Genitourinary syndrome of menopause is a symptom complex of changes on the part of the genitourinary system, which is caused by a decrease in the level of female sex steroids. It occurs in more than half of menopausal patients and is caused by specific reactions of epithelial cells to hormonal imbalance. The pathological condition is manifested by itching and dryness in the vagina, painful sexual intercourse, dysuric disorders. Colposcopy, vaginal smear tests for cytology and microflora, urodynamic examination and echosonography are performed for diagnosis. Treatment includes hormone therapy with estrogens, physiotherapy, minimally invasive and surgical methods.
ICD 10
N95.2 N95.8
General information
The term “genitourinary syndrome of menopause” (GSM) was approved by ISSWSH/NAMS experts in 2014. It replaced the outdated concepts of “atrophic vulvovaginitis”, “vulvovaginal atrophy” and “atrophic colpitis”. GSM occurs in 15% of perimenopausal women, in 40-57% – in postmenopausal women. Among gynecological patients over the age of 50, 41% of women have at least one sign of the disease. The risk of genitourinary syndrome increases with the duration of menopause: from 1.5% in the first 5 years to 71.4% in the absence of menstruation for more than 20 years.
Causes
The main cause of genitourinary syndrome of menopause is a sharp decrease in the production of estrogens and other female sex hormones. Estrogen receptors are present on the mucous membranes of the genital and urinary tracts, so hormonal imbalance negatively affects the pelvic organs. The following pathogenetic mechanisms play a role in the development of the disease:
- Atrophy of the mucous membrane. During menopause, the multilayer squamous epithelium becomes thinner, the processes of mitotic cell division are disrupted, and the histological structure of the walls of the genitourinary tract changes.
- Increasing the pH of the vagina. Atrophic processes are accompanied by a decrease in the production of glycogen, the main nutrient used by vaginal lactobacilli. Beneficial bacteria maintain a physiological acidic pH, therefore, with GSM, the acid-base balance is disturbed.
- Vaginal dysbiosis. Against the background of an increase in pH, the conditionally pathogenic microflora of the vagina is activated. Harmful microorganisms can cause local inflammatory processes and ascending urological infection.
Pathomorphology
Pathomorphologically, genitourinary syndrome is represented by thinning of the epithelium of the vagina and urethra, a decrease in the folding of the vaginal mucosa. Later, signs of ischemia and inflammation are added, individual petechial hemorrhages are visible on examination. The soft tissues of the intimate area lose elasticity and firmness, the functioning of the bartholin glands decreases, the nutrition of hair follicles is disrupted.
Symptoms
The most common sign of genitourinary syndrome of menopause is vaginal dryness, which occurs in 27-55% of patients. Women complain of constant discomfort, burning and itching in the vulva, soreness during the introduction of therapeutic suppositories and tampons (in perimenopause). Due to insufficient moistening of the vaginal mucosa, pain occurs during penetrative sexual intercourse, libido decreases and the ability to enjoy intimacy decreases.
Dryness and itching increase after washing the genitals with soap, when using low-quality intimate hygiene products, wearing synthetic underwear and contact with latex condoms. Recurrent vaginal discharge is characteristic, which can be white, gray or yellowish. After sexual intercourse, scanty spotting appears, caused by traumatization of the mucous membrane.
The second group of signs of genitourinary syndrome of menopause consists of urinary disorders. Women suffer from frequent and painful urge to urinate, multiple night trips to the toilet. Stress urinary incontinence may occur when laughing, coughing, physical exertion. Less often there is an urgent form of incontinence – involuntary discharge of urine after a sudden urge.
Complications
In 6-8% of women with genitourinary menopausal symptoms, recurrent infections occur. They are caused by both pathogenic pathogens and conditionally pathogenic flora, which penetrates into the thickness of the walls of the genital tract through microtrauma. Infectious processes according to the topic of the lesion are divided into vulvitis, vaginitis (colpitis), urethritis and cystitis. Urogenital infections mainly occur after the age of 65, have an erased clinical picture.
Vaginal discomfort complicates the sexual life of menopausal women. Problems in the sexual sphere are often accompanied by depressive disorders, a sense of one’s own unattractiveness, deterioration of relations with a partner. The situation is aggravated against the background of emotional lability and irritability – typical manifestations of menopausal syndrome.
Diagnostics
Women with complaints of intimate discomfort and urination disorders are advised by a gynecologist. To diagnose GSM, the features of the clinical picture of the disease are identified, the relationship between the onset of symptoms and the menopausal period is established. The diagnosis is carried out in conjunction with a urologist. To verify the genitourinary syndrome, the following studies are shown:
- Vaginal smear. The diagnostic criteria of the syndrome are an increase in the pH in the vagina of more than 5 units, an epithelial maturation index of more than 65%, a decrease in the number of lactobacilli with a simultaneous increase in the number of opportunistic bacteria. As part of cancer screening, a Pap test is performed.
- Colposcopy. A visual examination of the vagina and cervix determines the index of vaginal health. It includes information about the elasticity of the vaginal wall, the presence or absence of transudate, the condition of the mucous membrane and its humidity.
- Ultrasound of the pelvic organs. Echosonography is performed for a comprehensive assessment of the state of internal organs, excluding tumor processes, the risk of which increases 2-3 times with the onset of menopause.
- Urodynamic research. The technique is used to measure the physiological and maximum volume of the bladder, the rate of urine flow, the degree of resistance of the urethral sphincters. Additionally, a functional Valsalva test is performed.
Differential diagnosis
Manifestations of genitourinary syndrome of menopause are differentiated with chronic infectious vaginitis, contact dermatitis of the vulva and vagina. When spotting occurs, it is necessary to exclude cancer of the vulva, vagina and cervix. A comprehensive urological examination is performed for the differential diagnosis of various forms of urinary incontinence.
Treatment
Hormone therapy
Estrogen monotherapy is a pathogenetically based treatment method that is included in international clinical guidelines. As the “gold standard” of GSM therapy, local forms of hormones are used in the form of suppositories, cream or capsules. Intensive treatment lasts 2-4 weeks and eliminates the main clinical signs of the disease, after which patients are prescribed a long-term maintenance course of hormonal drugs. Local therapy is effective in 80-90% of cases.
When combined with genitourinary syndrome of menopause with other manifestations of menopause, systemic hormone therapy is indicated. In healthy women with a preserved uterus, a combination of estrogens and progestogens is used to protect the endometrium from dysplastic processes. Combined treatment is also used for genital endometriosis. Systemic monotherapy with estrogens is sufficient for patients with artificial menopause.
Non-hormonal treatment
It is prescribed in addition to hormone therapy or as an alternative to it in the presence of strict contraindications to the use of estrogen preparations. The main category of patients who are not recommended to use hormonal drugs are women with diagnosed breast, ovarian, and endometrial cancer. With caution, estrogens are used in carriers of oncogenic mutations BRCA1 and BRCA2. Non-hormonal areas of therapy include the following:
- Vaginal lubricants. They moisturize the mucous membrane of the genital tract, reduce burning and discomfort, replace natural lubrication during sexual intercourse. Lubricants are made on the basis of hyaluronic acid, phospholipids, plant extracts.
- Holinoblockers. The drugs are included in the first-line treatment for hyperactive bladder. They normalize the work of smooth muscles and sphincters, increase the reservoir volume of the organ, reduce the frequency of urges. In addition to M-holinoblockers, beta-3-adrenergic receptor agonists are used.
- Biofeedback. Biofeedback devices have found wide application for training pelvic floor muscles in urinary incontinence. They provide isolated contraction of different muscle bundles, give the patient visual information about the correctness and effectiveness of classes.
- Electrical stimulation of the bladder. The technique is used for bladder hypertension in combination with drug therapy. Treatment reduces detrusor tone and relaxes the wall of the organ, so patients are less likely to encounter imperative urge to urinate.
Surgical treatment
The help of specialists in the field of urogynecology is required for urinary incontinence. Mild and moderate forms of genitourinary syndrome are corrected by the introduction of volumetric gels into the tissues around the urethra to increase the locking function of the sphincters. Treatment is effective in 75-80% of patients. Severe variants of incontinence require loop (sling) urethropexy, urethrocystocervicopexy.
Prognosis and prevention
Genitourinary syndrome of menopause is successfully amenable to hormonal correction. Complex treatment is accompanied by the elimination or significant reduction of symptoms, improves the quality of a woman’s daily and intimate life. Less optimistic forecasts for patients with urinary incontinence and recurrent urogenital infections, which have an upward spread.
To prevent the development of the disease and reduce the intensity of its manifestations, preventive measures are recommended. Special attention is paid to regular sex life, careful personal hygiene with the use of gentle alkaline-free formulations, smoking cessation and weight normalization. Hormone replacement therapy, which is prescribed for the relief of vegetative and psychoemotional symptoms of menopause, is an important link in the prevention of GSM.
