Genitourinary syndrome of menopause (GSM), in addition to climacteric syndrome, has a significant impact on the quality of life in menopausal women. Lifestyle modifications should not be overlooked and should be accompanied by pharmacologic measures in the management of this syndrome.

Menopause affects approximately 14 million women in France alone. Between 20% and 25% of patients experience severe menopause-related symptoms, which significantly impact their quality of life. In France, GSM affects 25%-70% of women during perimenopause or menopause and can be highly debilitating.

Therefore, it is essential to know how to raise the issue and actively look for improvements in the quality of life of these women. In France, 48% of women younger than 50 years consider it difficult to talk about menopause, whether within their relationship or with their healthcare professional, and 34% of women aged 45-54 years said in 2019 that there was not enough information on this subject.

Identification and Risk Factors

GSM is a term used to define a compilation of signs and symptoms arising from decreased estrogenic stimulation of the vulvovaginal and lower urinary tract. The main signs and symptoms of GSM include burning, irritation, vulvovaginal dryness, dyspareunia, and urinary symptoms such as urgency, dysuria, or recurrent urinary tract infection.

Labial atrophy, vaginal introitus narrowing, and clitoral atrophy may also be observed.

Sexual symptoms, including introital dyspareunia and reduced libido (often related to pain), can significantly affect a patient’s ability to achieve sexual satisfaction.

A study conducted in Spain found that 75% of women with GSM reported that their symptoms affected their ability to experience sexual pleasure, and 66% noted an impact on sexual spontaneity.

Urinary symptoms include urinary frequency, urgency, nocturia, and incontinence. Urinary tract infections occur more often.

The main risk factors recognized to be associated with GSM, besides menopause itself, are the absence of vaginal childbirth, alcohol abuse, bilateral oophorectomy, decreased frequency and sexual abstinence, cigarette smoking, nonmenopausal hypoestrogenism, lack of exercise, (premature) ovarian failure, and cancer treatments via pelvic irradiation, chemotherapy, and endocrine agents.

Pathophysiology

The female genital and lower urinary tracts share a common embryologic origin and express estrogen receptors. Consequently, these tissues are affected by estrogen deficiency during menopause. Estrogen receptor activation stimulates the production of collagen, hyaluronic acid, and elastin, which are essential for maintaining vaginal mucosal health. Reduced levels of these proteins lead to thinning of the vaginal epithelium, resulting in irritation, pruritus, and mucosal sensitivity. Muscle atrophy impairs the contractile function of the bladder, urethral sphincter, and pelvic floor muscles. Loss of tissue elasticity contributes to vaginal dryness and deterioration of the genital tract integrity. 

These changes are also accompanied by an increase in vaginal pH and alterations in the vaginal microbiota, notably a decrease in lactobacilli. The vaginal microbiota plays a key role in preventing colonization by pathogens, including those responsible for sexually transmitted infections and urinary tract infections. A microbiota rich in Lactobacillus species is essential for maintaining vaginal health, whereas a lack of these bacteria is associated with increased susceptibility to infections and symptoms such as vaginal dryness.

Differential Diagnoses

Each symptom alone may indicate a specific diagnosis; however, in women undergoing menopause or perimenopause, it is important to consider the overall pattern of symptoms and rule out other potential causes of these symptoms. Isolated urinary symptoms should prompt a targeted evaluation of the urinary tract, including urinalysis with dipstick, urine culture, and ultrasound, to identify causes such as polyps or bladder cancer. Sexual symptoms, including reduced libido or dyspareunia, require assessment of the patient’s emotional and relational well-being, along with screening for depression or intimate partner violence. Similarly, genital symptoms appearing alone may reflect various gynecologic conditions, including infections, pelvic organ prolapse, and vulvar lichen sclerosus.

Treatment and Management

The therapeutic goal for GSM is to relieve symptoms by restoring vulvovaginal comfort, improving urinary function, and supporting sexual health. Lifestyle measures, such as stopping tobacco use and maintaining regular sexual activity, when possible, may help in reducing symptoms.

Local nonhormonal treatments are the first-line treatment for GSM, a chronic condition affecting vulvovaginal and urinary health in postmenopausal women. Options include water-, oil-, or hyaluronic acid-based lubricants and vaginal moisturizers, with hyaluronic acid especially useful for genital xerosis.

The French National College of Gynecologists and Obstetricians and GEMVi, a multidisciplinary study group on menopause and hormonal aging, recommend nonhormonal lubricants and vaginal moisturizers as first-line treatments.

The recommendation emphasizes that management must be individualized and should consider symptom severity, quality-of-life impact, and patient preference.

However, nonhormonal treatments are insufficient in a significant number of patients. Local hormonal treatment can then be considered the treatment of choice. Options include vaginal estrogen in the form of suppositories, rings, or creams, which restore vaginal pH, epithelial integrity, and microbiota balance. Dehydroepiandrosterone suppositories are also effective for vulvovaginitis and dyspareunia.

Systemic hormonal treatment may be required in selected cases. Tibolone has beneficial effects on the vagina and bladder. Ospemifene is particularly indicated for the treatment of severe dyspareunia and vaginal dryness.

CO₂ laser treatment is a nonhormonal alternative that has shown effectiveness, particularly for vaginal dryness and urinary symptoms. Treatment restores vaginal epithelium, microbiota, and pelvic vascularization.

GSM affects most postmenopausal women but remains undertreated despite the availability of effective treatments. General practitioners play a key role in the detection of this condition, and early management can improve symptoms and quality of life.

This story was translated from Univadis France.