Coined in 2014, this term replaced older designations like vulvovaginal atrophy or atrophic vaginitis.
How common is GSM?
GSM primarily impacts older women with 50-70% of postmenopausal women displaying GSM symptoms. Interestingly, even 15% of younger, premenopausal women might encounter similar symptoms, often linked to surgery or hormonal imbalances.
Nevertheless, GSM frequently goes unnoticed as women might refrain from seeking assistance due to embarrassment or misconceptions that these symptoms are a natural part of ageing.
“GSM frequently goes unnoticed as women might refrain from seeking assistance due to embarrassment or misconceptions.”
What can cause GSM?
Beyond natural menopause, several factors elevate the risk of GSM, such as no history of vaginal childbirth, alcohol misuse, ovary removal surgery, decreased sexual activity, smoking, lack of exercise and health conditions affecting the urinary and genital tracts. Recognising these factors aids in identifying individuals prone to developing GSM, enabling appropriate interventions.
How does GSM develop?
The decline in oestrogen during menopause affects oestrogen receptors in the urinary system, vulva and vagina. This leads to changes like thinner and less elastic tissues, modified muscle activity, reduced blood vessels, increased connective tissue and thinning of vaginal skin layers.
GSM symptoms and treatment
GSM manifests through symptoms affecting vaginal health, sexual life and urination.
Common problems include:
- dryness in the vagina,
- itching and discomfort in the vagina,
- pain during sexual intercourse (dyspareunia),
- insufficient lubrication during sexual activities,
- bleeding post-sex (post-coital bleeding),
- decreased sexual arousal and libido,
- difficulty in achieving orgasm,
- painful urination (dysuria),
- urgency in urination,
- stress/urge incontinence,
- recurring urinary tract infections.
The central objective of treating GSM is alleviating symptoms and enhancing the quality of life. Treatment options hinge on the severity of symptoms.
Prevalence of symptoms
Vaginal dryness becomes more common with age, affecting about 4% of people during early perimenopause, 25% a year after menopause, and 47% three years post-menopause. Severity varies with vaginal dryness and painful sex often causing the most distress.
Impact of GSM
Symptoms of GSM significantly affect a woman’s overall quality of life, as well as her relationships and social interactions. In contrast to certain menopausal symptoms that tend to improve over time, GSM symptoms endure and might worsen without treatment. This can lead to decreased self-assurance, intimacy challenges and even avoidance of sexual activity.
Diagnosing GSM
Diagnosing GSM can be complex as symptoms might be vague in approximately half of post-menopausal women. Healthcare professionals rely on medical history and physical examinations, particularly for peri- or post-menopausal women or those with low oestrogen levels.
“Diagnosing GSM can be complex as symptoms might be vague in approximately half of post-menopausal women.”
Complicating factors
GSM can be complicated by other medical conditions like lichen sclerosus, vulval eczema, stress or urge urinary incontinence and pelvic organ prolapse. Lichen sclerosus produces fragile white patches and itch on the vulva. Vulval eczema causes red, inflamed and itchy skin. Stress urinary incontinence leads to leakage when coughing or lifting. Pelvic organ prolapse occurs when pelvic tissues weaken and organs descend into the vaginal canal.
Management often involves a multidisciplinary team depending on the complicating factor. Always talk to your doctor about your symptoms and the best treatment plan for you. Treatment options include pelvic floor exercises, lifestyle changes and bladder training, medications, pessaries, creams or topical steroids.
Non-hormonal alternatives
There are a range of non-hormonal treatment options for GSM depending on how you are experiencing the condition and your personal preferences.
Lifestyle adjustments
Opt for emollients rather than soap for washing. Strive to maintain sexual activity using lubricants as described below, quit smoking and steer clear of irritants like perfumed products, non-cotton underwear and antibacterial cleansers that can disrupt the natural vaginal balance. All these measures can greatly alleviate symptoms.
Lubricants and moisturisers
Over-the-counter vaginal lubricants with water, silicone or oil bases provide rapid relief from dryness and discomfort during sex. Bio-adhesive vaginal moisturisers boost moisture and comfort. Brands include Yes (offering a range of vaginal moisturisers and lubricants), Uberlube (a reliable lubricant) and Replens (an accessible over-the-counter moisturiser in the UK).
Physiotherapy
Vital for addressing pelvic floor dysfunction, discomfort or urinary symptoms. Pelvic floor physiotherapists offer training and relaxation techniques.
Self-management
Pelvic floor exercises, mindfulness techniques, and lifestyle modifications are practical, non-invasive strategies that support vaginal and sexual health. These can be done privately and consistently, helping to ease symptoms of GSM. Self-care empowers women to take control of their well-being and fosters confidence.
Several therapeutic tools can be used at home to support vaginal health and comfort during menopause.
- Vibratory massage can gently stimulate the pelvic area, improving blood flow, arousal, and sexual sensation. This may help relieve dryness, reduced orgasmic response, and discomfort during sex. Normal vibrators can be used but there are also medical-grade vibrators designed for therapeutic use. Normalising their use and providing guidance on how to use them properly can improve outcomes.
- Pelvic wands are designed to release tight or painful pelvic floor muscles. They can also be helpful for vaginismus and chronic pelvic pain and are tools that are used with gentle pressure on specific areas. Deep breathing or mindfulness techniques before use can help relax the muscles and enhance comfort.
- Vaginal dilators help stretch and relax vaginal tissues that may have become narrow or tense due to menopause or medical treatments. Begin with the smallest size, apply a water-based lubricant, and insert slowly. Gradually move to larger sizes as tolerated. Regular use can restore flexibility and reduce discomfort.
Hormonal therapies
If you speak to a healthcare professional, they may recommend on of the following hormonal therapies.
Systemic HRT (oestrogen-containing medications)
Hormone therapy involving oestrogen stands as the standard approach for moderate to severe symptoms. This is given to women who are struggling with other perimenopausal or menopausal symptoms alongside GSM. It is called systemic as it is absorbed into all the organ systems of the body. It can be administered orally or via the skin alongside progesterone for women who have womb tissue.
Vaginal oestrogen
Vaginal tablets or creams are often favoured due to their efficacy for women struggling with only GSM. Low-concentration vaginal oestrogen treatments effectively alleviate symptoms like dryness, itching, and painful sex. These treatments enhance vaginal texture, natural lubrication and restore normal pH levels. They can be used alone or alongside systemic HRT. Clinical trials suggest minimal systemic absorption, reducing cancer and cardiovascular risks. Caution is advised for patients with oestrogen-sensitive cancers.
Emerging therapies
There are also a range of emerging therapies to which you may be referred.
Vaginal laser ablation (VLA)
A specialised treatment creating tiny abrasions in the vaginal wall to stimulate new blood vessel growth, temporarily enhancing the appearance of vaginal tissues. However, this approach is considered short-term as the absence of oestrogen can result in symptom recurrence.
Intravaginal dehydroepiandrosterone (DHEA)
This elevates sex hormone levels including oestrogen and testosterone locally in the vagina, helping to reverse vaginal atrophy and dryness.
Oral selective oestrogen receptor modulator (ospemifene)
A newer GSM treatment option, it is sometimes recommended for individuals who may struggle with inserting localised oestrogen into the vagina.
Consult a healthcare professional
GSM, stemming from decreased oestrogen levels during menopause, leads to challenges across various genitourinary areas. Its symptoms exert physical and emotional impacts on women. Timely diagnosis and proper management are crucial for enhancing the lives of affected women. If you experience these symptoms, consulting a healthcare professional is strongly advised.
