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

Menopause. 2020;27(9):976-992. 

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The diagnosis of GSM requires the presence of both characteristic examination findings and bothersome symptoms. The most commonly reported symptoms include irritation of the vulva, inadequate vaginal lubrication, burning, dysuria, dyspareunia, and vaginal discharge. Symptoms adversely affecting sexual function are often the most distressing.[12,46,47]

Signs of GSM include labial atrophy, vaginal dryness, introital stenosis, clitoral atrophy, and phimosis of the prepuce. Severe GSM can result in a vaginal surface that is friable and hypopigmented, with petechiae, ulcerations, and tears, as well as urethral findings such as caruncles, prolapse, or polyps. Bleeding may occur from minimal trauma, such as speculum insertion. Genitourinary atrophic changes increase the likelihood of trauma, pain, recurrent UTIs, bleeding with or after sex, and absence of sexual activity.[20,47]

The genitourinary syndrome of menopause most commonly develops in the setting of hypoestrogenism associated with natural menopause. Hypoestrogenic states also may occur in the setting of primary ovarian insufficiency (POI), surgical menopause (bilateral oophorectomy with or without hysterectomy), hypothalamic amenorrhea, the postpartum state and breastfeeding, use of gonadotropin-releasing hormone agonists or aromatase inhibitors (AIs), and cancer treatments such as surgery, pelvic radiation therapy, or chemotherapy that render ovaries inactive, either temporarily or permanently.

Several studies suggest that early estrogen deficiency caused by premature menopause or POI is associated with more severe sexual dysfunction compared with age-matched controls.[48,49] Younger women with vaginal atrophy and dyspareunia may be especially distressed by changes in sexual function.

Women with surgical menopause often present with a more severe GSM symptom profile than do women with natural menopause, likely because of the concomitant, abrupt, and persistent 50% decline in circulating androgen levels that occurs in addition to the loss of estradiol.[50,51] Genitourinary syndrome of menopause that develops in the setting of chemotherapy-induced menopause has been associated in some studies with greater sexual dysfunction and distress[52–54] and with poorer QOL outcomes.[55–58] Younger women with GSM related to induced menopause from cancer treatment may be especially distressed by changes in sexual function.[52,55] The stress, fatigue, and mood changes that accompany a cancer diagnosis and its treatment also contribute to sexual problems.

Aromatase inhibitors reduce breast cancer recurrence by blocking conversion of androgens to estrogens and inducing a profound estrogen-deficiency state. The magnitude and duration of estrogen deficiency induced by AIs result in the development of severe GSM in most survivors, particularly given that extended duration therapy is now typical.[59–61] Compared with tamoxifen, AIs result in a greater incidence of vaginal dryness and dyspareunia, causing a large percentage of AI users to express dissatisfaction with their sex lives.[60,62–64]