Dr Louise Newson is a co-author of a new paper, which calls for a redefinition of genitourinary syndrome of menopause (GSM) and more inclusive research
Much of the existing GSM research has focused on postmenopausal women; expanding research to younger women and different populations should make future evidence and clinical guidance much more relevant to the women who are currently being missed.
The key message of the paper [1] is that genitourinary symptoms caused by low estrogen and/or androgen levels are not simply a problem of menopause. They can affect women and other individuals at many different stages of life, yet they are often overlooked, misdiagnosed or undertreated.
Summary of new paper
This paper clearly states that we need to rethink the way we talk about vaginal, vulval and urinary symptoms.
The term Genitourinary Syndrome of Menopause (GSM) was introduced in 2014 to replace the rather narrow term “vulvovaginal atrophy”. It was an important step forward because it recognised that falling hormone levels can affect much more than the vagina, including the vulva, bladder, urethra, sexual function and pelvic floor. Low estradiol and androgen (testosterone) levels can contribute to vaginal dryness, burning, painful sex, urinary discomfort and recurrent urinary tract infections.
In this paper, we have real concerns that calling it “of menopause” has become a barrier to good care with appropriate hormone treatments. Genitourinary symptoms also occur in younger women and in people who are not menopausal, including those who are breastfeeding, women who have recently given birth, those taking hormonal contraception, who have received various cancer treatments, women with primary ovarian insufficiency (POI), women taking some medications such as steroids and other women with low hormone levels (including those with PMS, PMDD, PMOS and endometriosis).
Our paper proposes the broader term Genitourinary Syndrome (GS) should be used instead of GSM, with different subtypes depending on the underlying cause.
Genitourinary Syndrome is not just about menopause
One of the most important messages is that women can experience these localised symptoms at any age – and they are common.
For example, during breastfeeding, high prolactin levels suppress ovarian hormone production. This can create a temporary low-estrogen and low-androgen state, resulting in vaginal and urinary symptoms. We highlight the emerging concept of Genitourinary Syndrome of Lactation (GSL) and cite research showing that these symptoms can contribute to painful sex and pelvic floor problems.
Hormonal contraception is another important example. The synthetic hormones in contraceptives reduce estrogen and testosterone, levels so can lead to symptoms of vaginal dryness, reduced lubrication, painful sex and urinary discomfort, frequency and infections. Histological studies have also demonstrated changes in vaginal tissues in some women taking hormonal contraceptives in the long-term that resemble the changes traditionally associated with GSM.
Our paper also discusses women with primary ovarian insufficiency, Turner syndrome and other endocrine conditions, as well as people receiving treatments such as GnRH agonists. These can all produce significant hormone deficiency and consequently vaginal, vulval and urinary symptoms.
The urinary symptoms matter too
A particularly important point is that these hormone-related changes are not simply vaginal problems.
The tissues of the lower urinary tract are also hormone responsive. When hormone levels fall, women can experience urinary burning, urgency, discomfort and recurrent urinary tract infections alongside vaginal symptoms. Our paper emphasises that these symptoms are often mistaken for infections, stress or other problems, meaning that the underlying hormonal contribution are missed and women are given the wrong treatments.
This is why the broader term genitourinary is so useful: it reminds us that the vagina, vulva, urethra and bladder are all part of the same interconnected system.
What about vaginal hormones?
It is essential that more clinicians are able to both recognise and treat hormone-related genitourinary symptoms rather than simply accepting them as something women have to live with.
Broader recognition will lead to better, earlier and more individualised hormone treatment for more women. Unfounded fears of hormone treatments, including vaginal hormone treatments, prevents millions of women from receiving appropriate treatment. Vaginal hormones can usually be safely used by all women, including those who have had breast cancer.
The key message about Genitourinary Syndrome
The most important message from this paper is that we should stop thinking about vaginal and urinary symptoms as an inevitable consequence of getting older or something that only happens after menopause.
Women can experience these symptoms at all ages and for many different reasons. They deserve to be asked about them, properly assessed and offered effective treatment, including vaginal hormone treatments.
Our paper argues for routine screening, better education of healthcare professionals and more equitable access to the right treatment. Importantly, it notes that genitourinary symptoms can be recognised and managed by a wide range of healthcare professionals, so not just menopause specialists or urologists.
Ultimately, more women of all ages should have access to vaginal hormone treatments when appropriate, so that they can improve urinary symptoms as well as vaginal, vulval, sexual and other localised symptoms. We need to make local hormone treatments a much more normal part of women's healthcare; not something reserved only for women who have been labelled “menopausal”.
The terminology may change from GSM to the broader Genitourinary Syndrome, but the underlying message is wonderfully simple: if low hormone levels are affecting the tissues of the vagina and urinary tract, women deserve to have those symptoms recognised and treated, whatever their age or stage of life.
This is also why the paper's call for more inclusive research is so important. Much of the existing GSM research has focused on postmenopausal women; expanding research to younger women and different populations should make future evidence and clinical guidance much more relevant to the women who are currently being missed.
The paper, published in the journal Maturitas, can be accessed here.
