By Rebecca Nebel, PhD, Assistant Director of Scientific Programs at SWHR
In our previous Hormones Across the Lifespan posts, we gave an overview of genitourinary syndrome of menopause (a.k.a. vulvovaginal atrophy) and discussed the lower urinary tract symptoms that can accompany this condition. Despite the fact that genitourinary syndrome of menopause (GSM) is very common in postmenopausal women and nearly half of postmenopausal women experience symptoms from GSM, many women are unaware of this condition (1-3). So, for our final GSM post in our Hormones Across the Lifespan series, we’ll be addressing women’s conceptions and misconceptions about GSM.
There have been a few studies across the globe which surveyed postmenopausal women about their knowledge of GSM and GSM symptoms (1, 3, 4). Nearly 60 percent of surveyed women reported that GSM symptoms affected enjoyment of sex and 25 percent reported interference with each of sleep, general enjoyment of life, and temperament (1). Alarmingly, 55 percent of women reported experiencing GSM symptoms for 3 years or more (3). As we’ve mentioned previously, there are treatment options available for GSM, and symptoms can worsen without proper management (2, 5). So where’s the disconnect?
Lack of knowledge about GSM seems to be a major barrier in seeking help. For example, one study found that only 38 percent of the women they surveyed were aware of GSM (6), while another study reported only 4 percent of women attributed their postmenopausal symptoms such as vaginal dryness, itching, or burning to GSM (3). Others are hesitant to discuss their symptoms with their healthcare provider (HCP) or feel that their symptoms aren’t bothersome enough to discuss (1, 6). But patients aren’t the only ones not discussing GSM. About half of surveyed women reported that their HCP did not bring up postmenopausal vaginal health during their visits (1, 3).
Women who discussed their GSM symptoms with their HCP were twice as likely to be using treatment (1). The majority of women being treated for GSM were using non-hormonal products such as vaginal lubricants or moisturizers, which can help with mild vaginal symptoms (i.e. burning, itching, and dryness) (1, 3, 5). A smaller percentage, about 30 percent, were using hormonal treatments, such as local vaginal estrogen therapy, or a combination of hormonal and non-hormonal treatments (1). Local vaginal estrogen can improve both vaginal and lower urinary tract symptoms of GSM (7-11).
For postmenopausal women, one concern that remains is the safety of current GSM treatments, particularly hormonal ones. For example, about 30 percent of women reported concerns of increased breast cancer risk with hormone-based therapies (1, 3). The use of hormone replacement therapy, particularly a combination of estrogen + progestin taken orally, has significantly decreased after a study revealed an association between breast cancer and this combination therapy (12, 13). Although results from this study remain controversial, it is important to note that estrogen pills taken orally and local vaginal estrogen work differently. In estrogen pills taken orally, estrogen circulates throughout the body, whereas in local vaginal estrogen therapy, estrogen is absorbed by the vagina and the amount of circulating estrogen is limited. Data shows that even women with a history of breast cancer are not at increased risk for getting breast cancer again from using local vaginal estrogen therapy (14-16). And most recently, the American College of Obstetricians and Gynecologists recommended the use of local vaginal estrogen for treating GSM in women who had or are currently undergoing treatment for breast cancer, if they are unresponsive to non-hormonal treatments (17).
So ladies, you are not alone. GSM is not a just normal part of menopause and you do not have to grin and bear it. Safe and effective treatment options are available. If you are experiencing symptoms of GSM, please talk to your HCP and find out the right treatment options for you.
The Society for Women’s Health Research (SWHR®) believes that women should feel empowered to ask questions and educate themselves on changes to their health and bodies across their lifespan, including their hormonal health. To learn more about hormonal health across the lifespan, visit our website. Look for more information about hormones across the lifespan as we continue this series.
References:
1. Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. The journal of sexual medicine. 2013;10(7):1790-9.
2. Mac Bride MB, Rhodes DJ, Shuster LT, editors. Vulvovaginal atrophy. Mayo Clinic Proceedings; 2010: Elsevier.
3. Nappi R, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA)–results from an international survey. Climacteric. 2012;15(1):36-44.
4. REVEAL W. Revealing vaginal effects at mid-life: Surveys of postmenopausal women and health care professionals who treat postmenopausal women. Madison, NJ: Wyeth; 2009. 2012.
5. Society NAM. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902.
6. Freedman MA. Perceptions of dyspareunia in postmenopausal women with vulvar and vaginal atrophy: findings from the REVIVE survey. Women’s Health. 2014;10(4):445-54.
7. Casper F, Petri E, Group VRS. Local treatment of urogenital atrophy with an estradiol-releasing vaginal ring: a comparative and a placebo-controlled multicenter study. International Urogynecology Journal. 1999;10(3):171-6.
8. Eriksen PS, Rasmussen H. Low-dose 17β-estradiol vaginal tablets in the treatment of atrophic vaginitis: a double-blind placebo controlled study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 1992;44(2):137-44.
9. Foidart J-M, Vervliet J, Buytaert P. Efficacy of sustained-release vaginal oestriol in alleviating urogenital and systemic climacteric complaints. Maturitas. 1991;13(2):99-107.
10. Lose G, Englev E. Oestradiol‐releasing vaginal ring versus oestriol vaginal pessaries in the treatment of bothersome lower urinary tract symptoms. BJOG: An International Journal of Obstetrics & Gynaecology. 2000;107(8):1029-34.
11. Suckling JA, Kennedy R, Lethaby A, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. The Cochrane Library. 2006.
12. Investigators WGftWsHI. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Jama. 2002;288(3):321-33.
13. Chlebowski RT, Hendrix SL, Langer RD, Stefanick ML, Gass M, Lane D, et al. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women’s Health Initiative Randomized Trial. Jama. 2003;289(24):3243-53.
14. Le Ray I, Dell’Aniello S, Bonnetain F, Azoulay L, Suissa S. Local estrogen therapy and risk of breast cancer recurrence among hormone-treated patients: a nested case–control study. Breast cancer research and treatment. 2012;135(2):603-9.
15. O’Meara ES, Rossing MA, Daling JR, Elmore JG, Barlow WE, Weiss NS. Hormone replacement therapy after a diagnosis of breast cancer in relation to recurrence and mortality. Journal of the National Cancer Institute. 2001;93(10):754-61.
16. Ponzone R, Biglia N, Jacomuzzi ME, Maggiorotto F, Mariani L, Sismondi P. Vaginal oestrogen therapy after breast cancer: is it safe? European Journal of Cancer. 2005;41(17):2673-81.
17. Obstetricians ACo, Gynecologists. The use of vaginal estrogen in women with a history of estrogen-dependent breast cancer. Committee Opinion No. 659. Obstet Gynecol. 2016;127:e93-e6.
Reviewed by:
· Elizabeth R. Mueller, MD, MSME, Professor, Departments of Obstetrics/Gynecology and Urology, Loyola University Stritch School of Medicine, and SWHR Urology Network Chair.
· Cindy L. Amundsen, MD, Roy T. Parker Professor in Obstetrics and Gynecology, Associate Professor Surgery, Division of Urology, Duke University Medical Center, and SWHR Urology Network member.
· Candace Parker-Autry, MD, Assistant Professor, Department of Obstetrics and Gynecology, Wake Forest University, Baptist Medical Center, and SWHR Urology Network member.