Women’s Health Today

A newly dubbed condition that may help women talk about their menopause symptoms. 

It is estimated that as many as 50% of postmenopausal women will experience symptoms of genitourinary syndrome of menopause (GSM). However, the condition is not often diagnosed. Many women are too embarrassed or unable to find the words to talk about the sensitive nature of their GSM symptoms, which can range from sexual discomfort to frequent urinary tract infections. They may not know that these symptoms relate to menopause, unlike the hot flashes that they do tell their physician about. The decrease in estrogen and other sex steroids that occurs around menopause can lead to changes to a variety of structures including the vulva, vagina, urethra, bladder neck, and lower bladder.

As a woman ages and goes through her menopause, early detection and individually tailored treatment of GSM may be “paramount for not only improving quality of life but also for preventing exacerbation of symptoms in women with this condition” (Gandhi et al., 2016).

But is the notion that women live in a permanent state of hormone deficiency after menopause correct? The end of the fertile phase of a woman’s life has a biological function to protect her from pregnancy. So using hormones to treat menopause symptoms is not natural replacement, but medical therapy, which makes it important to weigh the possible benefits and harms against each other. That is not easy, either for patients or practitioners, when there is controversy over research findings and when women are not open about their symptoms or are fearful about available treatments.

Large studies, the Million Women Study (2003) and the Women’s Health Initiative (2002) pointed to a slight increased risk for deep vein thrombosis, coronary heart disease, breast cancer, and stroke seen with oral administration of estrogen, which raised concern and controversy. As a result, patients and providers became reluctant to use hormonal treatments in menopause (Rossouw, Anderson & Prentice, 2002). More recently, researchers have sought a reappraisal of the risks versus the benefits (Langer, 2017). The balance of benefit to harm always needs to be assessed but appears to have shifted (to some extent) favorably for hormone replacement therapy (HRT) in women under 60.

So what symptoms do women with this condition experience?

Symptoms of GSM

A need to urinate more frequently or urgently appears to be common in menopausal women. Many try to joke about their stress incontinence or the involuntary leaking when they cough, sneeze, laugh or otherwise put pressure on the bladder, for example, when exercising or lifting something heavy. This can range from being mildly surprising to extremely upsetting.

Nocturia can interfere with sleep if a woman wakes more than a couple of times in the night needing to get up to pee. She may also find she has to rush to the lavatory to open her bowels and/or that she is unable to control passing gas—farting in public is rarely funny unless you have a crude sense of humor! Constipation can be a problem too.

Body fat and visceral (belly) fat accumulation are associated with nocturia and stress incontinence and weight gain is common during menopause (Terauchi et al., 2015).

Urinary tract infections (UTIs) become more common during the menopause as do vaginal dryness, irritation, itchiness, burning, and pain during sexual intercourse.

These changes can happen as a result of the deterioration of the urinary tract and vagina and the name for this is “urogenital or vulvovaginal atrophy.” The atrophy occurs with the reduced production of the hormone estrogen and the loss of some elasticity that accompanies advancing age. Most muscles weaken as we grow older and the pelvic floor muscles that control the bladder and bowel are no exception. Weakened pelvic floor muscles—difficult births  add to the problem—can sometimes be involved in a prolapse or sagging of organs into the vagina.

The loss of elasticity means there is less stretch, so the bladder feels irritated as it fills with urine and if pelvic floor muscles have weakened, this combination makes control over urination more difficult.

What can help?

• A program of bladder training and pelvic floor exercises may help you regain more control.
• Estrogen cream, gel, tablet, suppository or a ring to insert into the vagina are sometimes prescribed to help with the symptoms of dryness, irritation, infection, or discomfort. Locally applied estrogen therapy is currently considered safe and effective for moderate-to-severe symptoms and does not carry the same risk as systemic hormone replacement therapies. Alternatives to estrogens are available to treat patients with a history of breast cancer, DVT, or stroke who may have concerns about using low-dose estrogen preparations. (Soe, Wurz,, & Kao, 2013;  Archer, 2015; Bouchard, Labrie, Archer, et al., 2015; Terauchi, Hirose, & Akiyoshi et al., 2015).
• Drinking cranberry juice is popularly recommended to help with UTIs, but Juthani-Mehta et al., 2016 found this to be little more than myth. The study used cranberry’s most potent components in capsule form to allow half of the women to take the equivalent of 20 oz of cranberry juice a day. The other half took a placebo. All were followed over a year, and had their blood and urine tested every two months for presence of bacteria associated with UTIs. The capsules did not seem to do much, either in reducing the amount of bacteria in the women’s urine or in lowering the number of UTIs during the study: both the women taking the cranberry capsules and the placebo had similar rates of both.
• Personal hygiene is very important during the menopause because of changes in vaginal bacteria. Always wipe from front to back.
• Maintaining a healthy weight is advisable because pelvic floor muscles carry your whole body. Women require fewer calories during and after menopause (sadly).
• Eat well, making sure to include plenty of fresh vegetables, fruit and fiber.
• Drink plenty of water (about 2 liters daily). Don’t have excessive amounts of caffeine, alcohol or fizzy drinks and when you drink any of these, follow with a glass of water as this will help to avoid bladder irritation.
• Exercise regularly. Walking is really good for you, and low impact. Even as little as half an hour spent walking daily is beneficial physically and mentally.
• Other health problems can complicate matters during menopause. If you have diabetes, you are more prone to nerve damage. Damaged nerves to the bladder or bowel cause a loss of feeling, insufficient emptying and constipation, so aim to keep your diabetes under control to avoid exacerbation of the problems.
• Go to the lavatory when your bladder feels full or when you get the urge to defecate and not simply because you are worried about going in advance to be on the safe side. Take time to empty your bladder and bowel completely by adopting a good sitting position on the toilet, leaning forward, elbows on knees, and support your feet on a footstool if that helps you relax your muscles better.

Talking about it

The International Society for the Study of Women’s Sexual Health and the North American Menopause Society recently endorsed the new term “genitourinary syndrome of menopause” (GSM) because it is medically more accurate, all encompassing, and publicly more acceptable than “vulvovaginal atrophy.” Other professional groups are adopting the new term too. Perhaps the change in language will help both women suffering the symptoms and their health practitioners to open conversations about what is happening during menopause.

Unlike hot flashes/flushes that mostly stop once a woman is postmenopausal (i.e. after she has gone 12 months without a menstrual period), genitourinary problems do not go away and are more likely to get worse with time, so women need to take care of their health and seek help if they are suffering.

References

Archer, D.F. (2015). Dehydroepiandrosterone intravaginal administration for the management of postmenopausal vulvovaginal atrophy. J Steroid Biochem Mol Biol. 145,139–143.

Beral, V. (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet. 362(9382),419–27.

Bouchard, C., Labrie, F., Archer, D.F., Portman, D.J., Koltun, W., Elfassi, E., et al. (2015). Decreased efficacy of twice-weekly intravaginal dehydroepiandrosterone on vulvovaginal atrophy. Climacteric. 18(4), 590–607.

Gandhi, J., Chen, A., Dagur, G., Suh, Y., Smith, N., Cali, B., Khan, S.A. (2016). Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynecol. 215(6),704–11.

Juthani-Mehta, M., Van Ness, P.H., Bianco, L., Rink, A., Rubeck, S., Ginter, S, Argraves, S., Charpentier, P., Acampora, D., Trentalange, M., Quagliarello, V., Peduzz,i P. (2016). Effect of cranberry capsules on bacteriuria plus pyuria among older women in nursing homes. A randomized clinical trial. JAMA 316(18),1879–1887.

Langer, R. D. (2017). The evidence base for HRT: what can we believe? Climacteric 20(2), 91.

Rossouw, J.E., Anderson, G.L., Prentice, R.L. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 288(3),321–333.

Soe, L.H., Wurz, G.T., Kao, C.J. (2013). Ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy: potential benefits in bone and breast. Int J Womens Health. 5, 605–611.

Terauchi, M., Hirose, A., Akiyoshi, M., Owa, Y., Kato, K., Kubota, T. (2015). Prevalence and predictors of storage lower urinary tract symptoms in perimenopausal and postmenopausal women attending a menopause clinic. Menopause 22(10),1084–90.

See too: Let’s Talk Menopause

Barbara Higham edits Women’s Health Today for Praeclarus Press.

Twitter: @WomensHealthEdu