NAMS Position Statement: The 2020 Genitourinary Syndrome of Menopause Position Statement of the North American Menopause Society

Menopause. 2020;27(9):976-992.

Terminology

Genitourinary syndrome of menopause describes the symptoms and signs resulting from the effect of estrogen deficiency on the female genitourinary tract, including the vagina, labia, urethra, and bladder.^[12] This syndrome includes genital symptoms of dryness, burning, and irritation; urinary symptoms and conditions of dysuria, urgency, and recurrent urinary tract infections (UTIs); and sexual symptoms of pain and dryness. Physical changes and signs are varied. Women may experience some or all of the symptoms and signs, which must be bothersome for a diagnosis of the syndrome. Other causes of similar signs and symptoms must be ruled out, including vulvovaginal dermatoses, infection, or cancer.

Vulvovaginal atrophy is a component of GSM.^[13] Although VVA was the commonly used term in the past to describe the genitourinary changes of menopause, it has limitations. Vulvovaginal atrophy describes the appearance of the genital tissues but not the associated symptoms. It does not include urinary tract changes related to estrogen deficiency, and the term atrophy has negative associations for women. The term genitourinary syndrome of menopause was developed during a consensus conference of experts^[12] and subsequently was accepted as the preferred term by many medical societies, including The North American Menopause Society and the American College of Obstetricians and Gynecologists.

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Table 1. Examples of nonhormone therapeutic options for dyspareunia secondary to GSM
Lubricants	Moisturizers
Water based	Replens
Astroglide Liquid	Me Again
Astroglide Gel Liquid	Feminease
Astroglide	K-Y SILK-E
Good Clean Love	Luvena
Just Like Me	Revaree
K-Y Jelly	Silken Secret
Pre-Seed	Hyalo-gyn
Slippery Stuff
Liquid Silk
YES WB
SYLK
Sliquid
Silicone based
Astroglide X
ID Millennium
K-Y Intrigue
Pink
Pjur Eros
Uberlube
Sliquid
Oil based
Elégance Women's Lubricants
Olive oil
YES OB

Table 2. Government-approved therapies for genitourinary syndrome of menopause in the United States and Canada
Type	Composition	Product name	Commonly used starting dose	Commonly used maintenance dose	Typical serum estradiol level (pg/mL)
Vaginal creams	17B-estradiol 0.01% (0.1 mg active ingredient/g)	Estrace vaginal cream^a	0.5–1 g/d for 2 wk	0.5–1 g 1–3 times/wk	Variable
	Conjugated estrogens (0.625 mg active ingredient/g)	Premarin vaginal cream	0.5–1 g/d for 2 wk	0.5–1 g 1–3 times/wk	Variable
	Estrone 0.1% (1 mg active ingredient/g)	Estragyn vaginal cream^b		0.5–4 g/d, intended for short-term use; progestogen recommended	Variable
Vaginal inserts	17B estradiol inserts	Imvexxy^a	4 or 10 μg/d for 2 wk	1 insert twice/wk	3.6 (4 μg) 4.6 (10 μg)
	Estradiol hemihydrate tablets	Vagifem Yuvafem	10 μg/d for 2 wk	1 tablet twice/wk	5.5
	Prasterone (DHEA) inserts	Intrarosa	6.5 mg/d	1 insert/d	5
Vaginal ring	17β estradiol	Estring	2 mg ring releases approx 7.5 μg/d	Replace ring every 90 days	8
Oral tablet	Ospemifene	Osphena^a	60 mg/d	1 tablet by mouth/d	N/A

DHEA, dehydroepiandrosterone.
Products not marked are available in both the United States and Canada.
^aAvailable in the United States but not Canada.
^bAvailable in Canada but not the United States.
Estrace⁸⁹; Premarin⁹⁰; Estragyn⁹¹; Imvexxy⁹²; Vagifem⁹³; Yuvafem⁹⁴; Intrarosa⁹⁵; Estring⁹⁶; Osphena.⁹⁷

Authors and Disclosures

Address correspondence to
The North American Menopause Society, 30100 Chagrin Blvd, Suite 201, Pepper Pike, OH 44124. E-mail: info@menopause.org. Website: www.menopause.org.

This position statement was developed by The North American Menopause Society (NAMS) consisting of representatives of the NAMS Board of Trustees and other experts in women's health: Stephanie S. Faubion, MD, MBA, FACP, NCMP, IF; Sheryl A. Kingsberg, PhD; Jan L. Shifren, MD, NCMP, FACOG; Caroline Mitchell, MD, MPH; Andrew M. Kaunitz, MD, FACOG, NCMP; Lisa Larkin, MD, FACP, NCMP, IF; Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSC; Amanda Clark, MD, MCR, NCMP, FACOG; James A. Simon, MD, CCD, NCMP, IF, FACOG. The Board of Trustees conducted independent review and revision and approved the position statement on May 5, 2020.

Financial disclosures/conflicts of interest
For the GSM Position Statement Editorial Panel: Dr. Faubion and Dr. Shifren report no relevant financial relationships. Dr. Kingsberg reports Consultant/Advisory Board for Amag, Astellas, Dare, Duchesney, Endoceutics, Lupin, Materna, Mitsubishi Tanaba, Ovaco, Palatin Technologies, Pfizer, Sprout, Strategic Science Technologies, TherapeuticsMD, and Viveve; Speaker for Amag and Therapeutics MD. Dr. Clark reports Consulting Fees for Butler Snow LLC; Grant Funding (paid to institution) from Pfizer. Dr. Kaunitz reports Consultant for Amag, Mithra, Pfizer; Clinical Trial Support (paid to institution) from Endoceutics, Mithra. Dr. Kellogg Spadt reports Speaker for Amag, Bonafide, TherapeuticsMD. Dr. Larkin reports Consultant/Advisory Board for Amag, Lupin, Procter & Gamble, TherapeuticsMD; Speakers' Bureau for Amag, Amgen, TherapeuticsMD. Dr. Mitchell reports Spouse Employee at Sanofi Genzyme; Consulting for Scynexis. Research Funding from Merck. Dr. Simon reports Research/Grant Support from AbbVie, Bayer Healthcare, Endoceutics, GTx, Inc, Ipsen, Myovant Sciences; Consultant for AbbVie, Amag, Bayer HealthCare, CEEK Enterprises, Covance, Dare Bioscience, Duchesnay, Hologic, KaNDy/NeRRe Therapeutics, Mitsubishi Tanabe Pharma Development America, Shionogi, Sprout2, TherapeuticsMD; Speaker for AbbVie, Amag, Duchesnay, TherapeuticsMD. For additional contributors, Ms. Develen and Ms. Method report no relevant financial relationships.
For the NAMS Board of Trustees members who were not members of the Editorial Panel: Dr. Crandall, Dr. El Khoudary, Dr. Shufelt, and Dr. Schiff report no relevant financial relationships. Dr. Thurston reports Consultant/Advisory Board for Astellas, Pfizer, Procter & Gamble, Virtue Health. Dr. Joffe reports Consultant/Advisory Board for Esai, Jazz, Merck, NeRRe/KaNDy, Sojournix; Grant/Research Support from Brigham and Women's Hospital Funds, Merck, NIH, NIA, NIMH, NCI, NeRRe/KaNDy, Pfizer, QUE Oncology, V Foundation; spouse employee for Merck, Arsenal Biosciences and Tango, consulting and equity. Dr. Liu reports Consultant/Advisory Board for Allergan, Amag, Astellas, Bayer, Daré, Ferring, Lupin, Mitsubishi, TherapeuticsMD; Research Grants from AbbVie, Allergan, Amag, Astellas, Femasys. All funds paid to the institution. Dr. Chism reports Consultant/Advisory Board for Hologic; Speakers' Bureau for Amag, Astellas, JDS Therapeutics; Royalties/Patents for Jones and Bartlett Publishing. Dr. McClung reports Consultant/Advisory Board for Amgen, Myovant; Speakers' Bureau for Amgen, Radius. Dr. Reed reports Grant/Research Support from Bayer, NIH; Royalties/Patents from UpToDate. Dr. Santoro reports Consultant/Advisory Board for Ansh Labs, Menogenix, Ogeda/Astellas; Stock/Ownership for Menogenix. Dr. Soares reports Consultant/Advisory Board for Lundbeck, Otsuka; Grant/Research Support from Ontario Research Fund, Ontario Brain Institute, AHSC AFP Innovation Fund.