Menopause, GSM And Painful Sex

Genitourinary Syndrome of Menopause (GSM) affects around 60% of post-menopausal women. It is characterised by vaginal dryness/discomfort and urinary issues, and often the first symptom is painful sex.  Professor Beverley Vollenhoven, Head of Gynaecology at Monash Health, did a fascinating presentation on this topic at the 2019 ‘Let’s Talk Sex’ course run by the O&G department of Monash University. She outlined the impact of GSM, and what we can do about it. 

What Is GSM?

GSM describes a collection of genital and urinary signs and symptoms associated with reduced oestrogen. It affects 50-70% of women aged 50-60, and over 70% of women over 70. Unfortunately, less than 1 in 10 women seek help. 
 

What Are The Symptoms Of GSM?

  1. Vaginal dryness / discomfort / itching / burning
  2. Superficial dyspareunia 
  3. Urinary symptoms: dysuria, stress or urge incontinence, urgency, frequency 
  4. Pelvic organ prolapse 

What Are The Signs Of GSM?

  1. Reduced vaginal secretions and lubrication
  2. Reduced elasticity of vulvo-vaginal tissues
  3. Altered vaginal pH
  4. Changes in vaginal epithelium

What Can Be Done To Help?

Professor Vollenhoven discussed that the first line treatment is vaginal oestrogen.  Interestingly, a randomised controlled trial of Vagifem low (10μg) has been found to be no better than placebo (Mitchell et al 2018).  Clinically, Gynaecologists find that the higher dose of Ovestin is more effective.  Lubricants have also been found to be less effective than vaginal oestrogen (NAMS, 2007). 
 
At the Australian Physiotherapy Association Conference in October 2019, Professor Chantale Dumoulin from Canada presented a cohort study on the impact of a physiotherapy led pelvic floor exercise program on the signs and symptoms of GSM. They found a significant improvement in severity of both signs and symptoms of GSM, including sexual function, ADL’s and quality of life scales. They theorised that the benefits were due to the pelvic floor exercises leading to improved vulvo-vaginal blood flow / vascularity, improved tissue elasticity, and improved muscle function (by improving strength and effective relaxation of the PFM).  
 
They did a follow up study looking at blood flow through the internal pudendal artery and dorsal clitoral artery, and found statistically significant improvement in peak systolic velocity in both arteries after PFMT.  Their research team are planning on completing a large randomised controlled trial on this topic. 
 

What About Women With A Cancer History?

Symptoms of GSM can be more pronounced in women with a cancer history.  Women may have medication or surgically induced early menopause, and also have often undertaken chemotherapy and/or radiation.  Women treated with Tamoxifen or AI can have significant vulvo-vaginal atrophic changes and dryness, often reporting significant dyspareunia. 
 
For women with a cancer history, some simple measures that Professor Vollenhoven outlined included:
  1. Good vulval hygiene: avoiding chemicals (eg. soaps, vaginal washes, fragranced toilet paper), wear loose fitting cotton underwear and avoid tight pants, and moisturising regularly with Dermeze. 
  2. Vaginal moisturisers eg. Replens, which hydrate the vaginal mucosa 
  3. Using a lubricant with intercourse, eg. almond or olive oil, Pjur, Olive and Bee cream
  4. Take Probiotics and vaginal acidifiers such as Acijel 
  5. Regular sexual activity to encourage blood flow 
  6. Pelvic floor physiotherapy – including pelvic floor muscle retraining and trainer therapy 
  7. Sexual counselling for the couple 
  8. Psychological treatment to address changes in body image, sexuality, fear, anxiety, and coping  

Screen Your Post-Menopausal Women For Symptoms Of GSM

Professor Vollenhoven’s key messages were that GSM is very common, has a big impact on a woman’s quality of life, and is treatable with a variety of different options.  She encouraged all of us to screen our post-menopausal women for the symptoms of GSM, as most women will not seek help.