Genitourinary Syndrome of Menopause (GSM)
TREATMENT OF GSM
GSM is a chronic, age-dependent condition that progressively worsens and if left untreated, leads to worsening sexual dysfunction and urogynecological consequences such as urgency, frequency, and urinary tract infections. Over time if left untreated, certain irreversible changes, such as vaginal narrowing and pelvic floor spasm, will set in that become hard to reverse.
Therefore the most important thing is to institute treatment early and maintain it throughout life.
Goals of treatment:
Educate patients as to what to expect after menopause.
The healthcare provider should communicate freely with the patients without making them feel awkward about their sexuality and the changes that they may be noticing after menopause.
Encourage women to talk about this and prepare to manage this from their 40’s.
Make the patients aware of their different treatment options available to them singly or in combination.
Healthcare providers should encourage patients to talk about their sexual history at every visit.
Involve the patient AND her sexual partner in these discussions so that the couple feels comfortable to discuss these issues between them. Singling out the female patient and not involving the partner may make it hard for the patient to explain to him as to what is going on and what is expected of them, especially in the bedroom.
Impress upon the patient that the treatment has to be done on an ongoing basis as this is a progressive condition. This should be adjusted at set intervals based upon patient’s symptoms and complaints.
Provide the patient validated questionnaires that can be checked for comparison once treatment has been instituted.
Treatment options available for GSM
We tailor the management based upon the patient’s history, family history, gynecologic history, surgeries and medications. It is also important to assess how long has this problem of menopausal change been going on. Some women may have undergone removal of the ovaries in their 30’s and now at 50 years of age they are already 20 years without estrogen.
We look at how severe the changes are on gynecologic examination. Based upon history and examination, we then discuss the options with the patients in a fair and unbiased manner based upon facts and evidence.
Finally and most importantly, we always take into consideration the patient’s beliefs, her and her partner’s desires and we respect their hesitations and fears. Our final management protocol is appropriately tailored to the need of that particular patient.
Local (vaginal) and not oral estrogen is the treatment of choice if the only symptom is GSM. If the patient has other symptoms such as hot flashes and night sweats then oral estrogen may also be given.
Different estrogen preparations available:
Estrace vaginal cream, Vagifem vaginal tablet, Estring vaginal ring and Premarin vaginal cream are the most commonly used vaginal estrogen preparations.
All estrogen preparations are equally effective in relieving the symptoms of vaginal atrophy.
What is a black box warning?
A black box warning is the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug.
Does estrogen have a black box warning and what is it?
After the release of the WHI (Women’s Health Initiative) data, the US Food and Drug Administration (FDA) enforced a “black box” warning on postmenopausal hormone use in women which mentions about increased risks of heart disease, heart attacks, stroke, blood clots and breast cancer in postmenopausal women.
What should a woman do to make sure that she does not have any contraindications?
It is important to be aware of this above list of contraindications. Also, it is important to discuss certain other issues with Dr. Khandwala and his team such as if there is history of fibrocystic breast disease or a strong family history of blood clots or stroke or breast cancer. Is there any history of abnormal vaginal bleeding that should always be checked out before starting estrogen.
Does estrogen cause uterine cancer?
If estrogen is given alone for a long period of time there is a potential risk of uterine cancer. Hence we are very careful when administering estrogen alone in women who have not undergone a hysterectomy.
Do I need any specific tests done periodically when I am on estrogen?
Based upon your history and your family history, you may need additional testing (surveillance). Please make sure that you always provide to your healthcare provider the details of your personal, medical, family history and a list of all your medications.
How long should estrogen treatment be continued?
Since GSM is a chronic condition, therapy should be continued without interruption, because signs and symptoms will come back once the treatment is stopped. The frequency of treatment may change as eventually the patient could be just on maintenance dose and not daily dose therapy.
Is it safe to continue estrogen treatment for a long period of time? Is there any specific monitoring that is required when on estrogen therapy?
For local estrogen therapy, the safety data only goes up to 12 months. This does not mean that it becomes unsafe after that time.
The latest North American Menopause Society position paper recommends that if a woman is at high risk of endometrial cancer or is using a higher dose of vaginal estrogens, transvaginal ultrasound or intermittent progestogen therapy may be considered. The same paper states that with appropriate clinical surveillance, vaginal estrogens can be continued as long as bothersome symptoms are present.
What do you do in your practice?
We assess each patient individually and determine their risk benefit profile. For example patients who are obese and diabetic may be at increased risk of uterine cancer and they may qualify for an annual uterine ultrasound. We also adjust the treatment based upon any new medical information or treatment options.
Undiagnosed abnormal genital bleeding.
Known, suspected, or history of breast cancer
Known or suspected estrogen-dependent cancers such as that of the uterus
Deep vein thrombosis, pulmonary embolism or a history of these conditions
Arterial thromboembolic disease such as stroke, myocardial infarction-heart disease
Liver dysfunction or disease
MonaLisa Touch This is a fractional CO2 laser that is equipped with a HiScanDot scanning system which delivers laser energy in a uniform, accurate and controlled manner that creates patterns of micro-wounds that results in stimulation of collagen and a subsequent emergence of new healthy more youthful tissue.
What is the DEKA pulse?
The DEKA pulse shape is specifically designed for vaginal treatment with the MonaLisa Touch laser. it involves a two-part laser that provides a suitable thermal energy transfer to the connective tissue and the vaginal lining in order to stimulate the reparative process.
How much time does the DEKA pulse firing take?
This is done in milliseconds! It is impossible to even gauge how quick and precise it is. The power is transmitted just for that short time. The depth of penetration of the laser is only 200 microns.
Vagina under microscope after menopause
As can be seen in this picture the surface lining is very thin. The underlying tissue also lacks the (deep pink) connective tissue ground substance that is important for the nutrition of the vaginal lining and maintenance of the elasticity and stretchability of the vagina.
Vagina after MonaLisa treatment
The vaginal epithelium is thick and is now formed of many cell layers (20–40). The lower part of the epithelium is now indented by the underlying rich connective tissue creating numerous papilla or projections. This tissue has increased water content that not only hydrates the lining but also allows for an easier movement of nutrients from the blood vessels to tissues. the MonaLisa laser also activates the heat shock proteins (HSPs), specifically HSP47, which are critical for collagen biosynthesis. Collagen is important for maintaining the strength and the pliability (elasticity) of the vaginal tissues.
Thus, in 1-3 treatment cycles the negative changes of menopause on the vaginal epithelium and the support tissues of the pelvis are almost completely reversed.
What is involved in the actual procedure?
This is almost like a speculum examination. The laser probe is inserted into the vagina and the laser is activated while rotating the probe inside the vagina. Within 3-4 minutes the vaginal cavity is completely treated. The probe is then changed and the vulva (opening of the vagina) is treated.
Where is the procedure done?
It is done in our office in one of the exam rooms.
How long does the procedure take?
Each treatment takes about 5 minute. Patients receive three treatments, spaced six weeks apart.
Does the procedure hurt?
The procedure does not require anesthesia. Local anesthetic ointment is applied to the vaginal opening only if this area is also to be treated. Some patients may experience slight discomfort the first time the probe is inserted if there is severe vaginal narrowing or dryness, but the actual treatment is not painful.
Do I need to prepare or do anything prior to the procedure?
Make sure that you do not use anything inside the vagina for at least 48 hours prior to the MonaLisa Treatment. The laser does not work well if there is water as it is absorbed by water. We therefore wipe the local anesthetic from the vulva prior to treatment.
For which patients is this treatment appropriate?
The MonaLisa Touch is appropriate for all postmenopausal women experiencing symptoms of GSM.
Is this procedure safe for women with breast cancer?
Yes, the MonaLisa Touch therapy is particularly well suited for patients (like those with breast cancer) who cannot take, or prefer not to take estrogen therapy.
Will the procedure be covered by insurance?
At this time, the procedure in not covered by insurance. However, if you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), contact your insurance company for eligibility.
When will I see results?
Most patients feel improvement after the very first treatment, although the procedure calls for three treatments that are generally spaced over an 18-week period.
Once this is successful, how long does it last?
Patients should expect to come back annually for one maintenance treatment.
What are my limitations after the procedure is done?
Patients should refrain from sexual activity for 2-3 days.
- In 30 women followed for a year, 92% were satisfied with their treatment. All GSM symptoms: dysuria, burning, itching, dryness, dyspareunia significantly improved with the MonaLisa laser therapy.
- An Italian study observed that 85% of women who were not sexually active resumed intercourse just after one treatment cycle. Also all symptoms of GSM improved significantly. All patients had significant improvement in their quality of life and satisfaction scores.
What is a SERM?
A SERM or selective estrogen receptor modulator is a medication that works on select estrogen receptors only. For example the breast cancer drug Tamoxifen blocks the effects of estrogen on breast tissue but may act like estrogen and stimulate the lining of the uterus. Thus the SERM acts like estrogen on certain body parts and either have no estrogen function or may oppose estrogen action on other body parts. Hence they are selective in their function.
What is Ospemifene or Osphena?
It is a selective estrogen receptor modulator (SERM) that has positive effects on vaginal tissue without any effects on the breast tissue.
What is Osphena used for?
Osphena has been shown to significantly reduce the symptoms of dyspareunia and vaginal dryness compared with placebo.
How is it administered?
It is given as an oral tablet of 60 mg daily.
What are the side effects of Osphena?
The adverse events most commonly reported are hot flushes and muscle cramps.
When is Osphena contraindicated?
Contraindications include estrogen-dependent neoplasia (breast and endometrium), active or previous VTE, stroke or myocardial infarction and undiagnosed vaginal bleeding.
Has Osphena been shown to be safe over the long term?
The long-term safety of Osphena up to 1 year demonstrated no clinical or significant adverse effects on the uterine lining. No data exists beyond 1 year.
HOW TO IMPROVE SEXUAL EXPERIENCE
Vaginal moisturizers rehydrate dry mucosal tissue and are absorbed into the vaginal epithelium and adhere to the vaginal lining, thereby mimicking natural vaginal secretions. Vaginal moisturizers are intended to be used for the non-hormonal improvement of vaginal dryness and they are applied regularly, from every day to once every 2–3 days. Their frequency of use is directly proportional to the severity of atrophy (i.e. the more severe the atrophy, the more frequent the application), and their effects are more long-term than those of lubricants, lasting 2–3 days. Vaginal moisturizers provide this longer relief by hydrating the epithelium (osmolality) and lowering the vaginal pH, thereby maintaining vaginal moisture and acidity.
They are therefore particularly beneficial not only for women with symptoms of GSM that cause pain during sexual activity, but also for women who are not necessarily sexually active, but experience day-to-day discomfort due to dryness.
The WHO recommends that the osmolality of a personal lubricant/moisturizer should not exceed 380 mOsm/kg, in order to minimize any risk of epithelial damage; however, because most of the commercially available preparations greatly exceed this value, an upper limit of 1200 mOsm/kg is generally deemed acceptable in practice. Greater osmolality of personal lubricant/moisturizer may cause irritation and tissue damage.
It is important to also understand what other individual components are present in the lubricant/moisturizer as they may also have some deleterious influence on the vaginal epithelium.
Parabens are found in some personal lubricants, such as KY Jelly, Replens and Astroglide. Parabens are weakly estrogenic compounds and there is some debate as to whether they present an endocrine-disrupting risk. Ideally they should be avoided in women with estrogen sensitive breast cancer.
Glycols serve as humectants/emollients in lubricants, and glycerol/glycerine and propylene glycol are the most common. High concentration of glycols could increase the osmolality of the lubricant beyond that stipulated by the WHO and this can cause vaginal wall irritation.
Antibacterials such as nonoxynol-9, chlorhexidine in personal lubricants can cause inflammation of the genital mucosa and may increase the susceptibility to sexually transmitted infections and bacterial vaginosis.
Therefore it is important to understand not only the osmolality and pH of the lubricants/moisturizers but also the constituents.
These are plastic or rubbery round-tipped cylinders that come in sets ranging in diameter from about 3/4 inch to the width of a fully erect penis. They are used to stretch and relax the vaginal muscles and can be helpful in treating either vaginal stenosis (constriction or tightening) or vaginismus (involuntary tightening of the pelvic muscles).
What is the goal of vaginal dilator therapy?
A key part of treating vaginismus or genitopelvic pain penetration disorder (GPPPD) is learning how to relax the tight vaginal muscles to regain control over them. Dilator therapy aims to teach a woman that she is in control of her body and what enters it. By retraining her body and regaining control of her pelvic muscles, she can free her body from feeling that it has to protect her by tightening the vaginal muscles to prevent penetration. A physical therapist or cognitive-behavioral therapist may teach the relaxation techniques.
How to use the dilators:
For vaginal stenosis, women simply perform dilator therapy at home at their own pace during practice sessions of 5 to 10 minutes daily.
Instructions for dilator therapy may vary, but one method is to start with the largest dilator that comfortably fits into your vagina. The dilator should always be comfortable, as any discomfort may increase the possibility of involuntary tightening of the vaginal muscles (vaginismus). After putting a small amount of lubricant on the dilator, place it gently into the vagina. It doesn’t have to go all the way in to stretch the opening; halfway in will work. Slowly move the dilator in and out of your vagina, leaving it in for 1 to 2 minutes each time. Spend about 5 minutes on these exercises while you recline with a book, listen to relaxing music, or watch television. Perform these exercises once or twice a day until the dilator is no longer stretching your vagina. Then repeat the process with the next larger dilator.
Intercourse will be most comfortable if you can successfully use the dilator that is just slightly larger than your partner.
If you have intercourse often, you may not need to use the dilator anymore. If you have intercourse less than once a week, you may need to use the dilator in between to maintain what you have accomplished. Dilators are also useful when partners are separated for a while or when one partner is ill and not able to have intercourse.
All of the lifestyle practices that promote better sexual function in women—weight loss, exercise, eating right, stopping smoking, moderation in alcohol use, adequate sleep—do the same in men. In fact, the most common sexual disorder in men at midlife and beyond—erectile dysfunction—is often linked to having an excess waistline, vascular problems, heart disease, or diabetes. For that reason, practices like stopping smoking, maintaining a healthy weight, and exercising are particularly important to sexual health in men. Don’t be shy about nudging your partner toward healthier practices!
Getting his erectile dysfunction treated. Men have it lucky: there are a host of effective treatments for erectile dysfunction, from the oral drugs Viagra, Levitra, and Cialis to injected drugs, pellet drugs, and devices like the vacuum pump and penile band. The biggest obstacle may be getting your partner to mention his erection difficulties to his healthcare provider in the first place.
Addressing ejaculation problems.Early or premature ejaculation is a common and frustrating problem in men, although it’s less common as men age and gain more sexual experience.
Joining the patient in couples counseling or sex therapy.
Other issues to address with your partner:
- Prevent sexually transmitted infections: Once you’ve reached menopause, just because you can’t get pregnant doesn’t mean you can’t contract a sexually transmitted infection (STI). In fact, women with severe vaginal atrophy who are sexually active may be at increased risk for STIs since their dry, thin vaginal tissue is susceptible to small tears where infection can begin. Discuss sexual histories with your partner, and don’t let embarrassment compromise your health.
Always insist that a male partner use a condom for genital, oral, and anal sex unless you are in a long-term, mutually monogamous relationship. Never use petroleum-based products like Vaseline or baby oil to lubricate condoms because they can cause condoms to break.
Don’t let a male partner’s erection difficulties keep him from using a condom. If all else fails, get a female condom.
- Schedule regular date nights.
- Plan a mini-trip away from home.
- Toy around.Use sex toys that address both the partners’ needs. Experiment with different gadgets to see which is best that suits you and your partner.
- Venture beyond the usual. Try new positions, different times of the day, or different rooms in the house.
- Plan an erotic surprise.The surprise might be making your partner’s favorite dish for dinner or preparing a candlelit bath for two or greeting your partner at the door wearing nothing but a _______ (use your imagination).
- Indulge your senses.Create an environment for you and your partner that engages all of your senses. You might try silk robes, seductive music or reading the kama Sutra.
- Be romantic and playful.Slow dance. Read poetry to each other. Leave hidden love notes. Tickle each other. Cuddle and laugh. At its most basic, sex is a form of play and an expression of love.
Lifestyle modification: Smoking is clearly a risk factor for the genitourinary syndrome because it accelerates estrogen deprivation. A BMI greater than 27 kg per meter square and no physical exercise also leads to an increase risk of vaginal symptoms possibly because there is less vascular supply to the genitourinary area.
Sexual intercourse or masturbation decreases symptoms related to vaginal atrophy by improving elasticity and lubrication and increasing vascularization due to mechanical stimulus and therefore an improvement in symptoms such as dyspareunia.
Should one use sex toys such as a vibrator?
This is entirely up to the couple. Some of these gadgets allow for a very quick arousal especially in women who have dryness and manual stimulation could become painful. There are a lot of options and places to find these gadgets.
It is important to note that these act more as additional helpers to the main treatment of GSM.
Yoga can improve women’s sexual function, according to a 2009 study published in the Journal of Sexual Medicine. The study involved sexually active women ages 22 to 55 who followed a 12-week regimen of an hour of yoga each day followed by breathing and relaxation exercises. The study showed that their sexual function scores improved by the end of the program across all six of the areas studied—desire, arousal, lubrication, orgasm, satisfaction, and pain. The biggest improvements were in women ages 45 or older. About 3 in 4 of the women reported that their sex lives improved after completing the yoga program.