Genitourinary syndrome of menopause (GSM) is a relatively new term that describes the constellation of lower urogenital tract signs and symptoms associated with a low-estrogen state.1 Prior nomenclature such as vulvovaginal atrophy and atrophic vaginitis failed to encompass the frequent urinary symptoms associated with menopause. GSM, which arose from a 2013 terminology consensus conference by the International Society for the Study of Women’s Sexual Health (ISSWSH) and North American Menopause Society (NAMS), is seen as a more generalizable and inclusive term with fewer negative connotations that should replace older jargon.
GSM describes the genital, sexual and urinary changes in the lower genital tract associated with menopause. It is a chronic disorder that is unlikely to improve over time without treatment. The estrogen receptors present throughout the lower genitourinary tract respond to the decrease in circulatory estrogen after menopause with thinning of the vaginal and uro-epithelium, an increase in vaginal pH, decreases in collagen and tissue elasticity and fewer blood vessels. Physiologically, this manifests with symptoms of vaginal dryness, vaginal irritation, vaginal itching and may affect sexual function due to dyspareunia and diminished lubrication (Table 1). It is important to note that GSM also includes urologic signs and symptoms. Postmenopausal patients are more prone to recurrent urinary tract infections (UTIs), dysuria, urinary frequency and urgency.2
GSM can be clinically detected in up to 90% of postmenopausal women undergoing evaluation. However, only about one-third of menopausal women report vulvovaginal symptoms when surveyed.3 According to the 2010 United States census, there are approximately 50 million women over age 51, the average age of menopause.4,5 That means approximately 17 million women experience GSM symptoms, a number that is likely increasing due to population demographics. Studies have shown that many of these women rate their symptoms as either moderate or severe. Affected women perceive declines in quality of life similar to those of patients with chronic conditions such as arthritis, chronic obstructive pulmonary disease (COPD) and irritable bowel syndrome.6 GMS symptoms also negatively impact sexual satisfaction in over half of patients and strain personal relationships.7
Despite the prevalence of GSM, the condition continues to be under-recognized and undertreated due to a combination of patient and provider factors. Only about one-quarter of women ever discuss their symptoms with a provider. Frequently, the burden falls on the patient to initiate the conversation.8 The most common barrier to patients discussing GSM is a belief that their symptoms should just be accepted as a natural part of aging and menopause.8 Other women fail to even link their symptoms with menopause.7 This demonstrates a large gap in patient knowledge and an opportunity to educate patients on GSM as a medical condition. Providers need to take the initiative in screening and patient education. However, studies have shown that providers are doing a poor job at this. One study found that only 13% of providers queried their patients for GSM symptoms.1 Even after diagnosis, the majority of women with GSM go untreated despite studies demonstrating a negative impact on quality of life. Hesitation to prescribe treatment by providers as well as patient-perceived concerns over safety profiles limit use of topical vaginal therapies.7,8
The authors report no potential conflicts of interest with regard to this article.
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