Genitourinary syndrome of menopause: Common problem, effective treatments

THE DIAGNOSIS IS CLINICAL

The diagnosis of GSM is based on the history and physical examination. Standardized diagnostic tools for GSM are lacking, but some tools are available.

In 2006, the US Food and Drug Administration (FDA) published guidelines for industry to better define patient-reported outcome measures in clinical trials.¹³ The most significant addition was having the patient define the symptoms and rate how “bothersome” the symptoms are. Although this measure does not help diagnose GSM, it can be used effectively to follow response to treatment.

The Vaginal Symptom Questionnaire¹⁴ can be useful for assessing symptoms. It is a validated 21-item questionnaire that measures the quality-of-life impact of genital, but not urinary, symptoms of menopause.

Ask patients about symptoms

Healthcare providers should ask about GSM symptoms (Table 1) during routine clinical visits with women who are peri- or postmenopausal or who have hypoestrogenism from other causes, as many women are reluctant to initiate this discussion. Conversely, in women who present with sexual problems, such as difficulty with arousal or dyspareunia, GSM should be considered as a possible cause.

Specifically, ask women if they have any of the following symptoms:

• Vaginal itching, burning, discomfort, or irritation
• Malodorous or irritating vaginal discharge
• Urinary frequency, urgency, dysuria, urethral discomfort, or recurrent urinary tract infections
• Sexual symptoms of entry dyspareunia, vaginal pain, or irritation with sexual activity, which may be complicated by postcoital bleeding, spotting, or fissuring.

Vulvovaginal pain or irritation may be constant or may be present in the absence of sexual activity, such as with exercise, wearing tight clothing, or sitting for long periods.

Physical examination

Characteristic physical findings of GSM include scarce pubic hair, thinning of the labia from loss of labial fat, resorption of the labia minora, or fusion of the labia minora and majora (Table 2).^15,16 The vulvar skin is pale and thin. The clitoral hood may retract, exposing the glans (which may lead to increased pain with sexual stimulation), or clitoral hood fusion may occur. The vagina is pale, dry, smooth, and shiny with loss of rugae; shortening or stricturing may be present. Vaginal elasticity decreases. Inflammation and petechiae (pinpoint, nonraised, round purple-red spots) may be present. The cervix may be flush with the vaginal fornices.

Prolonged atrophy may result in introital narrowing and friability, which may cause tearing with sexual activity or insertion of a speculum during pelvic examination. In addition, the epithelium of the lower urinary tract thins, and the muscular and fibrous layers atrophy—changes that may not be obvious during examination. A urethral caruncle may form, presenting as proliferative red tissue at the entrance of the urethra. Prolapse may become more prominent.

In women with severe genitourinary atrophy, pelvic examination may cause significant discomfort. Reassuring the patient that she can ask the clinician to stop at any time due to extreme discomfort is the first step in a successful pelvic examination.

In some situations, initial examination of the pelvic area may not include insertion of a speculum. Use of a hand-held mirror so the patient can observe the examination may help her relax during the examination.

Vaginal pH and cultures, if indicated, may be obtained by gently inserting a cotton-tipped swab into the vagina without a speculum and before applying lubricant. Lubricant should be used generously; in some instances, topical lidocaine gel (diluted, as it may burn) may be placed against the perineum on a gauze pad for 3 to 5 minutes before insertion of the speculum.

When an internal pelvic examination is necessary in a timely manner, such as with postmenopausal bleeding or a history of an abnormal Papanicolaou smear, but is too painful for the patient, the examination should be done under anesthesia.

Additional considerations

The history should review current medical conditions, medication use, nongenital skin disorders (eg, eczema), and systemic menopausal symptoms, such as hot flashes.

Also, consider other potential causes of GSM during the evaluation (Table 3).^17,18 Review the use of detergents, soaps, douches, or over-the-counter topical products that could cause genitourinary symptoms secondary to contact irritation or allergy.

Any isolated, ulcerated, or nonhealing lesion should be biopsied. Reevaluate patients who have not responded to previous topical therapy or consider referral to a specialist.

Assess the personal, interpersonal, social, and sexual impact of the symptoms: if they do not cause distress, GSM does not require treatment. Nevertheless, potential treatment options should be discussed as symptoms may progress, making intervention necessary.

Laboratory tests: Helpful, not essential

Laboratory tests are unnecessary for the diagnosis of GSM. However, office-based objective evaluations such as vaginal pH testing and the maturation index can support the diagnosis.

The pH of the estrogenized vagina ranges from 3.8 to 4.2, whereas in women with GSM, the pH may reach 5.5 or higher. The pH can be obtained by placing a pH-sensitive paper against the lateral vaginal wall, avoiding any discharge or cervical mucus. A vaginal pH of 5 or greater in the absence of blood, semen, or infection suggests vulvovaginal atrophy.¹⁹

The vaginal maturation index is determined by a vaginal smear using Rakoff staining, in which 100 cells are counted and the number of parabasal, intermediate, and superficial cells is determined. In general, a well-estrogenized vagina has mostly superficial and intermediate cells, which shifts to a predominance of parabasal cells as estrogen levels decline.²⁰

A recent review of vaginal atrophy suggests that after a diagnosis of GSM, healthcare providers can consider the most bothersome symptom along with the vaginal pH to assess the response to treatment.²¹ In general, schedule a follow-up appointment at 8 to 12 weeks to review treatment response. If treatment has not resulted in adequate symptom relief, consider a pelvic examination and further testing.