GSM often goes unnoticed, risking serious consequences and fatalities

MDlinx Nov 10, 2023

A recently published review explores a challenging reality in women’s health. The problem? Many patients’ quality of life and sexual health are affected by GSM, yet it is “sparsely studied, detected, and treated,” the authors state.

Wasnik VB, Acharya N, Mohammad S, Wasnik VB, Acharya N, Mohammad S. Genitourinary syndrome of menopause: a narrative review focusing on its effects on the sexual health and quality of life of women. Cureus. 2023;15(11).

“Only a few healthcare providers ask about the symptoms of GSM and a tiny percentage of women seek consultation for it. This may be because they are either embarrassed or believe it to be a part of the natural process of aging,” the authors continue.

What is GSM—and is there a lack of awareness around it?

According to Menopause, GSM is defined as “a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder.”

Portman DJ, Gass MLS, Panel on behalf of the VATCC. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the international society for the study of women’s sexual health and the north american menopause society. Menopause. 2014;21(10):1063.

Symptoms (not every patient will experience all of them) include:

Vaginal dryness, burning and irritation
Lack of lubrication,
Discomfort or pain
Impaired function during sex
Urinary urgency
Dysuria and recurrent urinary tract infections (UTIs)

While GSM certainly affects a patient’s life quality and sexual health, it can also be fatal due to the recurrent urinary tract infections it can cause, according to Rachel Rubin, MD, a board-certified urologist trained in sexual medicine.

Aggarwal N, Lotfollahzadeh S. Recurrent urinary tract infections. In: StatPearls. StatPearls Publishing; 2023.

Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The genitourinary syndrome of menopause: an overview of the recent data. Cureus. 12(4):e7586.

Mary Jane Minkin, MD, a gynecologist, certified menopause clinician, and co-director of the Sexuality, Intimacy and Menopause Program at the Smilow Cancer Hospital, says that the condition was ultimately renamed in 2014 because the term “atrophic” didn’t quite sit right with women.

“Lack of estrogen in the pelvis, which is what this is about, affects more than the vagina and vulva. The bladder and urethra have about as many estrogen receptors as the vagina, and menopausal women often suffer with recurrent UTIs and incontinence related to the lack of estrogen,” she says.

GSM has an awareness problem. “It’s not taught in med school…due to the very misogynistic culture we live in, as well as [an] inability to learn new things in the [medical] space,” Dr. Rubin says. Ageism is also at play, she says: “No one cares about [older people’s] sex life. And no one cares about urination.”

In a systematic review on GSM prevalence and treatment published in Menopause in 2021, researchers found that GSM was highly prevalent among women. “Nevertheless, women are frequently not aware of its cause and its treatment options,” the authors write. Their suggestion?: “The findings of this review underline the need for education of patients and healthcare professionals regarding GSM diagnosis and treatment options.”

Mili N, Paschou SA, Armeni A, Georgopoulos N, Goulis DG, Lambrinoudaki I. Genitourinary syndrome of menopause: a systematic review on prevalence and treatment. Menopause. 2021;28(6):706-716.

Diagnosing & treating GSM

“Diagnosing GSM is not a diagnosis of exclusion. It’s a diagnosis of inclusion,” Dr. Rubin says. “If a patient comes in with perimenopause, urinary frequency or urgency, a urinary tract infection, burning, irritation, vaginal dryness, pain with intercourse, diminished arousal…these are all symptoms of GSM,” she says.

Fortunately, GSM can be treated with easy-to-use and effective hormones. “We have data that says vaginal hormones prevent UTIs by half, and yet they’re only marketed as treatment for painful sex. Instead of [vaginal hormones] being a sex medication, it’s a bladder medication. It’s a life-and-death medication,” Dr. Rubin says.

There are different treatment options, including vaginal estrogen inserts, rings, and creams; vaginal dehydroepiandrosterone (DHEA); and an oral pill called ospemifene (Osphena). Patients must be urged to continue taking ospemifene for 2 to 3 months in order to ensure a healthy microbiome. Dr. Rubin stresses that patients should be told that these treatments are affordable “thanks to GoodRx.”

Dr. Minkin adds that the Food and Drug Administration's (FDA) “insistence” that vaginal estrogens carry a black box warning indicating that a risk of breast cancer also presents an issue. “There is very good data showing minimal absorption of vaginal estrogens. So many organizations, including the Menopause Society, have petitioned the FDA to remove the systemic estrogen black box warning as it terrifies many women and their partners,” she says.

Still, many MDs are unaware of the importance of these hormones, even though they should be ubiquitous. “If you can prescribe Tylenol, you can prescribe vaginal hormones,” Dr. Rubin says.

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