Working Together For GSM: Oestrogen & Physiotherapy

GSM impacts up to 50% of postmenopausal women^2,3, yet despite its prevalence, it is commonly undertreated which can take a significant toll on quality of life for those impacted⁴.

 

As Pelvic Health Physiotherapists, many of our patients experience the spectrum of GSM symptoms, either as a whole or part of their clinical picture. They are surprised to learn that symptoms can improve with a multidisciplinary, whole person and active approach.

 

There is good evidence to support the role of Pelvic Floor Muscle Training (PFMT) to manage symptoms of GSM.   In 2023, a group of reputable Canadian researchers published an article in Climacteric ², investigating the role of PFMT on GSM.  The study participants had undergone a 12 week supervised & individualised PFMT program which included exercises designed to improve PFM strength, endurance, power and/or relaxation.  They found a significant improvement in GSM signs and symptoms at the completion of the program.  They hypothesised this was due to improved blood flow to the vulvovaginal tissues, improved PFM relaxation capacity, and increased vulvovaginal tissue elasticity³.  

 

Additionally, an RCT published in 2021 found that PFMT decreased sexual dysfunction in postmenopausal women⁴.

 

In addition to pelvic floor muscle training, many of our postmenopausal patients experience symptom improvement through the use of topical vaginal oestrogen.  Pelvic Health Physiotherapists are primary contact practitioners but as non-prescribers we may request the opinion of the patient’s GP or Medical Specialist to determine if vaginal oestrogen could be an appropriate treatment adjunct to their physiotherapy program.  This request is based on our understanding of the evidence that supports the role of topical oestrogen for GSM.

 

Vaginal oestrogen continues to create divide and controversy regarding its indication, effectiveness and potential risks and side effects.  

 

Rueda et al published a systematic review in 2017⁵ who found that oestriol is an effective and safe medication for the treatment of vulvovaginal atrophy (GSM) in postmenopausal women.  They also found low and moderate quality evidence to show that when applied vaginally, the blood levels of oestriol increase 1 hour after application and then progressively return to baseline, meaning there is very little systemic absorption.  There are a number of factors that impact the absorption of vaginal oestrogen, including vaginal mucosa health and thickness, presence of vaginal mucous, contact time, dose frequency and the depth of insertion (insertion using an applicator leads to higher absorption than application close to the vaginal entrance)⁶.  

 

There has also been much debate regarding the safety of use of vaginal oestrogen with breast cancer.  Evidence does suggest that it is safe for use even for women who have risk factors for oestrogen therapy due to its low potency at the systemic level⁵.  For breast cancer survivors, the Australian College of GP’s recommends initial treatment with vaginal moisturisers and lubricants, but if this treatment is unsuccessful, vaginal oestrogen could be considered on a case by case basis, considering the risk of cancer recurrence with the efficacy of non-hormonal therapies, severity of GSM and the impact on quality of life⁶. 

 

A 2016 Cochrane review⁷ found low-quality evidence that various vaginal oestrogen treatments improved symptoms of vaginal atrophy (dryness, dyspareunia, itching, burning and discomfort) in postmenopausal women when compared to placebo.  In our physiotherapy practice, we find clinically that the use of vaginal oestrogen to be a helpful adjunct to their physiotherapy management.  With improved vaginal tissue health and lubrication, pelvic floor muscle awareness, strength, relaxation and coordination improves, thereby enhancing the effect of a PFMT program on PFM function.  Sensitivity with touch can also reduce allowing progression of and improved efficacy of touch desensitisation therapies. 

 

The 7th International Consultation on Incontinence also recommends (grade C) that when treating women with SUI and vaginal atrophy, combining PFMT and intravaginal oestrogen over oestrogen alone could be considered⁸. 

 

Dr Sandra Elmer, on behalf of the Urological Society of Australia and New Zealand (USANZ) recently published a submission⁹ to the ongoing senate inquiry into the issues related to menopause and perimenopause.  The submission draws attention to the prevalence of UTI’s with GSM, reporting a 60% lifetime incidence and a recurrence risk ranging from 20-40%.  They highlight the evidence supporting the use of low-dose topical vaginal oestrogen in reducing UTI risk by over 50%.   USANZ suggest a call to action for health care professionals to more readily consider the effective and evidence-based treatment options that are available for GSM, particularly the use of vaginal oestrogen to prevent and treat UTI’s.  

 

Whilst there is no evidence to suggest that GSM directly correlates with Pelvic Organ Prolapse (POP), topical oestrogen is often prescribed as a part of management to improve POP symptoms and bother.  The Australian Commission on Safety and Quality in Healthcare published a statement on treatment options for POP in 2018¹⁰, which includes the use of vaginal oestrogen as an option to reduce vaginal dryness and improve vaginal tissue quality, as well as assisting with UTI’s⁷.

 

Taithongchai et al published a Cochrane Review in 2023¹¹ investigating the use of oestrogen therapy for Pelvic Organ Prolapse (POP) in postmenopausal women.  Unfortunately, the quality of studies included in the systematic review was poor, therefore they could draw no strong conclusions on the efficacy of oestrogen for POP.  However, they did find evidence suggesting that topical oestrogen may reduce the risk of minor adverse vaginal events when pessaries are being used for POP¹¹.

 

The UK Clinical Guideline for best practice in the use of vaginal pessaries for pelvic organ prolapse recommends considering vaginal oestrogens prior to or with pessary management as part of the clinical pathway for pessary fitting¹².

 

In our clinical practice, it is protocol to refer all peri and post-menopausal women to their GP or specialist to consider the use of vaginal oestrogen prior to fitting a vaginal pessary. Following best practice clinical guidelines¹², we prefer patients to have been using topical oestrogen for at least 1 month prior to fitting a pessary.  

 

 

As Pelvic Health Physiotherapists we are also well placed to offer advice and support regarding various lifestyle strategies that can also improve GSM, including:

We often direct our patients to the Jean Hailes organisation, who have a collection of informative resources for patients with easy to read fact sheets about menopause https://www.jeanhailes.org.au/resources/fact-sheets.  Dr Louise Newson, a UK based a physician, menopause specialist and member of the UK Government’s Menopause Taskforce has also created a fabulous resource network on her website and app called Balance.

 

We wholeheartedly support Dr Sandra Elmer and USANZ in their call to increase awareness and improve the proactive and patient centred management options for Genitourinary Syndrome of Menopause.  Let’s continue to work together to improve the quality of life of the 50% of postmenopausal people who experience GSM by supporting them with evidence-based strategies.