The Menopause Symptom That Won't Just Go Away

When considering the long list of symptoms associated with perimenopause and menopause, it sounds like a lifetime of misery. Hot flashes, night sweats, insomnia, low energy, fatigue, brain fog, low libido, vaginal dryness, bladder leakage, mood swings, and dry skin, just to name a few. It's symptoms like these that prompt conversations, internet searches, and medical attention.

One of the most pressing questions is whether any of these frustrating symptoms will get better as the years go on: Do we have to have a treatment plan for each individual menopausal symptom, or can we "just wait it out?"

The good news is that several signs and symptoms that appear in perimenopause happen because of the hormonal fluctuations that occur around the time of the menopausal transition. Hormones are produced in varying amounts in the years prior to menopause, and it is actually those fluctuations that cause things like brain fog, low energy, poor concentration, and poor sleep. The body thrives on stability, and there is much evidence that once the transition to menopause is complete, these symptoms in particular tend to improve, whether they have been specifically treated or not.

Also, many other menopausal symptoms, like hot flashes and night sweats, are often easily relieved by the right hormonal combinations or some nonhormonal solutions. However, there is one menopausal manifestation that can start to occur as early as the late thirties or early forties that will never get better without treatment and will progressively get worse as time goes on if not specifically addressed. It is called genitourinary syndrome of menopause and has an interesting history of diagnosis and treatment.

Genitourinary syndrome of menopause (GSM) was once viewed as primarily a vaginal condition, but it is now recognized as a chronic, hormone-related condition affecting the vagina, vulva, urethra, and bladder. It is treatable, but will not resolve on its own. It's a condition that causes discomfort, painful sex, and urinary conditions that do not have to be accepted as an inevitable part of aging.

The terminology around GSM evolved as physicians began to realize that the condition involved much more than the lining of the vagina. The traditional diagnosis focused on the thinning, dryness, and fragility of the vaginal tissue; this is associated with a deficiency in estrogen that happens after menopause. The old term was "vaginal atrophy" or "atrophic vaginitis," terms that suggested inflammation or infection, neither of which truly describes the condition completely.

After calling it "vaginal atrophy" for years, the term evolved to include the vaginal tissue and the vulvar skin, and it was renamed "vulvovaginal atrophy" (VVA). However, that term still did not include the full range of symptoms, including those affecting the urinary tract. The word atrophy implies that something is wrong or abnormal and also has negative connotations.

Then, in 2012, the North American Menopause Society and the International Society for the Study of Women's Health recognized the need for new terminology. In 2013, the new name became genitourinary syndrome of menopause (GSM), which encompasses genital, sexual, and urinary symptoms associated with declining estrogen and other hormones.

GSM can occur in perimenopause and menopause. It can also be triggered by medications and procedures that reduce the amount of estrogen in the body, including some cancer therapies. The list of symptoms associated with GSM is long:

• Persistent vaginal dryness
• Burning, itching, or irritation of the skin
• Reduced lubrication during sexual activity
• Pain with penetrative sex or skin contact during sexual activity
• Fragile tissue or fissures that occur during sex
• Loss of vaginal elasticity and narrowing of the vaginal opening
• Urinary urgency and frequency
• Burning with urination
• Recurrent urinary tract infections
• Urinary leakage

Although some of these symptoms can certainly be caused by other conditions, such as infections and skin issues, an examination and appropriate testing can rule those out.

Why Does GSM Happen?

Estrogen helps maintain the thickness, elasticity, blood flow, lubrication, and integrity of the vaginal and vulvar tissues. It helps maintain a healthy vaginal environment. As estrogen levels fluctuate in perimenopause and then decline in menopause, the vaginal lining and the vulvar skin become thinner and more fragile. This causes the discomfort and other symptoms experienced at midlife and beyond. Without treatment, this low-estrogen environment continues, and symptoms will progressively worsen. This affects bladder health, sexual activity, and quality of life.

Treatment

Treating GSM depends on the severity of symptoms, tissues involved, medical history, and personal preference. More than one treatment can be tried, and sometimes they can be combined to give the best relief.

Vaginal Moisturizers and Lubricants

For mild symptoms, moisturizers can be used regularly to relieve dryness. Many of them can also be used during sexual activity. They contain no hormones and are usually made of ingredients like hyaluronic acid or polycarbophil. They are temporary and can relieve symptoms, but they do not restore healthy tissue changes as effectively as estrogen-based treatments. Lubricants can be water-, oil-, or silicone-based and are made to be used during sexual activity for comfort.

Topical Vaginal Estrogen

For persistent, moderate, or severe symptoms, estrogen is often the most effective and best-established treatment, especially when multiple symptoms of GSM are present.

The most common options include prescription estradiol creams and estradiol vaginal tablets or inserts. These treatments improve vaginal tissue thickness and elasticity, lubrication, and symptoms of dryness and painful sex. Vaginal estrogen also helps prevent recurrent urinary tract infections in postmenopausal women. Vaginal estrogen treatment does not raise blood levels of estrogen, so there is evidence that it may be safe for women who otherwise are not candidates for systemic estrogen, the type used to treat hot flashes.

Because GSM is driven by a persistent reduction in estrogen, symptoms will usually return when or if effective treatment is stopped. This means it must be used as long-term maintenance therapy to continue to provide benefit. The use of vaginal estrogen should be reassessed periodically to be sure there is benefit; the exact ongoing regimen depends on the product and the patient.

Genitourinary syndrome of menopause is a common, treatable condition. It is nothing to be embarrassed about, and once recognized, it should be discussed with a health care professional so you can feel more comfortable again. Many clinicians do not bring up the topic, assuming everything is fine; don't be afraid to start the conversation yourself—your comfort, sexual health, and quality of life are worth it.