Genitourinary Syndrome of Menopause
A VERY COMMON PROBLEM
GSM (previously known as vaginal atrophy or genitourinary atrophy) is a term used to describe the changes that can occur in the vulva, vagina, urethra and bladder when women reach menopause. These changes are common and are experienced by up to 50% of women post menopause. They can occur following natural menopause or surgical menopause. Unlike other symptoms of menopause such as hot flushes and night sweats, which can improve, symptoms of GSM persist and can worsen over time.
GSM can cause significant discomfort and distress and it is important that it is diagnosed and managed appropriately to reduce symptoms and improve quality of life.
WHAT ARE THE SYMPTOMS OF GSM?
Symptoms vary between individuals but can include:
- Vulval and vaginal irritation, pain, itching or burning.
- Vaginal dryness.
- Discomfort and pain with penetrative sex.
- Persistent discharge which has an offensive smell.
- Light bleeding as the tissues of the vagina become more fragile (if you have any bleeding post menopause it is very important to see a doctor and have this investigated).
- Weaker pelvic floor muscles that can cause urinary leakage when you cough, sneeze, jog etc.
- Bladder symptoms such as pain when your bladder is full, urgency when you need to pass urine (needing to rush to the toilet), and pain passing urine.
WHAT CAUSES GSM?
The symptoms caused by GSM are due to decreased levels of the hormone oestrogen post menopause. Oestrogen is important in maintaining the health of the tissues of the vulva, vagina and bladder. Oestrogen keeps the tissue of these areas thick and elastic, and when levels decrease the tissues become thinner, dryer, and less elastic.
The pH of the vagina also changes with decreased oestrogen and this can cause urinary tract infections as well as a condition called bacterial vaginosis which is an imbalance in the bacteria which occur in the vagina.
HOW CAN GSM BE MANAGED?
There are several ways that the symptoms of GSM can be managed and improved:
Use of vaginal lubricants and moisturisers:
The use of a vaginal lubricant during sex is very important to reduce friction and discomfort. Lubricants are either water-based or silicone-based. Personal preference is important and you may need to try a few to find what works best for you.
Silicone lubricants can provide a higher level of lubrication however they do not have moisturising properties.
Water-based lubricants can either provide lubrication only or can also act as a moisturiser, depending on their formulation. Using a lubricant which is also a vaginal moisturiser can be very helpful by reducing dryness as well as providing lubrication. If irritation and sensitivity are factors then you may want to use a lubricant for sensitive skin. There are several brands of lubricant which offer both lubrication and moisturising. This includes Astroglide which is available in pharmacies, supermarkets and online: astroglideaustralia.com
As discussed above there are water-based vaginal lubricants which also act as a vaginal moisturiser. There are also products designed specifically as a vaginal moisturiser, such as Replens. Replens is available in individual applicators which are inserted into the vagina. Each application lasts about 3 days. It is available through pharmacies as a 10 pack or 3 pack. Natural oils such as sweet almond oil, coconut oil or olive oil can also be used as effect vaginal moisturisers and lubrication. Any safe liquid substance which you find works for you is fine as well. Remember that if you are using condoms you need to avoid using oil as it is likely to increase the risk of condoms breaking.
Image: Natural oils such as sweet almond oil, coconut oil or olive oil can also be used as effect vaginal moisturisers and lubrication.
A form of oestrogen called oestriol is available in a cream or in pessaries. These are inserted into the vagina and can be very effective at reducing or relieving symptoms of GSM. The cream, in particular, is shown to be helpful and can be applied to the external tissues of the vulva as well. There is almost no absorption of the oestrogen into the body so it only acts on the local tissues, and there is also no need to take progestogen as is often the case for Menopause Hormone Therapy. Both forms of topical oestrogen are available on a prescription from your doctor. They are usually used every night for the first two weeks then two to three times a week ongoing. Vaginal oestrogen can be used alone or in combination with Menopause Hormone Therapy.
MENOPAUSE HORMONE THERAPY (MHT)
MHT (also known as hormone replacement therapy or HRT) is use of hormones (usually oestrogen and progestogen) in the form of a patch or tablet. MHT is most often used to relieve the other symptoms of menopause such as hot flushes and night sweats, but can also be effective in reducing the symptoms of GSM. MHT is only available on prescription.
You would need to discuss the use of MHT with your GP or make an appointment with one of the doctors at the Canberra Menopause Centre to discuss your suitability for MHT. Call 6247 3077.
VAGINAL LASER TREATMENT
Laser treatments for GSM have been available in Australia for a few years, however there is currently little evidence for the effectiveness of these treatments. There are clinical trials underway.
SEX AFTER MENOPAUSE
Although GSM can impact on your sex life, this does not need to be the end of it. The management discussed above can improve symptoms enough to allow you to continue to have and enjoy penetrative sex. Penetrative sex has been shown to assist in keeping the vagina healthy and the vaginal tissues more elastic. It’s also important to remember that penetrative sex is only a part of sex and intimacy, and if penetration is too uncomfortable then there are many other ways to enjoy sexual pleasure and closeness with a partner. Cuddling, massage, stroking, and mutual masturbation are just some of the ways to do this. Open communication between you and your partner is incredibly important of course, and can be the key to maintaining intimacy and a pleasurable sex life for many years to come. Dr Rosie King’s books Good Loving, Great Sex, and Where Did My Libido Go? are very useful books that discuss a lot of these issues and have very helpful suggestions.
If you find that you are having ongoing difficulties around sex then talking to someone may be very useful. SHFPACT doctors and nurses can give you further information about this and can refer you to a sex therapist.
MANAGEMENT OF URINARY SYMPTOMS OF GSM
Urinary symptoms may include a weaker pelvic floor, urinary leakage, urgency (needing to rush to the toilet), pain when your bladder is full, pain on urination, and getting up more frequently at night (nocturia). It is important to discuss these symptoms with your GP or a Canberra Menopause Centre doctor. Some of the treatments discussed above can improve urinary symptoms, and there are also medications available that can help. However if symptoms don’t improve, or are severe, then referral to a pelvic floor physiotherapist and/or a doctor who specialises in this area (a urogynaecologist) may be needed.
PAINFUL SEX BROCHURE PDF DOWNLOAD
Last updated Oct 2018. Australian Menopause Society. Jean Hailes for women’s health. RACGP. 2017 AFP: Genitourinary Syndrome of Menopause