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Genitourinary Syndrome of Menopause (GSM): Definitions & Management

Author Taylor Spurgeon-Hess covers Genitourinary Syndrome of Menopause (GSM): Definitions & Management on BackTable OBGYN

Taylor Spurgeon-Hess • Jan 16, 2024 • 60 hits

Genitourinary syndrome of menopause (GSM) presents a complex challenge in women's health, particularly in the post-menopausal phase. This condition, encompassing both genital and urinary symptoms, requires a nuanced understanding and a multi-faceted treatment approach. Read on to learn more about how GSM is defined, identified, and treated.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable OBGYN Brief

• Genitourinary syndrome of menopause is a comprehensive term for symptoms affecting the genital and urinary tracts in post-menopausal women, caused by hormonal deficiencies, including estrogen and androgen. Symptoms range from vaginal dryness and vulvar irritation to urinary discomfort and an increased risk of recurrent UTIs.

• A diverse range of local vaginal hormone supplementation options exists for the treatment of GSM including estradiol creams (Estrace), generic estradiol inserts, vaginal DHEA suppositories (INTRAROSA), and estrogen-releasing vaginal rings (ESTRING). These products cater to different preferences and medical needs, offering targeted GSM treatment.

• Estrogen-based vaginal suppositories, such as Vagifem and Uvifem, also play a role in GSM management. Providers should facilitate discussions on dosages, frequency, and patient adherence in order to achieve optimal therapeutic outcomes.

• Estrogen and DHEA play a crucial role in maintaining vaginal microbiome health and acidity, which is essential for preventing recurrent urinary and vaginal infections in post-menopausal women. Hormonal therapies contribute to tissue health and a balanced microbiome, thereby reducing infection risks.

Genitourinary Syndrome of Menopause (GSM): Definitions & Management

Table of Contents

(1) Defining Genitourinary Syndrome of Menopause

(2) Treatment Options for Patients with Genitourinary Syndrome of Menopause

(3) The Role of Hormonal Interventions in Decreasing Recurrent Vaginal & Urinary Infections

Defining Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause, a term coined in 2014, replaced “vaginal atrophy,” a now outdated title. The disease process manifests as much more than vaginal atrophy; GSM encompasses a broad range of symptoms affecting the genital and urinary tracts due to hormonal deficiencies (primarily estrogen and androgen). Symptoms include vaginal dryness, vulvar irritation, urinary discomfort, and an increased risk of recurrent urinary tract infections. This condition underscores the importance of comprehensive care beyond sexual activity considerations, highlighting the significant impact of GSM on overall urinary health.

[Dr. Suzette Sutherland]
We're talking about genitourinary syndrome of menopause, or also known as GSM. We hear a lot about this in the media, in our academic circles today, but unfortunately, we don't have a lot of information about it that's used readily for a lot of urologists and gynecologists. Rachel is doing a lot of work in this area, and that's what she's here to talk to us about today. Just to start off, can you actually simply define for us what is GSM and how is it primarily affected?

[Dr. Rachel Rubin]
Yes. No, thank you so much, because this is a topic that is near and dear to my heart. GSM, as you said, stands for genitourinary syndrome of menopause so genitals, but also urinary. It's a urologic condition. Now, we got this name in 2014 when a group of people sat in a room and decided that vaginal atrophy wasn't a very nice term. Not only is it not nice to tell a woman her vagina is atrophic, but it really doesn't describe what's actually happening to the tissue when it doesn't have the hormones that it so badly requires.

Now, this is a urologic problem, right? The urethra, the bladder, the vulva, it all requires hormones to stay acidic and to maintain a healthy microbiome and so it's not just vaginal atrophy, but it's the signs and symptoms that we see when there are no longer hormones in the tissue. The hormones are not just an estrogen story, but actually an androgen story as well. The symptoms can be, yes, vaginal dryness, yes, irritation of the vulva, but it can be itching, burning, dysuria, urinary frequency and urgency, bladder pain, which we all see quite frequently, and recurrent urinary tract infections, which we know can kill people. This isn't just a little vaginal dryness or a little vulvar atrophy. This is recurrent urinary tract infections, which are very dangerous for our patients.

[Dr. Suzette Sutherland]
That's great. Thank you for being so thorough with that. So many people really do think, well, it's just about my vaginal tissue, and if I'm not sexually active, then why do I need to replenish that vaginal tissue? But you just nicely pointed out many other areas that help with the health of the vaginal as well as the urinary system, recurrent UTIs, just localized burning, even urinary incontinence. It can help with some stress incontinence and certainly overactive bladder and urge incontinence. So it's not just about sex. Women think if I'm not sexually active, I don't need to use any vaginal supplementation, but that's just not true. There's so many wonderful benefits.

Listen to the Full Podcast

Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic with Dr. Rachel Rubin on the BackTable OBGYN Podcast)
Ep 33 Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic with Dr. Rachel Rubin
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Treatment Options for Patients with Genitourinary Syndrome of Menopause

Local vaginal supplementation has evolved significantly, and now clinicians can offer a variety of products. Estradiol creams such as Estrace and generic estradiol inserts are cost-effective and widely used. Other products include vaginal DHEA suppositories like prasterone (INTRAROSA), which uniquely incorporate androgen, and vaginal rings like ESTRING for prolonged estrogen release. These therapies, along with oral options like ospemifene, provide effective treatment choices for GSM.

Vaginal suppositories, including estrogen-based products like Vagifem and Uvifem, are essential in GSM treatment. They offer a low-dose, targeted approach to alleviate symptoms. The frequency of use and dosage can be adjusted based on individual patient needs, with some requiring more frequent application for optimal results. Patient education on proper usage and persistence with treatment is vital to achieving the desired therapeutic outcomes.

[Dr. Rachel Rubin]
We've had products since the 1970s. Premarin was the first to the market but since then, we have many more tools in our toolbox and I want to urge doctors to sometimes move away from things like Premarin. The reason is a lot of women don't like goopy creams in their vaginas. It can leak out, mess up their sheets and underwear, but also, Premarin is made from pregnant horse urine, which has some issues with animal cruelty and there's also some chemicals within it that can be irritating or burning.

Now, that being said, if it's the only product available to your patients, it's the best product available, but often, it's not even the cheapest product available. We have estradiol creams, that's your Estrace creams, which you can get on GoodRx or Mark Cuban's pharmacy for $20 a tube, which can last two and a half months. We also have generic estradiol inserts that are 10 micrograms that are fabulous to use every day for two weeks and then twice a week forever. We have branded vaginal estradiol inserts, so they're called Invexi. We have Intrarosa, which is vaginal DHEA, which is a nightly suppository that is fabulous because it's the only FDA-proof product that has androgen. DHEA is an androgen, which is really great. We also have vaginal rings. The ESTRING is a slowly producing estrogen ring that stays in for three months at a time. Now, those are the local therapies. There is one oral therapy called Ospemiphene, which has more systemic properties, and so I tend to use more of the local therapies, but it's approved and quite effective for genitourinary syndrome of menopause.

[Dr. Suzette Sutherland]
Great. You mentioned already some, too, that aren't specific estrogen supplementation, but of course, the downstream effect is still the same. Can you explain that a little bit more, go into detail how the DHEA and the SERMs, how that actually is beneficial in the estrogen side of things?

[Dr. Rachel Rubin]
Yes, I'll start with the DHEA. Now, this product is called Intrarosa. It's a once-nightly vaginal suppository. There's two ingredients, palm oil, and DHEAs, so there's not a lot of stuff in it. It comes with applicators that do get thrown away and they don't have to be reused. It's really important to know that the urethra, the bladder, the vulvar, and the vulvar vestibule tissue has lots of testosterone receptors in it, not just estrogen receptors, but testosterone receptors as well. Often that estrogen-only is often enough, but sometimes it's not. Sometimes that tissue at the opening of the vulva or the urethra is still irritated. What research is finding is that there is a lot of androgen story that we're not talking about because we don't have a lot of products. Well, DHEA is an FDA-approved product that adds androgen locally. The way it works is once you put it in, the body's own enzymes take the DHEA and turn it into both estrogen and testosterone. We presented data at the AUA this year, which won an award, which was very exciting, but that showed that you can decrease urinary tract infections by up to half. This goes into women in their 70s, 80s, and so on. Vaginal estrogen does that as well. It also reduces urinary tract infections and so this is a real preventative strategy that you can give to women.

We also have data that DHEA helps with urinary urgency and urinary frequency and so it's really a lovely product that I see is in your toolbox. Now, often first line is vaginal estrogen because it's often more affordable and better covered by insurance, but we certainly do get prior authorizations for our DHEA and they sample quite well. In terms of the aspemiphene or the CIRM, CIRMs like Tamoxifen is a CIRM, raloxifene is a CIRM. Well, aspemiphene is a CIRM that acts quite well on the vulvar tissue and so there are possibilities of other systemic effects. There is a very small risk of blood clots and things like that. In my older, older patients, I tend to stay away from that product. However, if you have a patient who really does not want to put anything vaginally, we all know we have those patients who it is a barrier. Aspemiphene can be a very great choice.



[Dr. Suzette Sutherland]
What's your experience with the suppositories? There are two that are on the market, the Vagifem, the Uvifem, are the estrogen suppositories. You also mentioned the Imvexi, but when I prescribe the Vagifem, you already mentioned it's 10 micrograms. It used to be 25 micrograms, and then they brought it down to 10 micrograms. What I find is oftentimes three times a week is really necessary to keep the woman where she needs to be. Do you have that same experience?

[Dr. Rachel Rubin]
Yes. Again, I'm not afraid of it, right? I think this is really the misnomers is so many people are messaging me on Instagram, Dr. Rubin, I'm perimenopausal. Is it safe for me to use this? Dr. Rubin, I'm breastfeeding, is it safe for me to use this? You sit there and you think, wait a minute. When you're breastfeeding, people give you birth control pills, which is like a nuclear bomb amount of hormones. Of course, a 10-microgram insert is totally safe for you to use. If you're perimenopausal, your own estrogen levels can get up to 600. Of course, it's okay to use 10 micrograms of estrogen and so, yes, I think three times a week is totally within reasonable limits.

Again, the worry is if you get very high with estrogen, which you don't with a 10-microgram insert, it's like the equivalent of 1 milligram per year of estrogen in your body. Whereas if I'm giving oral estrogen, which I hardly ever do, I usually do transdermal, but we give 2 milligrams a day of estrogen, right? It really becomes understanding the dose. This is such a low dose. If you wanted to use the insert, but you wanted to have them rub some cream on the opening, that's safe too, right? There's ways around it. Say they have some urethral or vestibule symptoms, well, you can do two things so that you don't have to do all creams. It's $20 a tube. That's kind of some of the workarounds that I use.

[Dr. Suzette Sutherland]
Well, and as you already mentioned, Mark Cuban's pharmacy has made it readily available to some. I've had some who've had some trouble with it, but most of the time these estrogens are pretty expensive on the patient's insurance plans and so if they're not using it appropriately, then they might as well just be flushing it down the toilet because they're not getting the benefit that they need. That's how I talk to patients. If you're using it one day a week, that's not enough to keep you where you need to be so don't even spend the money then.

[Dr. Rachel Rubin]
Letting them know that it's two to three months to start working. Mrs. Jones, if I gave you an acne treatment, it's not going to work tomorrow. It's going to take three months to start to see effects. The tissue has to regenerate, it has to heal, it has to plump up. Give me two to three months and then keep going. Two to three months. They really have to understand in that two to three months, their symptoms might not be immediately better. They may even get a yeast infection in which I say treat it with a Diflucan or whatever you use to treat yeast infections, but keep going with the vaginal hormones. Oh, this is a new one. Patients who say they feel itching with it. If it's not a yeast infection, has anyone ever had itching when a sunburn starts to heal? Your tissue's starting to heal and so it might be a little itchy. That's where I sometimes like the inserts as opposed to the creams because sometimes the ingredients in the creams can be itchy. The key is work with your patients to get the foundational product that really works for them and sometimes you've got to pivot a little bit, but don't give up. Don't go straight to your third-line OAB therapies. Get a foundational hormone product and then after two to three months, if they're still having symptoms, then of course go to your third-line therapies.

[Dr. Suzette Sutherland]
That's great advice. I think another practical piece is if the vaginal tissue is really not healthy. You have an older woman and it already looks to that almost reddish and angry stage, right? No wonder they're having a lot of burning and local irritation. They put the cream on and they say it stings and it burns so they stop. The analogy I give is if your hands are chapped, so dry and cracky, what are you going to do to fix it? You put on some cream. You know when you put it on and it burns, but you don't not put the cream on. You know I have to put on some more until it gets better. It's the same thing here. It might get a little uncomfortable until it gets to a stage where it's okay and then you won't have that burning anymore.

The Role of Hormonal Interventions in Decreasing Recurrent Vaginal & Urinary Infections

Hormonal changes during menopause significantly affect the vaginal microbiome, altering pH levels and reducing the prevalence of lactobacilli. This alteration increases susceptibility to urinary tract infections. Vaginal hormone therapies, including estrogen and DHEA, play a pivotal role in maintaining tissue health, acidity, and a healthy microbiome, thereby reducing the risk of recurrent infections. These hormonal interventions are crucial in the preventive strategy against UTIs in postmenopausal women.

[Dr. Rachel Rubin]
I wish I could replicate your infectious disease doctors because I wish more people understood how important the vaginal microbiome is to prevent urinary tract infection. The vagina would like to be a very acidic place with lots of lactobacilli supporting the tissue health so that it lubricates, that it's stretchy, that it's an acidic environment so that bad bacteria cannot grow. As we get older and we lose hormones in our body, now that's both estrogen and testosterone, and that can happen even before your periods stop, the tissue can change. Well, the tissue gets thin, it gets raw, it gets irritated, it loses acidity so that pH actually changes. I test this in my office, it's really fabulous. You can actually tell when the pH changes, the symptoms worsen and the microbiome changes and gets worse. You can grow E. coli, you can grow other bacteria that really will increase your risk of a urinary tract infection. Then you add sex or penetration, which is a contact sport. A lot of the outsides coming into the inside, but the problem is you get all of this change in the microbiome. The urethra is only four centimeters long or four, I don't know, how long? You're the urogynecologist. How long is the urethra?

[Dr. Suzette Sutherland]
About three centimeters.

[Dr. Rachel Rubin]
Three centimeters. All right. See, I was a little off, so it's very short and bacteria can kind of go in there and increase your risk of urinary tract infection. Vaginal hormones, either estrogen or DHEA, are there to bulk up the tissue to keep it acidic, keep that pH four and a half, to keep those lactobacilli growing, and so then when you have penetration or if you're just wearing tight yoga pants, the tissue doesn't increase your likelihood of getting a urinary tract infection. We can't prevent all UTIs, but man, we can prevent a lot of them.

[Dr. Suzette Sutherland]
Yes, those are great day-to-day examples too. Thank you for those. Let's move over into, there's this myth about the proper way to use the estrogen. You mentioned a little bit, especially when we're talking about creams, that seems to be the thing that's most widely used. I don't know if it's mostly due to insurance issues today, but estrogen cream. I hear people who come from other providers and they say, they told me to do a little pea size on the tip of my finger and I use it once to maybe twice a week or a little dab. Can you please speak to that? Debunk the myth and why.

[Dr. Rachel Rubin]
Let's debunk this myth and this is where Dr. Sutherland and I could scream from every rooftop available because it is not enough that you recommend these products to your patients. You must sell them. We as doctors are salespeople. You all are incredible. You sell your patients on urodynamics. Let me stick these tubes in your holes and test pressures. You sell your patients on InterStim. Let me put these leads into your spine and make you bionic. You sell people on prostatectomies. Hey, likelihood you'll have erectile dysfunction, but we're going to save you-- You sell patients every day. The problem is vaginal hormones in your mind are so easy that you forget to sell it.

You forget to explain why it's important and that's the whole story there. It's not that you don't know it's important and you don't know how to do it, but you're not getting it through to the patient that it's safe, that it's effective, and that it's actually probably the most important tool in their foundational bladder support. So I think that even if you give them the cream or the inserts, if you don't explain why, if you don't explain that it's used forever, and if you don't combat it with, hey, the box says some pretty egregious things that are not true, you're going to fail in this adventure of helping patients prevent urinary tract infections, and then you're going to call them non-compliant. I would argue it's not that they're non-compliant, it's that you're not a good salesperson. That little dab of estrogen on the urethra, it's not enough. You can't prove to me that it acidifies the vagina completely and fixes the microbiome. By telling patients to only use a dab, you are literally telling them any more might be dangerous, which is not true. So if you're going to use creams, it's okay to take a dab and put it on the urethra and put it at that vulvar vestibule, vulvar opening. That's great, but you've got to take at least a gram of this stuff. You could probably get away with half a gram, but let's say a gram every day for two weeks and then twice a week till death do you part.

Now if you're going to use creams, one hack that we use is take a gram and put it out on your finger so you don't have to reuse the applicator and rub it into the tissue, just like you're rubbing in sunscreen on your face, because women do not like how messy and goopy this cream can be. If your patient doesn't like the creams, be quick to pivot to a tablet insert like an Estradiol 10-microgram tablet that goes in every day for two weeks and then twice a week till death does she part, or the DHEA that goes in every night till death does she part, or the ring for your dementia or poor dexterity patients that goes in for three months at a time. So you have tools, but you have to make sure patients are actually using this stuff. I get pH paper in my office, and we can test that the pH is actually four and a half and I tell you, my after-hours and weekend phone does not ring with UTIs, every now and then but really, I'm not a UTI clinic.

Podcast Contributors

Dr. Rachel Rubin discusses Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic on the BackTable 33 Podcast

Dr. Rachel Rubin

Dr. Rachel Rubin is a urologist and sexual medicine specialist in North Bethesda, Maryland.

Dr. Suzette Sutherland discusses Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic on the BackTable 33 Podcast

Dr. Suzette Sutherland

Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 18). Ep. 33 – Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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