Abstract
Menopause is a natural physiological process experienced by women, characterized by a hypoestrogenic state. This hormonal deficiency can arise from various factors such as aging, premature ovarian failure, or surgical oophorectomies. Historically, the focus has been primarily on the vasomotor and psychological manifestations of hypoestrogenism in menopausal women, likely due to the prevalence of these symptoms. However, it is important to recognize that genitourinary syndrome of menopause (GSM) significantly impacts a substantial portion of women during this stage of life. These symptoms are often overlooked or underreported due to feelings of embarrassment.” This paper provides comprehensive overview of GSM, including its pathophysiology, epidemiology, clinical presentation, and impact on the quality of life. Furthermore, it will discuss current management strategies to provide healthcare professionals with a thorough understanding of GSM to improve patient outcomes through timely diagnosis and appropriate management.
Introduction
Genitourinary syndrome of menopause (GSM) is a term coined by the International society for the study of women’ s sexual health and the North American Government Menopause Society in 2014, that encompasses a range of symptoms and signs associated with decreased oestrogen and other sex steroids, affecting and causing urological, genital and sexual changes.
This term was used as a substitute and to include vaginal atrophy, vulvovaginal changes and urological symptoms secondary to menopause. Around half of menopausal women, with some studies suggesting two-thirds, will experience at least one symptom of GSM, although these are often under-reported for multiple reasons.
Pathophysiology of genitourinary syndrome of menopause
The genitourinary syndrome of menopause (GSM) encompasses a variety of symptoms affecting the female genital tract and lower urinary tract, owing to the shared embryological origin of these tissues. Both anatomical areas are in close proximity and possess oestrogen receptors, making them highly dependent on oestrogen for maintaining normal histology and function. The urinary tract predominantly expresses oestrogen receptor alpha (ERα), whereas the genital tract mainly expresses oestrogen receptor beta (ERβ), both of which play significant roles in tissue differentiation and functionality. The vaginal epithelium consists of three distinct layers, with the superficial layer being particularly sensitive to oestrogen. Activation of oestrogen receptors in this layer maintains the health of the vaginal epithelium by promoting adequate blood supply and lubrication. This process ensures that the vagina retains its elasticity and length due to the stimulation of collagen production. Furthermore, oestrogen helps maintain the acidic environment of the vagina by supporting the growth of lactobacilli, which convert glycogen to lactic acid, thereby maintaining a vaginal pH of less than 4.5. This acidic environment not only protects the vagina from infections but also contributes to the health of the urethral epithelium, thereby lowering the risk of lower urinary tract infections.
In the absence of sufficient oestrogen, several pathological changes occur a seen in Figure 1 , including:
- 1
Thinning of the vaginal epithelium: the vaginal epithelium becomes thinner, less elastic, and more fragile. This leads to symptoms such as dryness, irritation, and dyspareunia. The loss of oestrogen reduces the cellular proliferation and differentiation in the vaginal epithelium, causing atrophy and decrease in the glycogen content, which is essential for the sustenance of lactobacilli.
- 2
Decreased vaginal blood flow: reduced oestrogen levels result in diminished blood flow to the vaginal tissues. This decreased vascularization contributes further to the reduction in lubrication and elasticity, exacerbating symptoms of vaginal dryness and discomfort.
- 3
Loss of vaginal microbial diversity: the decline in oestrogen levels adversely affects the vaginal microbiota. Specifically, there is a decrease in the population of lactobacilli, which are crucial for maintaining the acidic pH of the vagina. The resultant increase in vaginal pH can predispose women to infections, as the protective acidic environment is compromised.
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Changes in the urethra and bladder: oestrogen deficiency also affects the urethral and bladder tissues, leading to symptoms such as urinary urgency, frequency and incontinence.
GMS presentation
GSM is a constellation of symptoms and clinical signs associated with the decrease in oestrogen and other sex steroids that occurs during menopause. These symptoms primarily affect the vulvovaginal, urological, and sexual domains.
The manifestations of GSM frequently overlap and can exacerbate one another, necessitating a comprehensive and multidisciplinary approach for effective diagnosis and management. Clinicians should maintain a high index of suspicion for GSM in postmenopausal women, especially when such symptoms are either overlooked or underreported. Table 1 shows the different symptoms and signs of GSM.
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