BackTable / Urology / Article
Genitourinary Syndrome of Menopause: Medical & Holistic Treatment Approaches
Ishaan Sangwan • Aug 27, 2021 • 113 hits
Genitourinary syndrome of menopause is a new term that describes a cluster of menopausal symptoms including dryness, atrophy, pain, dysuria, and recurrent UTIs. Genitourinary syndrome of menopause can often be misdiagnosed as a recurrent UTI, which leaves the underlying condition untreated. Treatment of genitourinary syndrome of menopause is multifactorial, and includes topical estrogen to tackle atrophy related symptoms, various medications for pain management, and intermittent antibiotic treatments to treat UTIs. Holistic therapy may involve a mental health professional and improved nutrition, and can supplement clinical therapy. Lastly, pain management is also important for managing genitourinary syndrome of menopause.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Vaginal estrogen supplementation, delivered as a cream or a vaginal estrogen ring, is a mainstay of genitourinary syndrome of menopause therapy.
• Antibiotics may be used to treat active infections, but should not be prescribed long-term.
• Involving a mental health professional may be helpful for psychosomatic symptoms of genitourinary syndrome of menopause, especially if the patient has a history of sexual violence.
• Consuming a healthy, fiber rich diet can also be beneficial, especially if the patient currently suffers from constipation, which can worsen symptoms.
• Chronic opioids and NSAIDs are not recommended for pain management of genitourinary syndrome of menopause. Vaginal baclofen and diazepam, nerve block injections, and neuromodulation are some good options.
Table of Contents
(1) Medical Treatment of Genitourinary Syndrome of Menopause
(2) Holistic Treatment of Genitourinary Syndrome of Menopause
(3) Pain Management in Genitourinary Syndrome of Menopause
Medical Treatment of Genitourinary Syndrome of Menopause
The medical treatment for genitourinary syndrome of menopause includes vaginal estrogen supplementation for at least six months. This medication may be applied incorrectly if used as a cream, so some patients may need to use a different mode of delivery, such as an estrogen ring. To manage pain, patients may try vaginal diazepam and baclofen. While antibiotics are prescribed to treat active UTIs, patients are usually not put on long-term antibiotics, as estrogen supplementation slowly changes the vaginal microbiome to be less susceptible to recurrent UTIs. In patients who are hesitant to try estrogen supplementation, such as those with a breast cancer history, suppressive therapies like methenamine, D-mannose, post-coital antibiotics, and RepHresh cream can be an option.
[Dr. Yahir Santiago-Lastra]
Their comprehensive treatment plan is going to include number one, vaginal estrogen supplementation. And it can be really hard because some women will say, "Oh, I tried vaginal estrogen and it didn't work." And what happens is that sometimes they're not applying it properly because just dabbing it in the front of the vagina is not going to be effective. So it's sometimes transitioning them to a different mode of estrogen delivery, like an estrogen ring for example. And then also explaining to them that this medication has to be tried for at least six months for it to achieve a full effect.
So when I tell them that it can be a disappointing thing to say because who wants to wait six more months for a treatment option to work? What we'll typically say then is that, "Look, this is what I think is going to be the investment that's going to keep you from getting these infections in the long-term. But in the short-term, this is what we can do." And we'll order them a standing urine culture so that whenever they have these symptoms, they can submit a urine sample and we'll treat them based on the sensitivities. For some women that are reliable, I'll also give self-start antibiotics if I can trust them to submit a urine sample before. And then for the levator myalgia, I really try to partner with them with a pelvic floor therapist so that they get pelvic floor physical therapy. And sometimes pelvic floor therapy can be really difficult for these women because of the pain.
And what I'll recommend then are also some locally delivered vaginal treatments like vaginal diazepam and baclofen. We have a really good relationship with a compounding pharmacy that will also make us some estrogen supplementation vaginally, because some commercially available estrogen products like Premarin for example, or like Vagifem, are going to be made in these moieties that can have certain components like polyethylene glycol and other sort of emollients that make them slippery. That can actually be very irritating to atrophic vaginal tissue. So in the beginning it may be really hard for them to apply. So sometimes I'll partner with a compounding pharmacy who will make me these ovules in almond oil, or even emu oil, there's one that offers it in emu oil, but those are a little better tolerated. The other way that a compounding pharmacy can be really helpful is that a lot of these treatments can be expensive. So we'll partner with them so that they can offer lower cost options to patients who maybe can't afford the vaginal estrogen that's covered by their insurance.
[Dr. Jose Silva]
And for those patients that have the symptoms and always have a positive urine culture, do you treat the positive urine culture always? Or do you start suppression therapy until you figure it out? Or do you try to get rid of it? How that period of time until everything's settle down, do you give them antibiotics?
[Dr. Yahir Santiago-Lastra]
It's on a case-by-case basis. But as a general rule, I will try to not put patients on long-term antibiotics. Sometimes there are exceptions to everything because medicine is an art and not everybody's going to follow the pathway that you have set out for 80, 90% of patients. But some patients, for example, will refuse to try vaginal estrogen. One common group that feels very uncomfortable with it are patients that have a breast cancer history, and patients who have recently been diagnosed with breast cancer who are on anti-estrogen treatments, because we have demonstrated efficacy and safety of vaginal estrogen supplementation in post-menopausal breast cancer survivors. But there isn't a lot of data about what we do with peri-menopausal or pre-menopausal women who have breast cancer who are on anti-estrogen treatment.
So those women, I'll often partner with their oncologist to determine whether or not they would be candidates for estrogen supplementation. Some oncologists are very much on board with that for quality of life purposes, but even so some patients are very concerned about it. So those are patients that may not want to proceed with estrogen supplementation. So for those patients, we still have to change the microbiome environment of the vagina to make it less likely that they will experience UTIs. And again, remember this assumes these women have a completely normal genitourinary tract. So it completely changes if they don't empty their bladder all the way, or if they have these other anatomical issues. But we're talking about a woman who voids completely normally, has had a completely normal urologic history who all of a sudden, with loss of estrogen or with getting older, has started developing all of these urinary symptoms associated with potentially menopause.
So for those women who do not want to do vaginal estrogen supplementation, there are other things that you can try. There's RepHresh cream that helps stabilize the vaginal pH, and that can be beneficial. But often you will have women who are having UTIs who will not use estrogen. And those women, sometimes you have to think about other suppressive therapies like methenamine, D-mannose if they get e-coli infections, and also prophylactic nightly or postcoital antibiotics, although that's not my preferred route. Sometimes I'll use these for six months at a time, reassess, see how the patients are doing and then make decisions.
Listen to the Full Podcast
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs.
Follow the button below to get started with CMEfy.
Stay Up To Date
Holistic Treatment of Genitourinary Syndrome of Menopause
A holistic management of genitourinary syndrome of menopause is useful since some bladder related issues in this condition can be associated with stress. It is important to ask if the patient is a survivor of sexual violence, as this may worsen pain symptoms, and make it harder for patients to administer local treatments. It may be helpful to partner with psychology to address the emotional and physical consequences of trauma. Lastly, it’s also important for the patient to consume a healthy high fiber diet in order to avoid constipation, as chronic constipation can also worsen symptoms.
[Dr. Yahir Santiago-Lastra]
So I've tried to implement holistic treatments within my practice because I do think that for a lot of women, similar to how patients can have irritable bowel syndrome associated with stress, there can be some bladder related issues also associated with stress. So for example, I'll partner with pain management if the pain component is a huge issue. And through pain management service we do have pain psychology, and they do a great job at pain mitigation and stress reduction. I will also, as part of my comprehensive history, try to get an understanding of the psychosocial environment of that woman. And another thing that I think is really understated in urology and in the evaluation of these women is that a lot of these women can be survivors of sexual trauma, and that can be a big component of the pain. So if I feel comfortable with this patient, or if there is something in the history of this patient that suggests to me that she's high-risk for some of this gender violence or sexual violence, I will ask them and you'll see sometimes that the truth is very painful for them to share, but it is something that contributes to how they feel.
So for those women, I also counsel to seek beyond the treatments that I offer organically, and to also look at not just stress management strategies, but also treatments directly related to addressing the emotional and physical consequences of that trauma. And it is more common than we think. And also getting a really bad UTI is traumatizing in and of itself. So we definitely make sure that they're cared for in that sense, and we do partner a lot with psychology. I try to do it in a way that patients don't get the impression that I'm saying that things are all in their head, because these are patients that are really symptomatic and in pain. But I just emphasize to them that this is a stressful situation, that it takes a psychological toll on them to be sick and to be needing antibiotics all the time, and that they need support not just for their pelvic floor, but also for the psychology behind it and that seeking care for that can be really useful.
In addition to that, I always encourage them to try a really healthy diet and to avoid processed foods as much as possible, because I do think that the diet does play into a lot of the ailments associated with the bladder and the bowel. One way, for example, is if they're eating foods that make them chronically constipated and constipation is a huge issue when it comes to bladder and pelvic floor health, so I'll make sure that patients have a comprehensive diet plan to control their constipation. And if there is constipation on their exam, I will recommend to them to try some kind of bowel regimen. And I always tell them the bowel and the bladder are like two wings on the same bird, and you may know that from our Puerto Rican sayings, but yes, and absolutely related and is very important to address.
Pain Management in Genitourinary Syndrome of Menopause
Pain management of genitourinary syndrome of menopause rarely involves opioids, unless the patient is newly post-op. Ganglion block and pudendal nerve block injections, as well as neuromodulation are effective pain management options. NSAIDs may be prescribed for flare ups, but should not be prescribed long-term. Other treatments include vaginal baclofen and diazepam, vaginal lidocaine and gabapentin, and in some cases, vaginal ketamine. Medical marijuana is also a treatment option in legal states, and both vaginally delivered and systemic cannabis have a relaxing effect on pelvic pain, especially for patients with dyspareunia.
[Dr. Yahir Santiago-Lastra]
So I only really prescribe opioids to my post-op patients and those patients get very few opioids. I don't think that opioids have a strong role in the management of pelvic floor disorders or pelvic pain. Occasionally, I will have patients that will ask and I typically will recommend to them if they have already been on those opioids that we collaborate with a pain management specialist, but it's extremely rare that they will prescribe them as well. We typically try to find them an alternative pain management route, either through injections. A lot of these patients will also have lower back pain issues, so sometimes ganglion blocks, pudendal nerve blocks and other things can really help. There's also neuromodulation that can be really helpful, and I partner with my pain management specialist to try dual pain stimulator and sacral neuromodulation concomitantly.
So that will be another strategy. But opioids play an extremely limited role and I honestly can't remember the last time I prescribed an opioid to a patient with pelvic pain. And then with regards to NSAIDs, I typically try not to prescribe NSAIDs because I don't want to rely on a medication that when used chronically, and this is a chronic problem, that when used chronically can cause some adverse effects. So what I'll usually prescribe them or recommend to them is pyridium for flares. And I rely heavily on the vaginally directed treatments like the vaginal diazepam or the vaginal baclofen. And I have patients who are even on this mixture of vaginal lidocaine, Gabapentin. And I've had patients come to me with even vaginal ketamine, which is really interesting and I don't tend to prescribe, but some pain management specialists will use that as well.
Another new kid on the block, as far as pelvic floor treatments for pain are concerned is cannabis. In California, obviously we have had a very strong medical marijuana treatment paradigm. I don't prescribe it, but I do have a lot of patients that I send to colleagues that specialize in medical marijuana. And sometimes vaginally delivered cannabis, or even systemic cannabis will have a relaxing effect on the pelvic pain, especially for women who have dyspareunia.
Dr. Yahir Santiago-Lastra
Dr. Yahir Santiago-Lastra is an associate professor of urology and the director of the Women's Pelvic Medicine Center at UC San Diego in California.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, July 28). Ep. 12 – Management of Cystitis & Pelvic Pain Syndrome [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.