SOAP. – Genitourinary Syndrome of Menopause

Genitourinary Syndrome of Menopause

Cheryl A. Glass and Rhonda Arthur

Definition

A.In 2014 the International Society for the Study of Women’s Sexual Health (ISSWSH) and the North American Menopause Society (NAMS) reached a terminology consensus on the change in language to genitourinary syndrome of menopause (GSM) for vulvovaginal atrophy (VVA). GSM is medically more accurate, and all-encompassing. 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.

Incidence

A.GSM is very common and is thought to affect about 50% of postmenopausal women, ranging from mild to debilitating. Symptoms of GSM are also present in preadolescence, postpartum, and during breastfeeding.

B.Unlike the low-estrogen state in postmenopausal period, vasomotor symptoms often improve over time. GSM, however, is chronic and progressive and encompasses premenopausal to the elderly female population. Women do not need to display all of the symptoms for the diagnosis of GSM. Symptoms include the following:

1.Dryness, burning sensations, and irritation in the genital area.

2.Dyspareunia.

3.Urinary frequency, pain with urination, urgency, nocturia, urinary incontinence (UI), or recurrent urinary tract infections (UTIs).

Pathogenesis

A.Decrease in estrogen and other sex hormones.

1.Lack of sufficient estrogen promotes an increase in vaginal pH that supports the development of bacterial infections. Estrogen loss also results in a decrease in vaginal glycogen and a thin-walled epithelium, promoting friability and inflammation.

2.The female genital tract and the lower urinary tract share a common embryonic origin. As such, estrogen plays an important role in the function of the lower urinary tract.

B.Anatomic changes occur, including reduced collagen, decreased elastin, and fewer blood vessels.

C.Physiologic changes result in reduced vaginal blood flow, resulting in decreased lubrication, flexibility, and elasticity of the vaginal vault and increased vaginal pH.

Predisposing Factors

A.Preadolescence.

B.Postpartum.

C.Breastfeeding.

D.Perimenopause.

E.Postmenopause.

F.Ovarian failure.

G.Medications:

1.Aromatase inhibitors.

2.Antidepressants.

3.Anticholinergics.

Common Complaints

A.Vaginal dryness, irritation, and/or bleeding.

B.Dyspareunia.

C.Dysuria.

Other Signs and Symptoms

A.Postcoital bleeding.

B.Thin vaginal discharge.

C.Vaginal itching.

Subjective Data

Because patients may be reluctant to volunteer information about GSM symptoms, ask specific questions about the presence, severity of symptoms, and impact on her quality of life and sexual function.

A.Question the patient regarding onset, duration, and course of symptoms.

B.Is this a new problem? If so, review the use of a new soap, laundry detergent, or hygiene products.

C.Describe the color, amount, and odor of vaginal discharge or bleeding.

D.Determine existence of coexisting vasomotor symptoms, such as hot flashes.

E.Is she experiencing any or all of the symptoms of GSM, dysuria, urinary frequency, vulvar dryness and itching, or dyspareunia? With dyspareunia, ask the patient if discomfort occurs with foreplay or pain occurs with deep penetration, or both.

F.Determine if the patient is breastfeeding and for what length of time.

G.Ask the patient the date of her last menses and if she is having irregular cycles. Determine if the patient had a hysterectomy with oophorectomy or ovarian failure.

H.Review the number of the patient’s sexual partners and any new sexual practices.

I.Review the patient’s current medications, including antidepressants and medications with anticholinergic side effects.

J.Explore whether she is currently taking or whether she has stopped hormone therapy (HT).

K.Has the patient tried any self-help measures? Was there any relief?

L.When was her last Pap smear, and what were the results?

M.Review all medications, including over-the-counter (OTC) and herbal products.

N.Review her medical history, specifically for diabetes, urinary system dysfunction, autoimmune disorders, and breast cancer.

Physical Examination

A.Check temperature (if infection is suspected), blood pressure (BP), pulse, respirations, height, and weight to calculate body mass index (BMI).

B.Inspect: Observe the patient generally for discomfort before, during, and after pelvic examination.

C.Palpate:

1.Back: Check for costovertebral angle (CVA) tenderness.

2.Abdomen: Note suprapubic tenderness.

Pelvic Examination

A.Inspect:

1.Examine external genitalia for friability, erythema, lesions, condyloma, and amount and color of discharge.

2.Sparse and brittle pubic hair, shrinking of the labia minora, and inflammation of the vulva may be noted in menopausal women.

3.The vulva may appear erythematous, and there may be labial edema.

4.Excoriation may be present if the woman has complained of pruritus.

B.Palpate: Milk urethra for discharge to rule out infection.

C.Speculum examination:

1.Check rugae, friability of vaginal epithelium, and color and amount of discharge; evaluate cervix for lesions, friability, and erythema.

2.Typical atrophic symptoms on inspection: Thin, friable vaginal epithelium; decreased or absent vaginal rugae; scant vaginal discharge.

3.A pediatric speculum may be needed for geriatric women due to a narrowed introitus.

4.If the speculum examination cannot be completed, it should be delayed until HT has had

adequate time to alter the introitus.

D.Bimanual examination:

1.Check for cervical motion tenderness (CMT), uterine size, and position (if no hysterectomy).

2.Check adnexa for masses.

Diagnostic Tests

A.Serum hormone levels should only be measured when clinically indicated. There is no laboratory blood test that will confirm or negate the diagnosis of GSM. There is no cut-off serum concentration for any sex steroid below which most women will experience GSM symptoms.

B.Vaginal pH—measure the pH of the vaginal vault secretions:

1.pH of a healthy vagina ranges from 3.5 to 5.0.

2.Normal pH in premenopausal women is 4 to 4.5.

3.pH may reach levels of 5.5 or higher in women with GSM and can be considered an indicator of vaginal atrophy due to hormonal deficiency.

C.Wet prep:

1.Multiple white blood cells (WBCs) indicate inflammation, may show increased bacteria, and may have decreased lactobacillus, suggesting atrophic vaginitis.

2.Test should be negative for Trichomonas. Bacterial vaginosis (BV): Whiff test should be negative.

D.Pap smear with maturation index. (Vaginal wall maturation index evaluation is controversial.)

E.Cultures for gonorrhea (GC) and Chlamydia trachomatis (CT), if applicable.

F.Urine culture, if applicable.

G.Ultrasound for uterine lining thickness (<4 or 5 mm suggest loss of estrogenic stimulation).

H.Endometrial biopsy, if indicated.

I.A vulvar biopsy may be indicated.

Postmenopausal vaginal bleeding, however scant or infrequent, must be thoroughly investigated to rule out the possibility of endometrial hyperplasia or endometrial cancer.

Differential Diagnoses

A.GSM:

1.Preadolescence.

2.Breastfeeding.

3.Perimenopausal.

4.Postmenopausal.

B.Ovarian failure.

C.Trauma.

D.Foreign body in the vagina.

E.UTI.

F.Vaginitis from infective cause: fungus, bacteria, or virus.

G.Contact irritation: latex (condom), spermicide, lubricant.

H.Dermatologic conditions of the vulva (e.g., lichen sclerosus or planus, eczema).

I.Vulvodynia/vaginismus.

J.Autoimmune disorders.

K.Chronic pelvic pain.

Plan

A.General interventions: Treat any underlying infections (GC, CT, vaginitis) as diagnosed.

B. See Section III: Patient Teaching Guide Genitourinary Syndrome :

1.Women should be reassured that this problem is physical, not emotional, and that about half of women experience these same symptoms.

2.Treatment should be individualized therapy dependent on the woman’s symptoms, sexual function, relationships, and quality of life.

3.Discuss the benefits of regular sexual activity to decrease problems of genitourinary symptoms. An important reason for decreased sexual activity is unavailability of a partner. Masturbation also facilitates the natural resumption of the production of lubricating secretions by the body. Decline in sexuality is influenced by culture and attitudes as well as physical problems.

4.Symptomatic relief of dryness during sexual activity may be obtained with the use of water-soluble lubricants and adequate foreplay. Lubricants are used to reduce friction and dyspareunia related to vaginal dryness. There are many commercially available lubricants. Coconut, olive, or sweet almond oils are natural alternatives.

5.Vaginal moisturizer for relief of symptoms.

6.Discuss pregnancy prevention and inform that perimenopausal symptoms do not ensure lack of fertility.

7.Refer for pelvic floor therapy for training and relaxation to help reduce symptoms.

8.Discuss the use of vaginal dilators for the vaginal introitus.

9.Pessary.

10.Fractional CO2 laser therapy.

C.Pharmaceutical therapy:

1.Calamine lotion may be applied externally for local symptomatic relief.

2.Estrogen therapy (ET): An individualized approach should be taken with all hormone therapies (HTs). Discuss risks versus benefits with the patient and consider patient goals and preferences. Benefits of ET appear to outweigh risks in most women younger than 60 or within 10 years of menopause:

a.Vaginal hormonal therapy (preferred over systemic hormone replacement if symptoms are confined to the vagina):

Absolute contraindications for use of ET also apply to use of topical estrogen (breast cancer, active liver disease, history of recent thromboembolic event). Vaginal estrogen creams are systemically absorbed. As with use of oral and transdermal estrogen, a progestin must be administered to women who have an intact uterus, secondary to the risk of endometrial hyperplasia or cancer.

i.Conjugated estrogen (Premarin) cream 0.625 mg/g; use 0.5- to 1.0-g applicator inserted intravaginally at bedtime every night for 1 to 2 weeks, then every other night for 1 to 2 weeks, then as needed. Not for daily use if the patient has an intact uterus.

ii.Estradiol (Estrace) 0.1 mg/g, one-half (2 g) to one (4 g) applicator inserted intravaginally at bedtime every night for 1 to 2 weeks. When vaginal mucosa is restored, maintenance dose is one-quarter applicator (1 g) one to three times weekly in a cyclic regimen. Not for daily use if the patient has an intact uterus.

iii.Estradiol acetate transvaginal ring (Femring) 0.5 mg a day to 0.1 mg a day. Insert one ring per vagina and replace every 90 days.

iv.Estradiol (Estring) 7.5 mcg/24 hr, insert one ring per vagina and replace every 90 days.

v.Estradiol hemihydrate (Vagifem) vaginal tablets 10 mg one tablet each day for 14 days, the one tablet twice weekly for 10 weeks.

b.Oral estrogen replacement therapy:

i.Conjugated estrogen (Premarin) 0.625 mg orally every day from days 1 through 28 of month. Plus medroxyprogesterone acetate (Provera) 5 mg orally on days 15 through 28.

ii.See section Menopause for other regimens of HT.

For long-term ET, consider use of oral or patch methods of delivery if the patient shows additional symptoms of hypoestrogenemia (i.e., hot flashes, night sweats).

c.Ospemifene (Osphena) is an estrogen agonist/antagonist that was approved by the Food and Drug Administration (FDA) in 2013 for the treatment of moderate-to-severe dyspareunia secondary to vulvar and vaginal atrophy due to menopause:

i.Dosage 60 mg/d with food.

ii.Use for the shortest duration consistent with treatment goals and risk for the individual patient.

iii.Contraindications for the use of ospemifene:

1.Undiagnosed abnormal genital bleeding.

2.Known or suspected estrogen-dependent neoplasia.

3.History of or active deep vein thrombosis (DVT) or pulmonary embolism (PE).

4.History of or active arterial thromboembolic disease (i.e., stroke, myocardial infarction [MI]).

5.Ospemifene is a category X associated with embryo-fetal harm and/or death. It should not be prescribed for women who are or may become pregnant.

d.Intravaginal DHEA (prasterone) has been approved by the FDA for the management of moderate to severe dyspareunia due to menopause.

Ospemifene has estrogenic agonistic effects on the endometrium. As with use of oral, vaginal, and transdermal estrogen, a progestin must be administered to women who have an intact uterus, secondary to the risk of endometrial hyperplasia or cancer.

Follow-Up

A.Breastfeeding women should be reevaluated following weaning, especially if symptoms persist (i.e., alternate etiology is suspected).

B.Postmenopausal women should be evaluated for additional etiologies (i.e., endometrial hyperplasia) if vaginal bleeding persists beyond 3 to 6 months following treatment.

C.The patient should return to clinic 1 to 2 months after beginning oral or vaginal drug therapy; the patient then needs to be seen in 3 to 6 months to check side effects, BP, and response to therapy.

D.Perform Pap smears and physical examination per patient health history or risks and symptoms.

Consultation/Referral

A.If bleeding is a symptom in a postmenopausal woman, the practitioner must rule out bleeding of uterine origin. If there is any doubt, consultation for endometrial biopsy or dilatation and curettage (D&C) must be obtained.

Individual Considerations

A.Breastfeeding women have amelioration of symptoms as weaning progresses unless an alternate etiology exists.

B.Postmenopausal women:

1.Evaluate the patient for other risks of hypoestrogenemia, such as cardiovascular disease and osteoporosis. Continuous systemic ET may be indicated.

2.Evaluate need for continuous systemic HT.

3.Vaginitis in the postmenopausal woman is rarely due to any of the organisms responsible for vaginitis in the premenopausal woman (unless she has new sexual partners). Candidiasis, trichomoniasis, and BV are uncommon after the menstruating years.

C.Geriatrics:

1.Physical examination in the elderly:

a.The pelvic examination may be more difficult related to the lack of hip mobility, arthritis, or spinal deformities.

b.The examination may need to be performed on the patient turned to her left side.

c.Allow extra time to explain each step of the examination and for positioning. An assistant can help the patient onto the exam table and may help gently support the patient’s legs if necessary.

d.Expected age-related changes include thinning pubic hair and decreased elasticity of the introitus.

e.Bluish swelling may be varicosities.

2.UTIs dramatically increase in elderly women. UI, anatomic changes such as a cystocele, increased residual urine, and diabetes are risk factors for recurrent UTIs in older women.

3.Patients who use pads or adult diapers should be informed of risks associated with infrequent changing. Because of the high cost of absorbent pads and undergarments, infrequent changing is common and contact dermatitis and candidal rashes may develop. If these occur, patients should be encouraged to change pads/garments more frequently and avoid wearing absorbent garments overnight, instead should using mattress/bedding pads.

4.For the older adult with existing GSM associated urinary symptoms, NPs should practice special consideration of the following geriatric syndromes:

a.Delirium is a common early sign of acute illness or infection in the elderly. It is more common in patients with existing cognitive impairment. Dehydration is more common in the elderly. Signs of dehydration include confusion, muscle weakness, fever, dizziness, poor skin turgor, hypotension, and tachycardia. Diminished thirst mechanism and decreased body water exacerbate dehydration:

i.At a minimum, patients and family should be asked if the patient has experienced episodes of altered mental status.

ii.The Brief Confusion Assessment Method (bCAM) is a well-documented assessment for delirium. The bCAM is available at www.mnhospitals.org/Portals/0/Documents/ptsafety/LEAPT%20Delirium/HELP%20Program%20CAM%20Flowsheet.pdf

b.Falls: Consistently assess for falls. Discuss the risk of dizziness or lightheadedness when standing. Many falls occur en route to the bathroom when the patient hurries and may not be able to remove their pants and undergarments in time:

i.At the minimum, older adults should be asked how many times they have fallen since their last visit. A reported fall should trigger questions about whether the fall led to injury, a visit to urgent care or hospital emergency department, or a hospital admission.

ii.See Section III: Patient Teaching Guide Safety Issues: Fall Prevention.