Genitourinary Syndrome of Menopause (GSM)

Genitourinary Syndrome of Menopause (GSM)

GSM is the modern, umbrella term used to describe the collection of genital, urinary, and sexual symptoms that arise due to low sex hormone levels, primarily oestrogen deficiency, in menopause (whether natural, surgical, or in POI).

It replaces older terms like “vulvovaginal atrophy” because it more accurately reflects the wide range of tissues affected (vagina, vulva, bladder, urethra, pelvic floor).

Causes

• Oestrogen deficiency:

    ◦ Oestrogen maintains the thickness, elasticity, blood flow, and lubrication of the vaginal and lower urinary tract tissues.

    ◦ With reduced oestrogen (as in POI or natural menopause), tissues become thin, dry, fragile, and less elastic.

• Androgen deficiency (testosterone) may also contribute to reduced libido, vaginal tissue changes, and sexual dysfunction.

• Progesterone plays less of a direct role in GSM, but may influence vaginal epithelium and overall hormonal balance.

Hormones and their roles

• Oestrogen:

     ◦ Maintains vaginal epithelium thickness and glycogen content → supports lactobacilli → maintains acidic pH (protects against infection).

     ◦ Increases blood flow and elasticity → lubrication, less irritation.

     ◦ Supports urethral mucosa and bladder health → reduces urinary frequency, urgency, and recurrent infections.

• Testosterone:

     ◦ Contributes to sexual desire and arousal.

     ◦ May play a role in genital tissue sensitivity.

• Progesterone:

     ◦ Limited role in vaginal health, mainly regulates endometrial protection when systemic oestrogen is used.

How this affects women with POI

Women with POI experience hypoestrogenism at a much younger age, so:

•  They are at higher risk of developing GSM earlier in life compared to natural menopause.

•  Symptoms may be prolonged, given the earlier and longer duration of low hormone exposure.

•  This can significantly impact sexual health, urinary health, relationships, self-image, and quality of life.

•  Psychologically, it may compound the challenges of infertility and diagnosis.

Symptoms of GSM

•  Genital:

    ◦  Vaginal dryness, burning, itching

    ◦  Thin, fragile mucosa (prone to tearing/bleeding)

    ◦  Pain with intercourse (dyspareunia)

    ◦  Reduced elasticity

•  Urinary:

    ◦  Frequency, urgency, nocturia

    ◦  Recurrent urinary tract infections

    ◦  Stress or urge incontinence

•  Sexual:

    ◦  Painful sex

    ◦  Reduced arousal and orgasmic response

    ◦  Loss of libido (partly hormonal, partly secondary to discomfort)

Treatment options:

Non-hormonal approaches

•  Lubricants (short-term use during intercourse).

•  Vaginal moisturisers (longer-lasting hydration).

•  Avoidance of irritants (perfumed soaps, douches).

•  Pelvic floor physiotherapy.

Hormonal approaches

•  Local vaginal oestrogen (cream, pessary, ring):

    ◦  Very effective for GSM.

    ◦  Minimal systemic absorption, considered safe long-term.

•  Systemic hormone replacement therapy (HRT):

    ◦  Strongly recommended for women with POI up to the natural age of menopause (~51 years).

    ◦  Provides systemic oestrogen (and progesterone if uterus intact) → prevents GSM and protects bone, cardiovascular, and cognitive health.

•  Ospemifene (SERM):

    ◦  Oral selective oestrogen receptor modulator, used if local oestrogen not suitable.

•  Prasterone (DHEA) vaginal inserts:

    ◦  Converts locally to oestrogen and androgen, improving vaginal health.