptoms and infection risk.
Estrogen Therapy can be administered in many forms:
Local Vaginal Estrogen: Available as creams, tablets, rings, and inserts, targets the affected tissues without significantly impacting systemic hormone levels.
The most often prescribed products as estradiol vaginal cream and Yuvafem vaginal tablets. Honestly, I love to use these two products together and have you apply a thin layer of the cream to the external skin and insert the tablet up inside the vaginal. This avoids the mess of the cream while getting all the benefits of internal and external vaginal estrogen application.
Imvexxy is an excellent branded product (the ovule-shaped pink product above) that comes in two strengths, 4mcg, and 10mcg. It does tend to be on the pricier side.
Estring is a 90-day vaginal ring that works really well and is a set-it-and-forget-it method. It does tend to be poorly covered on insurance plans and tends to be more expensive, but it is a great option if you can get coverage. Its sister product, Femring, is a stronger dose, offering systemic benefits as well as vaginal benefits.
Systemic Estrogen Therapy: For women experiencing systemic menopausal symptoms like hot flashes alongside GSM, systemic estrogen therapy may be enough to treat your vasomotor symptoms and GSM however see below.
Dual Therapy: Approximately 40% of women on systemic estrogen therapy will need additional localized estrogen therapy to adequately treat GSM symptoms. These two therapies complement one another and can be used in tandem.
How to use vaginal estrogen
When first prescribed, I typically recommend a 14-day loading dose where you use your vaginal estrogen product of choice every night for two weeks.
Then after this, you can take your dose administration down to 2 times per week. Some individuals will require more frequent dosing (e.g. 3-4 times per week) and this is okay too.
And remember, GSM is CHRONIC and PROGRESSIVE. Medication therapy is recommend till death do you part!
DHEA/Prasterone
Dehydroepiandrosterone (DHEA) is a precursor to estrogen and androgens. Vaginal prasterone, a DHEA-based product, FDA-approved as Intrarosa for GSM, works locally within the vaginal tissues to restore estrogen and androgen levels.
It tends to be more expensive than vaginal estrogen therapies and is dosed nightly as opposed to 2-3 times per week like estrogen products.
Testosterone/Androgens
Androgens, such as testosterone, may play a supportive role in improving sexual function and tissue health in postmenopausal women. Though their use is less common than estrogen, they can be beneficial for women with persistent symptoms.
Sometimes, when vaginal estrogens do not fully treat the GSM symptoms, vaginal estrogen/testosterone combination cream can be compounded as an alternative treatment.
Non-Hormonal Prescription Therapies
Ospemifene: A selective estrogen receptor modulator (SERM) approved for the treatment of dyspareunia associated with menopause. It acts on vaginal tissue to improve thickness and hydration without significant effects on the endometrium or breast tissue.
This medication is taken orally once daily.
Adjunctive Measures
Lubricants: Provide temporary relief during sexual activity by reducing friction and discomfort.
These are not a substitute for vaginal hormone products but rather meant to be used in addition to them during personal or coupled intimacy.
Moisturizers: Offer longer-lasting hydration by mimicking the natural moisture of the vaginal tissues. Unlike lubricants, they can be used regularly to address daily symptoms of dryness.
My favorite is hyaluronic acid suppositories. They work great on the days you are not inserting vaginal estrogen products.
I love Bonafide’s Revaree product, but if you are on a budget, Costco sells a jumbo-sized bottle of HA capsules that can be inserted vaginally.
Pelvic Floor Therapy: Working on pelvic floor muscle tone through physical therapy can help manage stress urinary incontinence and improve support for the bladder and urethra. It can also help with painful intercourse caused or exacerbated by hypertonicity in the pelvic floor built up from discomfort, tension, and guarding.
Lifestyle Modifications: Staying hydrated, avoiding irritants (like scented soaps or douches), can support overall genitourinary health.
The genitourinary changes associated with menopause can have a profound impact on quality of life, but they are highly treatable with the right approach. Do not suffer in silence!
