Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society

Analysis of the Impact of Type 2 Diabetes on the Psychosocial Functioning and Quality of Life of Perimenopausal Women

Menopause is a natural period resulting from the decrease in hormonal activity of the ovaries. Growing hormonal deficiencies and changes in the body influence a variety of functions in women, leading to depression and decreased quality of life. The relationship between body composition, the severity of depressive and climacteric symptoms and the quality of life of women with type 2 diabetes and healthy women in the perimenopausal period was studied. Statistically significant differences were observed between the study and control groups regarding all body composition parameters except for protein and the content of torso soft tissues (p < 0.05). In both the study and control groups, resulting symptoms were significantly correlated with numerous body composition parameters (e.g., body mass, fat tissue mass, minerals, abdominal circumference), while symptoms of depression were significantly correlated with similar parameters only in the control group. A statistically relevant relationship was observed between the study and control groups with respect to quality of life in certain domains. The quality of life of women suffering from type 2 diabetes was worse compared with healthy women. Analysis of body composition showed significant differences between healthy women and those with type 2 diabetes. Healthy women showed a tendency to establish a link between body composition and depressiveness.

Effective Prevention of Recurrent UTIs With Vaginal Estrogen: Pearls for a Urological Approach to Genitourinary Syndrome of Menopause

OBJECTIVE

To review the available data related to the prevention of recurrent urinary tract infection (rUTI) in postmenopausal women with vaginal estrogen preparations and provide the urologic community with the confidence to identify and treat genitourinary syndrome of menopause (GSM).

MATERIALS AND METHODS

A literature search of MEDLINE and the Cochrane Central Register of Controlled Trials databases was performed to identify studies utilizing vaginal estrogen in the treatment of urological conditions related to rUTI and GSM.

RESULTS

In the setting of untreated GSM, the etiology of rUTIs (at least 3 episodes of UTIs in 12 months or at least 2 episodes in 6 months) is not fully elucidated, but estrogen deficiency is a contributing factor. The diagnosis of GSM is primarily a clinical diagnosis supported by other objective findings including: a vaginal pH >5, decreased content of superficial cells, and/or increased proportion of parabasal cells on vaginal maturation index. Local vaginal estrogen, dehydroepiandrosterone (prasterone), and ospemifene are commonly used GSM treatments. Thirty-one trials were identified utilizing estrogen preparations for rUTI in postmenopausal women.

CONCLUSION

Overall, multiple randomized clinical trials have successfully been completed to show the efficacy of local estrogen preparations for the treatment of rUTIs. This high yield review provides a framework for assessing GSM, prescribing recommendations for local vaginal hormone preparations, and a summary of the substantial evidence supporting the new 2019 American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Guidance for local vaginal estrogen use for rUTI.

Carbon dioxide laser treatment for vulvovaginal atrophy in women treated for breast cancer: Preliminary results of the feasibility EPIONE trial

BACKGROUND AND OBJECTIVE

Quality of life preservation after anti-cancer therapy is a major challenge for breast cancer survivors. Approximately 42-70% of patients who receive systemic therapy for breast cancer, including endocrine therapy, will develop vulvovaginal atrophy (VVA). For these patients, the commonly proposed gel-based treatments for topical applications are restrictive. Recently, innovative, non-hormonal therapeutic approaches, such as laser therapy, have emerged. The purpose of this feasibility study is to investigate the safety and efficacy of CO₂ laser therapy in women with a history of breast cancer.

MATERIAL AND METHODS

This prospective monocentric study included 20 patients with vulvovaginal atrophy who were treated at Henri Mondor University Hospital between 2017 and 2018. We included patients with a vaginal health index (VHI) score<15 and a contraindication for hormone administration due to a history of breast cancer. Two carbon dioxide laser sessions were used. The treatment was delivered using the following settings: vaginal tightening, FinePulse (pulse width 0.9ms), and energy density of 11.5J/cm² that allows coverage of 70% of the targeted vaginal area to be treated. All patients had their follow-up visit at one (M1), three (M3), and six (M6) months after the first treatment to evaluate efficacy of the treatment on vulvovaginal atrophy. Vaginal health index score and female sexual distress (FSD) score were used to assess treatment efficacy and its impact on sexual quality of life. A score≥11 was associated with sexual dysfunction. The vaginal health index and female sexual distress scores were evaluated at baseline, M1, M3, and M6 of follow-up.

RESULTS

The mean age of the patients was 56.1±8.8 years (range, 27-69 years). Seventeen of the 20 patients had experienced menopause (mean menopausal age, 51.25±1.5 years). At inclusion, the mean vaginal health index and the female sexual distress scores were 10.58±1.71 and 21.36±15.10, respectively. Fourteen out of 20 patients (70%) had FSD scores≥11 at the baseline. At M1, the mean vaginal health index score increased significantly to 13.42±2.3 (P=0.03), which represented an improvement of 21% from the baseline. A persistent and significant improvement in the vaginal health index score was observed at M6, with the score increasing to 16.75±4.23 post-treatment (P<0.0001), representing a 34% improvement from the mean baseline score. The mean female sexual distress at M1 was 19.83±13.57, representing a 7% decrease compared to the baseline scores (P<0.01). At M3, the female sexual distress significantly decreased to 13.88±15.58, representing an improvement of 35% (P=0.006). It increased to 10.35±14.7 at M6, representing an improvement of 52% (P=0.001). At M3, 35% of the patients had a female sexual distress score>11, and at M6, only 15% had a female sexual distress score>11. No side effects were reported during follow-up.

CONCLUSION

This pilot feasibility study showed that carbon dioxide laser treatment appears to be an effective and safe method to improve the trophicity and decrease vaginal mucosal dryness in women with vulvovaginal atrophy that developed after systemic breast cancer therapy.

Genitourinary syndrome of menopause

Genitourinary syndrome of menopause affects approximately 50% of women post-menopause and is under-reported. This review of the condition including established and newer treatment options aspires to empower clinicians to ask about symptoms and be more proactive in their management.

Ospemifene plus fractional CO2 laser: a powerful strategy to treat postmenopausal vulvar pain

This study is a single-center, retrospective analysis of postmenopausal women presenting with dyspareunia and vulvar pain, aiming to evaluate relative effectiveness of vestibular CO₂ laser therapy as a treatment. Three monthly sessions of laser were performed to each patient and thereafter a three-months follow-up was stablished. A total number of 72 patients undergoing vestibular laser treatment were recruited from patient files in the period between 2016 and 2018. Among these, 39 women also received a concomitant treatment with ospemifene (60 mg/day) during the study period. There was a statistically significant reduction of all the symptoms in both groups up to the three month follow-up. Regarding dryness and dyspareunia, the relief tent to be more prominent in the ospemifene + laser group at all follow-ups and remained statistically significant at three-month follow-up. Specifically, vestibular dryness was significantly lower in the ospemifene + laser group compared with the laser treatment group (-87% vs - 34%, respectively), and the vestibular health score started declining faster in the ospemifene + laser group. Although, additional research is needed to understand the mechanism of action, our data shows that a combination regimen of laser and ospemifene may improve clinical effectiveness for long-term treatment of symptoms associated with the under-recognized genitourinary syndrome of menopause.

Vaginitis in Nonpregnant Patients: ACOG Practice Bulletin, Number 215

Vaginitis is defined as inflammation or infection of the vagina and is associated with a spectrum of symptoms, including vulvovaginal itching, burning, irritation, dyspareunia, "fishy" vaginal odor, and abnormal vaginal discharge. Vaginal symptoms are some of the most frequent reasons for patient visits to obstetrician-gynecologists () and may have important consequences in terms of discomfort and pain, days lost from school or work, sexual functioning, and self-image (). Distinguishing vaginal from vulvar symptoms is important to direct evaluation and treatment. The purpose of this document is to provide updated evidence-based guidance for the diagnosis and treatment of the common causes of vaginitis in nonpregnant patients. Information on the treatment of vaginitis in patients with human immunodeficiency virus (HIV) is covered elsewhere (). Guidelines are subject to change. For the most up-to-date information on vaginitis diagnosis and treatment, see the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases webpage, which is available at https://www.cdc.gov/std/.

A systematic review of the efficacy and safety of vaginal estrogen products for the treatment of genitourinary syndrome of menopause

OBJECTIVE

We updated a systematic review to evaluate the totality of evidence available for the efficacy and safety of vaginal estrogen products for the treatment of genitourinary syndrome of menopause (GSM) based on published randomized controlled trials.

METHODS

We searched the Cochrane Library, Ovid, PubMed, Medline, Embase, and Clinicaltrials.gov for English-language articles from database inception to June 2018. Our search consolidated 2,086 potential sources to 53 full-text articles that were reviewed and found relevant to our systematic review.

RESULTS

We identified 53 studies that met the inclusion criteria that evaluated the efficacy and safety of vaginal estrogen versus placebo or other hormone and nonhormone controls. Compared with placebo, all vaginal estrogens demonstrated superiority in objective endpoints and subjective endpoints of GSM, whereas some trials demonstrated superiority versus placebo in urogenital symptoms. No significant difference was observed between various dosages and dosage forms of vaginal estrogen products. Vaginal estrogen showed superiority over vaginal lubricants and moisturizers for the improvement of objective clinical endpoints of vulvovaginal atrophy but not for subjective endpoints. Unopposed vaginal estrogens seemed safe, although studies were not powered to detect a long-term estrogenic side effect.

CONCLUSION

Estrogen products were found to be clinically effective for the treatment of GSM with doses as low as 4 μg. Vaginal estrogen products seem to be safe with few adverse effects, although there is a lack of long-term controlled clinical trial safety data. This review supports the use of commercially available vaginal estrogen therapies as an effective and safe first-line therapy for the treatment of moderate-to-severe GSM.

Women's experience of vulvovaginal symptoms associated with menopause

OBJECTIVE

This study describes women's experiences of the genitourinary syndrome of menopause (GSM) elicited through focus groups and cognitive debriefing sessions during development of a novel patient-reported outcome measure (PROM) designed for use in both clinical care and research.

METHODS

A draft questionnaire to identify and assess bothersome genitourinary symptoms associated with estrogen deficiency in menopausal women was developed in five discrete phases from multiple sources of information in accordance with standards for PROM development. GSM was confirmed by report of symptoms in conjunction with a confirmatory pelvic examination and laboratory assessments.

RESULTS

Qualitative content interviews were completed in 36 menopausal women with GSM. Cognitive testing of draft PROM items was performed in nine focus groups, including 26 menopausal women with and 15 without GSM. Participants reported a range of symptoms and described associated impacts on more than 15 quality-of-life domains. The majority of women reported that their symptoms impacted their sexual functioning and had a negative effect on their overall quality of life. GSM affected many aspects of menopausal women's lives beyond sexual function, with descriptions of pain when walking, urinating, wearing tight clothes, and with other activities of daily living.

CONCLUSIONS

Women's own words methodically recorded and analyzed during qualitative interviews and cognitive debriefing focus groups illuminate the subjective experience of women with GSM. It is hoped that the PROM currently in development will provide an effective tool for increasing our understanding of the prevalence, predictors, and impact of GSM in menopausal women's lives.

The Genitourinary Syndrome of Menopause: An Overview of the Recent Data

The genitourinary syndrome of menopause (GSM) is a relatively new term for the condition previously known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. The term was first introduced in 2014. GSM is a chronic, progressive, vulvovaginal, sexual, and lower urinary tract condition characterized by a broad spectrum of signs and symptoms. Most of these symptoms can be attributed to the lack of estrogen that characterizes menopause. Even though the condition mainly affects postmenopausal women, it is seen in many premenopausal women as well. The hypoestrogenic state results in hormonal and anatomical changes in the genitourinary tract, with vaginal dryness, dyspareunia, and reduced lubrication being the most prevalent and bothersome symptoms. These can have a great impact on the quality of life (QOL) of the affected women, especially those who are sexually active. The primary goal of the treatment of GSM is to achieve the relief of symptoms. First-line treatment consists of non-hormonal therapies such as lubricants and moisturizers, while hormonal therapy with local estrogen products is generally considered the “gold standard’’. Newer therapeutic approaches with selective estrogen receptor modulators (SERMs) or laser technologies can be employed as alternative options, but further research is required to investigate the viability and scope of their implementation in day-to-day clinical practice.

Local treatment with a polycarbophil-based cream in postmenopausal women with genitourinary syndrome of menopause

Introduction and hypothesis

Genitourinary syndrome of menopause (GSM) is a common problem associated with lower urinary tract and gynecological symptoms due to the decrease in estrogen production in postmenopausal women. Topical estrogen therapy is shown to improve these symptoms; nonetheless, there are limited data on the efficacy of nonhormonal moisturizers in these patients.

Methods

A prospective cohort study was conducted to compare the symptoms of GSM before and after treatment with a polycarbophil-based cream in 42 women. The quality of life (QoL) and sexual scores were obtained from the Thai version of the International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms (ICIQ-LUTS) along with uroflow measurements before and 4 and 12 weeks after treatment.

Results

Significant improvements in ICIQ-LUTSqol scores were observed after 4 weeks (9.38 ± 7.47 vs 6.76 ± 5.77; p = 0.017) and 12 weeks (10.03 ± 7.49 vs 5.97 ± 4.02; p = 0.002) when compared with the baseline values before treatment. The ICIQ-LUTS sexual scores were also improved after treatment at 4 weeks (2.29 ± 2.26 vs 0.88 ± 1.34; p < 0.001) and 12 weeks (2.13 ± 2.22 vs 0.42 ± 0.81; p < 0.001) compared with the baseline scores. No differences in ICIQ-LUTSqol and sexual scores were observed between the 4- and 12-week treatment groups.

Conclusion

The polycarbophil-based cream improved the overall LUTS and sexual symptoms in the patients with GSM, thus indicating that the nonhormonal polycarbophil-based cream may prove effective for the treatment for women with this condition.

Female Sexual Dysfunction: ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists, Number 213

Female sexual dysfunction encompasses various conditions that are characterized by reported personal distress in one or more of the following areas: desire, arousal, orgasm, or pain (). Although female sexual dysfunction is relatively prevalent, women are unlikely to discuss it with their health care providers unless asked (), and many health care providers are uncomfortable asking for a variety of reasons, including a lack of adequate knowledge and training in diagnosis and management, inadequate clinical time to address the issue, and an underestimation of the prevalence (). The purpose of this document is to provide an overview of female sexual dysfunction, to outline updated criteria for diagnosis, and to discuss currently recommended management strategies based on the best available evidence.

Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause is a condition comprising the atrophic symptoms and signs women may experience in the vulvovaginal and bladder-urethral areas as a result of the loss of sex steroids that occurs with menopause. It is a progressive condition that does not resolve without treatment and can adversely affect a woman’s quality of life. For a variety of reasons, many symptomatic women do not seek treatment and, of those who do, many are unhappy with their options. Additionally, many healthcare providers do not actively screen their menopausal patients for the symptoms of genitourinary syndrome of menopause. In this review, we discuss the clinical presentation of genitourinary syndrome of menopause as well as the treatment guidelines recommended by the major societies engaged in women’s health. This is followed by a review of available treatment options that includes both hormonal and non-hormonal therapies. We discuss both the systemic and vaginal estrogen products that have been available for decades and remain important treatment options for patients; however, a major intent of the review is to provide information on the newer, non-estrogen pharmacologic treatment options, in particular oral ospemifene and vaginal prasterone. A discussion of adjunctive therapies such as moisturizers, lubricants, physical therapy/dilators, hyaluronic acid, and laser therapy is included. We also address some of the available data on both the patient and healthcare providers perspectives on treatment, including cost, and touch briefly on the topic of treating women with a history of, or at high risk for, breast cancer.

Sexual Health Issues in Cancer Survivors

OBJECTIVE

To review the sexual health issues cancer survivors may experience, including incidence, association with treatment modalities, and approach to evaluation and treatment.

DATA SOURCES

Peer-reviewed journal articles, medical society or government Web sites.

CONCLUSION

Cancer diagnosis and treatment often impacts sexual function and addressing this is a key component of health-related quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Screening, evaluation, and treatment of sexual dysfunction should be incorporated into routine oncologic care.

An overview of dehydroepiandrosterone (EM-760) as a treatment option for genitourinary syndrome of menopause

Introduction: Dyspareunia caused by vulvovaginal atrophy is a primary symptom of genitourinary syndrome of menopause (GSM), a chronic, progressive medical condition that results from estrogen and androgen deficiency at menopause. Dehydroepiandrosterone (DHEA, prasterone) is an endogenous precursor steroid hormone that is metabolized into both androgens and estrogens that has been recently been approved by the FDA for the treatment of moderate to severe dyspareunia caused by vulvovaginal atrophy secondary to menopause.Areas covered: This is a comprehensive drug evaluation describing the chemical composition, pharmacokinetics, metabolism, clinical efficacy and safety of dehydroepiandrosterone (prasterone) in the treatment of dyspareunia and VVA secondary to menopause. Preclinical and clinical data suggesting further potential uses, benefits, and contraindications in the genitourinary health of postmenopausal women are also considered.Expert opinion: Intravaginal dehydroepiandrosterone (prasterone) is effective for the management of dyspareunia secondary to menopause and may be effective in the treatment of other types of sexual dysfunction that are secondary to menopause. Further studies should explore additional dosing regimens and different indications.

Ospemifene in the Management of Vulvar and Vaginal Atrophy: Focus on the Assessment of Patient Acceptability and Ease of Use

Endocrinological changes that occur with menopause lead to a chronic and progressive condition named vulvar and vaginal atrophy (VVA). This disease is characterized by symptoms such as dryness, dyspareunia, itching, burning, and dysuria. According to recent epidemiological studies, VVA has a high prevalence and can also occur in younger women prior to the menopause, negatively affecting quality of life, sexual function, intimacy and relationship with the partner. Accordingly, therapy should be effective, initiated early and continued for as long as possible. Up to recent years, available therapeutic options have included over-the-counter lubricants and moisturizers, vaginal oestrogens and systemic hormones. These products are not indicated for all women. Hormones are mostly contraindicated in women with a history of hormone-sensitive cancer and are frequently not accepted even by women without contraindications. Local therapies are frequently considered uncomfortable, difficult to apply, and messy. Indeed, these treatments have a high spontaneous discontinuation rate, mostly due to dissatisfaction, safety concern, side effects and difficulty in vaginal placement. Recently, ospemifene, a new non-hormonal systemic remedy, was approved by FDA (Food and Drug Administration) and EMA (European Medicines Agency) for the treatment of the two most bothersome symptoms of VVA: dryness and dyspareunia. Because ospemifene is a selective estrogen receptor modulator (SERM), it can be administered also in women with a history of breast cancer, and this makes it more acceptable by any woman. In addition, its route of administration minimizes those bothersome side effects intrinsic to the vaginal route of administration. Available data indicate that women using ospemifene have higher adherence to treatment, higher persistence and lower discontinuation rate. Satisfaction is higher than with other local therapies and overall health care cost is lower.

Genitourinary syndrome of menopause (GSM) and laser VEL: a review

The purpose of this publication is to summarize the results of the vaginal erbium:yttrium-aluminum-garnet (Er:YAG) Smooth® laser (VEL) on the vaginal atrophy component of the genitourinary syndrome of menopause (GSM). GSM has two categories of clinical signs related to estrogen deficiency: symptoms of vulvovaginal atrophy (VVA) and urinary symptoms. This symptomatology is chronic, progressive over the years and affects a majority of women concerned by natural menopause but not exclusively: we must also consider the growing number of survivors of gynecological or non-gynecological cancers (breast, cervix, uterus, vagina, anus, etc.). At a time when hormonal treatment of menopause is contested as is the installation of under urethra prosthesis, the innovation provided by the VEL technology has the merit of offering the women concerned an effective therapeutic alternative with the security of a patent. The VEL technology has an original and unique process: acting only by thermal effect and not by ablation on tissue, VEL is a safe solution in terms of side effects and potential complications. Studies have been increasing since 2012 and all demonstrate a significant improvement in the GSM signs and symptoms, as well as an improved sexual life after VEL treatment. Double-blind, placebo-controlled, randomized studies are expected in order to ultimately confirm the safety and effectiveness of VEL.

Measurement properties of patient-reported outcome measures (PROMs) for women with genitourinary syndrome of menopause: a systematic review

OBJECTIVE

Genitourinary syndrome of menopause affects up to 50% of postmenopausal women and has negative impacts on the women's quality of life. In this systematic review, we aimed to identify and assess the measurement properties of all existing patient-reported outcome measures (PROMs) specific for genitourinary symptoms that were developed and/or validated for measuring patient-reported outcomes in postmenopausal women.

METHODS

Studies which evaluated, described, or compared measurement properties of PROMs were considered as eligible. We performed a systematic literature search in MEDLINE, EMBASE, and Web of Science. The methodological quality of each study was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. Furthermore, predefined quality criteria for good measurement properties were applied and the quality of the evidence was graded.

RESULTS

Nine articles reporting on four PROMs were included. Two instruments, the Vulvovaginal Symptoms Questionnaire and the Day-to-Day Impact of Vaginal Aging Questionnaire, can be further recommended for use. Both showed moderate to high quality of evidence for sufficient structural validity, internal consistency, and construct validity. The two other instruments, urogenital atrophy quality of life (UGAQoL) and the Urogenital Symptom Scale, cannot be recommended for use, whereby the UGAQoL still has the opportunity to be recommended if the authors gave access to the instrument and further validation studies were conducted.

CONCLUSIONS

Both Vulvovaginal Symptoms Questionnaire and Day-to-Day Impact of Vaginal Aging Questionnaire can be recommended for use and results obtained with these two instruments can be seen as trustworthy. Future validation studies should focus on those two instruments.

Early onset of action with a 17β-estradiol, softgel, vaginal insert for treating vulvar and vaginal atrophy and moderate to severe dyspareunia

OBJECTIVE

The softgel 17β-estradiol (E2) vaginal inserts (4 and 10 μg; Imvexxy; TherapeuticsMD, Boca Raton, FL) are FDA approved for treating moderate to severe dyspareunia associated with postmenopausal vulvar and vaginal atrophy (VVA). The objective here was to determine responder rates at week 2 and whether week-2 findings predicted week-12 responders in the REJOICE trial.

METHODS

Postmenopausal women received E2 vaginal inserts 4, 10, or 25 μg, or placebo for 12 weeks. Proportion of responders (having ≥2 of the following: vaginal superficial cells >5%, vaginal pH <5.0, or dyspareunia improvement of ≥1 category) were calculated. Odds ratios (ORs) for positive response at week 12 given a positive response at week 2 were determined in the efficacy evaluable (EE) population.

RESULTS

The responder rate (in EE population [n = 695]) was 74% to 82% with E2 inserts versus 24% with placebo at week 2, and 72% to 80% versus 33% at week 12. Positive treatment responses were 9- to 14-fold higher with vaginal E2 than with placebo at week 2, and 5- to 8-fold higher at week 12. Response at week 2 predicted response at week 12 in the total population (OR 13.1; 95% CI, 8.8-19.7) and with active treatment only (OR 7.9; 95% CI, 4.7-13.2).

CONCLUSIONS

A high percentage of postmenopausal women with moderate to severe dyspareunia responded with the E2 softgel vaginal insert at week 2, and a positive response at week 2 predicted a positive response at week 12.

Histological and Gene Expression Analysis of the Effects of Menopause Status and Hormone Therapy on the Vaginal Introitus and Labia Majora

Background

The study aimed to determine the effect of menopausal status and hormone therapy on the introitus and labia majora at the levels of histology and gene expression.

Methods

Three cohorts of 10 women each (pre-menopause, post-menopause and post-menopause + hormone therapy) were selected based on the presentation of clinical atrophy and vaginal pH. Biopsies were obtained from the introitus (fourchette) and labia majora and processed for histology and gene expression analyses with microarrays. Other data collected included self-assessed symptoms, serum estradiol, testosterone, serum hormone binding globulin and the pH of the vagina and labia majora.

Results

The introitus appears exquisitely sensitive to hormone status. Dramatic changes were observed in histology including a thinning of the epithelium in post-menopausal subjects with vaginal atrophy. Furthermore, there was differential expression of many genes that may contribute to tissue remodeling in the atrophic introitus. Levels of expression of genes associated with wound healing, angiogenesis, cell migration/locomotion, dermal structure, apoptosis, inflammation, epithelial cell differentiation, fatty acid, carbohydrate and steroid metabolism were significantly different in the cohort exhibiting atrophy of the introitus. While changes were also observed at the labia, that site was considerably less sensitive to hormone status. The gene expression changes observed at the introitus in this study were very similar to those reported previously in the atrophic vagina providing further evidence that these changes are associated with atrophy.

Conclusions

The histological and gene expression changes occurring within the introitus after menopause may contribute to the constellation of symptoms that constitute the genitourinary syndrome of menopause.

The impact of genitourinary syndrome of menopause on well-being, functioning, and quality of life in postmenopausal women

OBJECTIVE

Symptoms of genitourinary syndrome of menopause (GSM) are bothersome to middle-aged and older women, and affect their quality of life (QoL), sexuality, and daily activities. The objective of the study was to evaluate the impact of vaginal symptoms and GSM on the well-being, functioning, and QoL of postmenopausal women from Spain.

METHODS

This study involved 423 postmenopausal women participating in the GENISSE study (a multicenter, cross-sectional, descriptive, observational study) who presented at least 1 vaginal symptom. All women completed the "day-to-day impact of vaginal aging" (DIVA) questionnaire. Analysis of total scores and subdomains of the questionnaire were performed in women diagnosed with GSM and those without the condition.

RESULTS

In these women, the highest mean scores on the DIVA questionnaire were found in the sexual functioning domain long version (mean 1.8; SD 1.0), followed by the sexual functioning domain short version (mean 1.7; SD 1.1), self-perception and body image (mean 1.4; SD 1.1), activities of daily living (mean 0.7; SD 0.8), and emotional well-being (mean 0.7; SD 0.8) scales. A total of 299 women (70.7%) had vaginal symptoms with a diagnosis of GSM, whereas 124 (29.3%) had no GSM diagnosis. Scores on the DIVA questionnaire were significantly higher in women with a diagnosis of GSM than in those without this condition.

CONCLUSIONS

Vaginal symptoms impact the well-being, functioning, and QoL of postmenopausal women, especially sexual function, self-perception, and body image. This impact is significantly higher in women with GSM. Identifying and treating patients affected by vaginal symptoms and GSM may be beneficial for improving their QoL.

Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations

There is a new appreciation of the perimenopause - defined as the early and late menopause transition stages as well as the early postmenopause - as a window of vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects of hormone therapy; and 5) efficacy of other therapies (eg, psychotherapy, exercise, and natural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women, particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

No. 358-Intravaginal Laser for Genitourinary Syndrome of Menopause and Stress Urinary Incontinence

OBJECTIVE

This technical bulletin reviews the evidence relating to risks and benefits of using intravaginal laser technology in the management of genitourinary syndrome of menopause and stress urinary incontinence.

INTENDED USERS

Gynaecologists, urogynaecologists, urologists, and other health care professionals who assess, counsel, and provide care for women with genitourinary syndrome of menopause and stress urinary incontinence.

TARGET POPULATION

Adult women with genitourinary syndrome of menopause and stress urinary incontinence seeking complementary or alternative treatment options to topical estrogen, non-hormonal vaginal moisturizers, physiotherapy, intravaginal devices, and surgery.

OPTIONS

The discussion relates to intravaginal laser treatments for genitourinary syndrome of menopause compared with topical estrogen and that for stress urinary incontinence.

OUTCOMES

The outcomes of interest are objective and subjective rates of response to treatment, histologic outcomes, and procedural complications.

EVIDENCE

PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words "genitourinary syndrome of menopause," "vaginal laser," "topical estrogen," and "urogenital atrophy." Results were restricted to English and human research. Articles were included until the end of September 2016. Clinical practice guidelines and guidelines of specialty societies were reviewed. Included studies were observational or prospective cohort when available. Only publications with study groups larger than or equal to 20 individuals were included, and non-peer-reviewed papers were excluded.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.

BENEFITS, HARMS, AND/OR COSTS

It is expected that this technical bulletin will benefit patients with genitourinary syndrome of menopause by ensuring treating physicians are aware of all treatment options including the potential benefit and associated risk with intravaginal laser therapy. This should guide patient informed consent before such procedures are undertaken. There are no direct harms or costs identified with the implementation of this guideline.

SPONSORS

The SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review

OBJECTIVE

The objective of this consensus document is to broaden the perspective on clinical management of genitourinary syndrome of menopause to include androgens.

METHODS

A modified Delphi method was used to reach consensus among the 14 international panelists representing multiple disciplines and societies.

RESULTS

Menopause-related genitourinary symptoms affect over 50% of midlife and older women. These symptoms have a marked impact on sexual functioning, daily activities, emotional well-being, body image, and interpersonal relations. Tissues in the genitourinary system are both androgen and estrogen-dependent. The clitoris, vestibule, including minor and major vestibular glands, urethra, anterior vaginal wall, periurethral tissue, and pelvic floor are androgen-responsive. Historically, treatment of postmenopausal genitourinary symptoms involved both androgens and estrogens. This subsequently gave rise to predominantly estrogen-based therapies. More recently, double-blind, placebo-controlled clinical trials have demonstrated that local vaginal dehydroepiandrosterone improves symptoms in postmenopausal women, including moderate to severe dyspareunia. Limited data suggest that systemic testosterone treatment may improve vaginal epithelial health and blood flow. Open-label studies that have used high doses of intravaginal testosterone in the presence of aromatase inhibitor therapy for breast cancer have resulted in supraphysiological serum testosterone levels, and have been reported to lower vaginal pH, improve the vaginal maturation index, and reduce dyspareunia.

CONCLUSIONS

Vaginal dehydroepiandrosterone, hypothesized to enhance local production of both androgen and estrogen, is effective for the management of dyspareunia in menopause. Vaginal testosterone offers potential as a treatment for genitourinary syndrome of menopause, but more studies are needed.

Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women's Sexual Health

The objective of The North American Menopause Society (NAMS) and The International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel was to create a point of care algorithm for treating genitourinary syndrome of menopause (GSM) in women with or at high risk for breast cancer. The consensus recommendations will assist healthcare providers in managing GSM with a goal of improving the care and quality of life for these women. The Expert Consensus Panel is comprised of a diverse group of 16 multidisciplinary experts well respected in their fields. The panelists individually conducted an evidence-based review of the literature in their respective areas of expertise. They then met to discuss the latest treatment options for genitourinary syndrome of menopause (GSM) in survivors of breast cancer and review management strategies for GSM in women with or at high risk for breast cancer, using a modified Delphi method. This iterative process involved presentations summarizing the current literature, debate, and discussion of divergent opinions concerning GSM assessment and management, leading to the development of consensus recommendations for the clinician.Genitourinary syndrome of menopause is more prevalent in survivors of breast cancer, is commonly undiagnosed and untreated, and may have early onset because of cancer treatments or risk-reducing strategies. The paucity of evidence regarding the safety of vaginal hormone therapies in women with or at high risk for breast cancer has resulted in avoidance of treatment, potentially adversely affecting quality of life and intimate relationships. Factors influencing decision-making regarding treatment for GSM include breast cancer recurrence risk, severity of symptoms, response to prior therapies, and personal preference.We review current evidence for various pharmacologic and nonpharmacologic therapeutic modalities in women with a history of or at high risk for breast cancer and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. Treatment of GSM is individualized, with nonhormone treatments generally being first line in this population. The use of local hormone therapies may be an option for some women who fail nonpharmacologic and nonhormone treatments after a discussion of risks and benefits and review with a woman's oncologist. We provide consensus recommendations for an approach to the management of GSM in specific patient populations, including women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

Vaginal CO2 laser for the treatment of vulvovaginal atrophy in women with breast cancer: LAAVA pilot study

PURPOSE

Vulvovaginal atrophy (VVA) is a commonly reported issue among breast cancer patients, and its aetiology is multifactorial. Treatment is difficult in these women, particularly because the use of oestrogens has traditionally been discouraged. Vaginal laser treatment has been reported to improve symptoms. We aimed to assess the impact on symptoms and sexual function of vaginal laser in women with early breast cancer (EBC).

METHODS

We performed a single-arm investigator initiated pilot study of female EBC patients with symptomatic VVA. A total of 3 vaginal laser treatments were administered 4 weeks apart. Questionnaires were completed at baseline, 4, 8 and 12 weeks. Our primary endpoint was symptomatic improvement of VVA at 12 weeks on 10 cm visual analogue scales. Our secondary endpoints were improvement in sexual function using the Female Sexual Function Index (FSFI) and patient-reported improvements in symptoms, sexual function and quality of life. Statistical analysis was performed with a Wilcoxon Signed Rank test.

RESULTS

26 patients were enrolled between February 2016 and August 2017. All patients were post-menopausal, 25 of whom had received anti-oestrogen therapy for their breast cancer. Questionnaire compliance was high (98%) and all patients received the three pre-planned treatments. There was significant improvement in each of the VVA symptoms: dryness (p < 0.001), itch (p < 0.001), burning (p = 0.003), dysuria (p < 0.001) and dyspareunia (p < 0.001). Patients also reported improvement in sexual function on the FSFI (p ≤ 0.001).

CONCLUSIONS

Patients receiving vaginal laser had improvement in VVA symptoms and sexual function. Further randomised sham-controlled trials are needed to further assess this treatment.

The menopausal woman: The need for an individualized plan of care

With life expectancy increasing, women will spend one-third of their lives in and beyond menopause. A collaborative discussion with the clinician facilitates informed decision-making and should include evidence-based discussion of physiologic changes, assessment of symptoms and treatment options, review of screening recommendations, and discussion of disease risk-reduction strategies and psychosocial issues.

Psychosomatic and vasomotor symptom changes during transition to menopause

Menopause is the condition in which the gradual decline in ovarian function finally leads to the permanent cessation of menstruation. Oestrogen deficiency may cause early symptoms during the menopausal transition and late symptoms after menopause. Menopause is a normal period of life. During this period, women need adaptation to new biological, social, and psychological parameters. Vasomotor symptoms are among the most common menopausal symptoms. Menopause per se is not correlated with specific psychiatric disorders, but data suggest that perimenopausal women are more likely to develop depressive disorders even without a previous history. Vasomotor symptoms are correlated with mood and sleep disturbances, neuroticism, anxiety, decreased cognitive function, and stress. Personality traits, social, and other factors are also important mediators of vasomotor symptoms during the menopausal transition phase.

This is a review based on the existing evidence concerning the correlation between psychosomatic and vasomotor symptoms of menopause during the menopausal transition period. Healthcare providers should take these correlations into consideration when planning the treatment of vasomotor symptoms. Vasomotor symptoms during menopause are associated with significant social costs. There are numerous traditional hormone therapy, and complementary and alternative therapy including over-the-counter treatments and dietary supplements for managing menopause-related vasomotor symptoms. Additional costs include follow-up physician visits, laboratory testing, management of adverse events, and loss of productivity at work. Social support and planning may help women to deal with menopausal symptoms and may reduce overall social costs during this transitional phase.

The Rationale for Photobiomodulation Therapy of Vaginal Tissue for Treatment of Genitourinary Syndrome of Menopause: An Analysis of Its Mechanism of Action, and Current Clinical Outcomes

Objective: Light, particularly in the visible to far-infrared spectrum, has been applied to the female genital tract with lasers and other devices for nearly 50 years. These have included procedures on both normal and neoplastic tissues, management of condylomata, endometriosis, and menometrorrhagia, and, more recently, a number of fractional laser devices have been applied for the management of genitourinary syndrome of menopause (GSM) and stress urinary incontinence (SUI), and to achieve so-called vaginal rejuvenation. Photobiomodulation therapy (PBMT) has been proposed as an alternative for use in managing GSM and SUI.

Methods: This article reviews the biological basis, symptoms, and management of GSM, and investigates the current status and rationale for the use of PBMT.

Results and conclusions: Based on the preliminary evidence available, PBMT is safe and appears to be efficacious in treating GSM.

A randomized, multicenter, double-blind study to evaluate the safety and efficacy of estradiol vaginal cream 0.003% in postmenopausal women with dyspareunia as the most bothersome symptom

Objective:

Vulvovaginal atrophy (VVA) is characterized by vaginal changes, dyspareunia, and itching/irritation. Efficacy and safety of a lower-dose estradiol vaginal cream (0.003%) were evaluated in postmenopausal women with VVA-related dyspareunia.

Methods:

This was a phase 3, randomized, double-blind, placebo-controlled study. Sexually active postmenopausal women with moderate–severe dyspareunia as the most bothersome symptom, ≤5% vaginal superficial cells, and vaginal pH >5.0 were randomized (1:1) to 0.003% estradiol vaginal cream (15 μg estradiol; 0.5 g cream) or placebo (0.5 g cream) applied daily for 2 weeks followed by three applications/week for 10 weeks. Coprimary outcomes were changes in dyspareunia severity, vaginal cytology, and vaginal pH from baseline to final assessment. Additional efficacy outcomes and safety were assessed.

Results:

A total of 550 participants (average age, 58 y) were randomized. Compared with placebo, estradiol reduced dyspareunia severity (mean change from baseline ± SD: −1.5 ± 1.0 estradiol vs −1.2 ± 0.9 placebo), decreased vaginal pH (−1.36 ± 0.89 vs −0.53 ± 0.92), and improved vaginal cytology (percentage superficial and parabasal cells 10.1 ± 16.7 vs 1.4 ± 6.1 and −48.5 ± 45.1 vs −14.6 ± 39.6; P < 0.001, all) at the final assessment. In addition, estradiol decreased dyspareunia severity at weeks 8 and 12, vaginal/vulvar irritation/itching at weeks 4 and 12, and dryness at week 12 versus placebo (P < 0.01, all). VVA severity, pH, and cytology improved at week 12 with estradiol versus placebo (P < 0.001, all). Vulvovaginal mycotic infections were more frequent with estradiol. One serious event leading to discontinuation occurred with estradiol. No deaths occurred.

Conclusions:

Lower-dose estradiol vaginal cream (0.003%) dosed three applications/week is an effective and well-tolerated treatment for VVA-related dyspareunia.