Abstract and Introduction
Objective: To update and expand the 2013 position statement of The North American Menopause Society (NAMS) on the management of the genitourinary syndrome of menopause (GSM), of which symptomatic vulvovaginal atrophy (VVA) is a component.
Methods: A Panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on vaginal hormone therapies as well as on other management options available or in development for GSM. A search of PubMed was conducted identifying medical literature on VVA and GSM published since the 2013 position statement on the role of pharmacologic and nonpharmacologic treatments for VVA in postmenopausal women. The Panel revised and added recommendations on the basis of current evidence. The Panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees.
Results: Genitourinary syndrome of menopause affects approximately 27% to 84% of postmenopausal women and can significantly impair health, sexual function, and quality of life. Genitourinary syndrome of menopause is likely underdiagnosed and undertreated. In most cases, symptoms can be effectively managed. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of symptoms. These include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hormone therapy, and the estrogen agonist/antagonist ospemifene. Long-term studies on the endometrial safety of vaginal estrogen, vaginal DHEA, and ospemifene are lacking. There are insufficient placebo-controlled trials of energy-based therapies, including laser, to draw conclusions on efficacy and safety or to make treatment recommendations.
Conclusions: Clinicians can resolve many distressing genitourinary symptoms and improve sexual health and the quality of life of postmenopausal women by educating women about, diagnosing, and appropriately managing GSM. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of treatments for the individual patient, and patient preference. Nonhormone therapies available without a prescription provide sufficient relief for most women with mild symptoms. Low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are effective treatments for moderate to severe GSM. When low-dose vaginal estrogen or DHEA or ospemifene is administered, a progestogen is not indicated; however, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data at present to confirm the safety of vaginal estrogen or DHEA or ospemifene in women with breast cancer; management of GSM should consider the woman's needs and the recommendations of her oncologist.
Genitourinary syndrome of menopause (GSM) describes the symptoms and signs resulting from the effect of estrogen deficiency on the female genitourinary tract. Symptoms associated with GSM are highly prevalent, affecting approximately 27% to 84% of postmenopausal women.[1–4] In one report of more than 900 women undergoing routine examinations, GSM was identified in 84% of women 6 years after menopause. Principal symptoms included vaginal dryness, painful sex, burning, and dysuria. In contrast to vasomotor symptoms (VMS) that usually improve over time, GSM is generally progressive without effective therapy. Despite the high prevalence of GSM and lack of improvement without treatment, only a minority of affected women seek help or are offered treatment by their healthcare providers.[5,6]
In a survey of 1,858 US postmenopausal women with genitourinary symptoms, 50% had never used any therapy for this problem. The reluctance of women as well as healthcare providers to initiate discussion of genitourinary symptoms and safety concerns about hormone therapies contribute to limited assessment and treatment of GSM.[7,8]
The genitourinary syndrome of menopause often has significant adverse effects on a woman's sexual health and quality of life (QOL). Women who are not sexually active also experience bothersome symptoms of GSM, affecting activities of daily living. In the Vaginal Health: Insights, Views & Attitudes (VIVA) online survey of 3,520 postmenopausal women in six countries, 45% reported experiencing vaginal symptoms, and 75% felt that their symptoms negatively affected their lives. In 500 US women in the VIVA survey, of the 48% with vaginal discomfort, the most common symptoms were vaginal dryness and pain during intercourse. Women in VIVA in the United States reported these adverse events (AEs) of vaginal discomfort:
Negative effect on their lives (80%)
Adverse effects on sexual intimacy (75%)
Feeling less sexual (68%)
Feeling old (36%)
Negative consequences on marriage/relationship (33%)
Negative effect on self-esteem (26%)
Lower QOL (25%)
In a survey of 3,046 US women, Real Women's Views of Treatment Options for Menopausal Vaginal Changes (REVIVE), women reported that their vulvovaginal atrophy (VVA) symptoms:
Led to some loss of intimacy (85%)
Detracted from enjoyment of sex (59%)
Interfered with their relationship (47%)
Negatively affected sleep (29%)
Adversely affected general enjoyment of life (27%)
This updated position statement reviews the science of genitourinary aging and assesses the safety and effectiveness of available treatment options for postmenopausal women with GSM.
Menopause. 2020;27(9):976-992. © 2020 The North American Menopause Society