Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause

Impact of Endocrine Disruptors on the Genitourinary Tract

Over the last decades, the human species has seen an increase in the incidence of pathologies linked to the genitourinary tract. Observations in animals have allowed us to link these increases, at least in part, to changes in the environment and, in particular, to an increasing presence of endocrine disruptors. These can be physical agents, such as light or heat; natural products, such as phytoestrogens; or chemicals produced by humans. Endocrine disruptors may interfere with the signaling pathways mediated by the endocrine system, particularly those linked to sex hormones. These factors and their general effects are presented before focusing on the male and female genitourinary tracts by describing their anatomy, development, and pathologies, including bladder and prostate cancer.

Efficacy and Safety of Non-Ablative Dual Wavelength Diode Laser Therapy for Genitourinary Syndrome of Menopause: A Single-Center Prospective Study

INTRODUCTION

This study evaluates the efficacy and safety of non-ablative diode laser therapy for genitourinary syndrome of menopause (GSM) in post-menopausal women unable to use hormonal therapies.

METHODS

A pilot prospective study was conducted from September 2023 to April 2024, involving 22 post-menopausal women aged 45-73 years. Participants underwent three sessions of diode laser treatment with the Leonardo® dual-wavelength Diode laser. Assessments were made at baseline, 3 months, and 6 months post-treatment. Main outcome measures included Visual Analog Scale (VAS) scores for GSM symptoms, Vaginal Health Index Score (VHIS), and sexual function evaluated using the Female Sexual Function Index (FSFI-6), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and Sexual Quality of Life-Female (SQOL-F) questionnaire.

RESULTS

Significant improvements were observed in VHIS, increasing from 12 to 19.27 at 6 months (p < 0.001). GSM symptoms improved significantly: vaginal dryness scores decreased from 7.72 ± 2.37 to 3.72 ± 2.53, burning sensation scores dropped from 6.00 ± 3.22 to 1.90 ± 1.81, and dyspareunia scores reduced from 8.09 ± 2.11 to 3.90 ± 2.58 (all p < 0.016). Sexual function improved, indicated by FSFI-6 scores increasing from 12.27 ± 7.29 to 19.30 ± 6.24 (p < 0.016) and SQOL-F scores rising from 63.18 ± 22.93 to 71.45 ± 23.31. No adverse events were reported.

CONCLUSION

Non-ablative diode laser therapy is effective and safe for managing GSM symptoms in post-menopausal women, offering significant symptom relief and enhancing sexual health without serious side effects. Further research with a larger cohort and extended follow-up is needed to confirm these findings.

TRIAL REGISTRATION

Clinical Trials ID NCT06503003.

Effect of Vaginal Laser and Topical Therapies on Vulvovaginal Atrophy Symptoms in Breast Cancer Patients: A Systematic Review and Meta-Analysis

Background: Vulvovaginal atrophy (VVA) significantly impacts the quality of life in breast cancer patients leading to symptoms like vaginal dryness, dyspareunia, and genital discomfort. Quality of life in this context is measured using validated scales like the Vaginal Health Index, Visual Analog Scale (VAS), and the Female Sexual Function Index (FSFI). Methods: We performed a systematic review and meta-analysis to identify effective treatment options for VVA, including topical estrogen, systemic hormone therapy, vaginal DHEA, ospemifene, and non-hormonal methods like intravaginal laser therapy, moisturizers, and lubricants. A systematic search of four databases (MEDLINE, Scopus, CENTRAL, Embase) identified studies on VVA treatment efficacy in breast cancer patients, yielding 13,039 records, with 32 eligible studies and 8 included in the meta-analysis. Results: Significant improvements were found with intravaginal laser therapy, showing notable differences in the Vaginal Health Index (MD = 8.24, p < 0.01), dyspareunia (MD = -4.82, p = 0.05), and dryness (MD = -5.05, p = 0.01). However, no significant changes were observed in FSFI and vaginal pH. Notably only intravaginal laser therapy was included in the meta-analysis, as other treatment options lacked comparable data. Both hormonal and non-hormonal treatments improved quality of life, with laser therapy showing the most substantial effects. Conclusions: Intravaginal laser therapy is an effective treatment for VVA symptoms in breast cancer survivors, particularly in improving the Vaginal Health Index and reducing dyspareunia. Despite the strengths of the study, variability among studies, lack of RCT-s and data limitations, especially on long-term effects, present challenges.

Short and long-term effect of polycarbophil vaginal gel on vaginal atrophy of peri- and post-menopausal women. The TRIPLE study

OBJECTIVES

This TRIPLE study was aimed to evaluate the efficacy of polycarbophil vaginal gel (PCV) in treating symptoms of vaginal atrophy (VA) of peri- and post-menopausal women.

MATERIALS AND METHODS

Sexually active women in peri- (n = 29) and post-menopause (n = 54) suffering from VA, were progressively enrolled and treated for 30 days with PCV. Those wishing to continue (n = 73) were treated for additional 180 days. PCV was administered as one application twice a week. The vaginal health index (VHI; range 5 to 25) and the visual analogue score (VAS range for 0 to 100 mm for each item) for vaginal dryness, irritation, and pain at intercourse, along with the global symptoms score (GSS; range 1 to 15) and treatment safety, were evaluated at baseline and after 30 days. In those continuing the treatment an evaluation was performed after additional 180 days.

RESULTS

Women in peri and post-menopause were of 48.7 ± 3.3 years and 57.5 ± 5.7 years old., respectively. At baseline all outcomes were significantly worse (p<0.002) in postmenopausal group, except the VHI (p < 0.056). After 30 days VHI increased (p < 0.001) of 4.1 ± 0.5 (mean ± SE), and 5.1 ± 0.4 in peri- and post-menopausal women respectively. VAS of vaginal dryness decreased (p < 0.001) of -24.4 ± 3.6, and -52.7 ± 2.6 (p < 0.001), VAS of irritation decreased (p<0.001) of -18.6 ± 4.4 and -47.8 ± 3.2, VAS of pain decreased (p < 0.001) of -26.2 ± 4.3 and -55.6 ± 3.1 and the GSS decreased (p < 0.001) of -3.9 ± 0.3, and -4.9 ± 0.2, in peri and post-menopausal women, respectively. All the modifications were significantly greater (p < 0.001)(p < 0.032 for GSS) in postmenopausal women, and after 30 days all outcomes were similar in the two groups of women. In comparison to baseline, after 210 days of treatment VHI increased of 7.7 ± 0.3 (p < 0.001), VAS of vaginal dryness decreased of -53.6 ± 1.9 (p < 0.001) VAS of irritation of -42.6 ± 1.4 (p < 0.001) VAS of pain of -46.7 ± 2.3 (p < 0.001) and the GSS of -6.5 ± 0.2 ± 0.2 (p < 0.001). All outcomes improved (p < 0.001) over the values observed after 30 days of treatment (p < 0.001). No side effect was reported.

CONCLUSIONS

In peri- and post-menopausal women PCV administration rapidly improves VA symptoms, and its prolongation up to 6 months further increases its efficacy.

Multifaceted Impact of CO2 Laser Therapy on Genitourinary Syndrome of Menopause, Vulvovaginal Atrophy and Sexual Function

Genitourinary syndrome of menopause (GSM) encompasses a range of distressing symptoms in the vulvovaginal and/or bladder-urethral regions related to menopause changes, negatively influencing woman's quality of life and sexual activity. Fractional micro-ablative CO2 laser therapy has shown the potential to reinstate the vaginal epithelium to a condition akin to the premenopausal state, thereby ameliorating the subjective symptoms associated with GSM. We conducted a prospective, pilot study in 73 sexually active postmenopausal women treated with CO2 laser for their GSM symptoms, while assessing Vaginal Health Index Score (VHIS) and sexual function through the Female Sexual Function Index (FSFI) Questionnaire. The laser treatment resulted in a decrease in VHIS and patient-reported vulvovaginal atrophy (VVA) symptoms, with a significantly lower prevalence of vaginal itching, dryness, and burning (p < 0.001), as well as dyspareunia (p = 0.002). The occurrence of urinary incontinence, urgency, and vaginal heaviness significantly reduced, with an improvement in the staging of cystocele, either to Stage 1 or complete resolution (p < 0.001). FSFI total and domain scores were significantly higher after the treatment, indicating better sexual function, with a post-treatment score median of 25 (p < 0.001). Therefore, using a three-cycle fractional CO2 laser was an effective choice for reducing urogenital discomfort related to GSM in postmenopausal women.

Oral lasofoxifene's effects on moderate to severe vaginal atrophy in postmenopausal women: two phase 3, randomized, controlled trials

OBJECTIVE

The aim of this study was to demonstrate whether lasofoxifene improves vaginal signs/symptoms of genitourinary syndrome of menopause.

METHODS

Two identical, phase 3 trials randomized postmenopausal women with moderate to severe vaginal symptoms to oral lasofoxifene 0.25 or 0.5 mg/d, or placebo, for 12 week. Changes from baseline to week 12 in most bothersome symptom, vaginal pH, and percentages of vaginal parabasal and superficial cells were evaluated. These coprimary endpoints were analyzed using analysis of covariance, except superficial cells, which were analyzed by the nonparametric, rank-based Kruskal-Wallis test.

RESULTS

The two studies enrolled 444 and 445 women (mean age, ~60 y), respectively. Coprimary endpoints at week 12 improved with lasofoxifene 0.25 and 0.5 mg/d greater than with placebo ( P < 0.0125 for all). Study 1: most bothersome symptom (least square mean difference from placebo: -0.4 and -0.5 for 0.25 and 0.5 mg/d, respectively), vaginal pH (-0.65, -0.58), and vaginal superficial (5.2%, 5.4%), and parabasal (-39.9%, -34.9%) cells; study 2: most bothersome symptom (-0.4, -0.5), vaginal pH (-0.57, -0.67), and vaginal superficial (3.5%, 2.2%) and parabasal (-34.1%, -33.5%) cells. Some improvements occurred as early as week 2. Most treatment-emergent adverse events were mild or moderate and hot flushes were most frequently reported (lasofoxifene vs placebo: 13%-23% vs 9%-11%). Serious adverse events were infrequent and no deaths occurred.

CONCLUSIONS

In two phase 3 trials, oral lasofoxifene 0.25 and 0.5 mg/d provided significant and clinically meaningful improvements in vaginal signs/symptoms with a favorable safety profile, suggesting beneficial effects of lasofoxifene on genitourinary syndrome of menopause.

The LADY study: epidemiological characteristics of prevalent and new genitourinary syndrome of menopause cases in Greece

OBJECTIVE

The genitourinary syndrome of menopause (GSM) is often underdiagnosed and undertreated despite its significant impact on postmenopausal quality of life. We assessed the prevalence of GSM and associated symptoms in Greek perimenopausal/postmenopausal women attending gynecology clinics.

METHODS

Four hundred and fifty women, aged 40-70 years (93.1% postmenopausal), attending three gynecology clinics at university hospitals completed a validated questionnaire and underwent pelvic examination.

RESULTS

GSM was diagnosed in 87.6% of the women at the study visit, whereas only 16% of the overall sample had been previously diagnosed with the condition. Vaginal dryness (72.7%), vulvar burning sensation or itching (58.0%) and dyspareunia (52.7%) were the most prevalent symptoms. Pelvic signs consisted of vaginal dryness (89.1%), loss of vaginal rugae (80.6%) and vulvovaginal pallor (86.9%). However, only 31.3% of the participants had discussed genitourinary symptoms with their health-care professionals (HCPs). Regarding management, only 11.1% of women had prior experience with any form of therapy, and currently only 8.7% were receiving treatment.

CONCLUSION

GSM is highly prevalent in this Greek perimenopausal/postmenopausal population. Nevertheless, the majority of women remain undiagnosed and untreated. Education for both women and HCPs regarding GSM will lead to improved diagnosis and better management of this syndrome.

Effects of a therapeutic lifestyle modification intervention on cardiometabolic health, sexual functioning and health-related quality of life in perimenopausal Chinese women: protocol for a randomised controlled trial

INTRODUCTION

Perimenopause is a critical transitional period in reproductive ageing. A set of physiological and psychological changes can affect perimenopausal women's quality of life and further threaten their older adult health conditions. In China, less than one-third of midlife women with menopausal symptoms have actively sought professional healthcare. Regarding the public health significance of comprehensive menopause management, the current study aims to investigate the effects of a therapeutic lifestyle modification (TLM) intervention on cardiometabolic health, sexual functioning and health-related quality of life among perimenopausal Chinese women.

METHOD AND ANALYSIS

A randomised controlled trial with two parallel arms will be conducted at the gynaecology outpatient department of Yunnan Provincial Hospital of Traditional Chinese Medicine in China. 94 eligible perimenopausal women aged between 40 and 55 years will be recruited for the study. The TLM intervention consists of four elements: menopause-related health education, dietary guidance, pelvic floor muscle training and Bafa Wubu Tai Chi exercise. Participants will be randomly assigned (1:1) to receive either the 12-week TLM intervention or routine care via stratified blocked randomisation. The primary outcome is quality of life; secondary outcomes of interest include sexual functioning and cardiometabolic health. The outcome measures will be assessed at baseline and post-intervention. To explore the effects of the intervention, linear mixed models will be applied to test the changes between the two groups over time in each outcome based on an intention-to-treat analysis.

ETHICS AND DISSEMINATION

The Research Ethics Review Committee of Chulalongkorn University (COA No 178/66) and the Medical Ethics Committee of Yunnan Provincial Hospital of Traditional Chinese Medicine (IRB-AF-027-2022/02-02) approved the study protocol. Written informed consent will be obtained from all participants. Results will be published in peer-reviewed journals and disseminated through conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300070648.

Diffuse reflectance spectroscopy and imaging for non-invasive objective assessment of genitourinary syndrome of menopause: a pilot study

The genitourinary symptom of menopause (GSM) affects up to 65% of women, resulting in symptoms such as vulvovaginal dryness, discomfort, and dysuria, which significantly impacts quality of life. The current assessment methods rely on subjective questionnaires that can be influenced by individual differences, as well as invasive measurements that are time-consuming and not easily accessible. In this study, we explore the potential of a non-invasive and objective assessment tool called diffuse reflectance spectroscopy and imaging (DRSI) to evaluate tissue chromophores, including water, lipid, oxyhemoglobin, and deoxyhemoglobin. These measurements provide information about moisture content, lipid levels, oxygen saturation, and blood fraction, which can serve as surrogate markers for genital estrogen levels. Our findings reveal distinct differences in these chromophores among pre, peri, and postmenopausal subjects. By using lipid and blood fraction tissue chromophores in a K-Nearest Neighbour classifier model, we achieved a prediction accuracy of 65% compared to vaginal maturation index (VMI) that is clinically used to assess estrogen-related hormonal changes. When age was included as the third feature, the accuracy increased to 78%. We believe that by refining the study protocol and configuring the fiber probe to examine tissue chromophores both in the superficial vulva skin for epidermal water content and the deeper layers, DRSI has the potential to provide objective diagnosis and aid in monitoring the treatment outcome of GSM.

Skin Rejuvenation in Women using Menopausal Hormone Therapy: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the effect of menopausal hormone therapy (MHT) on skin aging in menopausal women.

METHODS

Studies were identified by searching PubMed, Cochrane Library, Google Scholar, and ClinicalTrials.gov databases using the key words "hormone replacement therapy" AND "skin" AND "menopausal." Studies that used and compared oral/transdermal MHT with placebo or another type of treatment in menopausal women aged 45-55 years were selected.

RESULTS

From 1,526 studies identified, 15 studies comprising 1,589 patients were included in the final analysis. Our meta-analysis aimed to compare skin elasticity (standard [Std] mean difference = 0.28; 95% confidence interval [CI], 0.03-0.54; P = 0.03), skin thickness (Std. mean difference = 1.27; 95% CI, 0.88-1.66; P < 0.00001), collagen content (Std. mean difference = 2.01; 95% CI, 1.42-2.61; P < 0.00001), and skin dryness (Std. mean difference = 0.15; 95% CI, -0.05 to 0.35; P = 0.14).

CONCLUSIONS

MHT increases elasticity and collagen content in the skin, thereby reducing the severity of wrinkles and increasing skin thickness. Nevertheless, more well-conducted clinical trials are required to answer all questions in an evidence-based manner.

Injection Treatments for Vulvovaginal Atrophy of Menopause: A Systematic Review

BACKGROUND

Injection treatments have been proposed as novel treatment options for Vulvovaginal Atrophy of Menopause (VVA) also known as Genitourinary Syndrome of Menopause (GSM). However, to date data about these treatments are poor.

OBJECTIVE

To assess all available injection treatments for VVA.

METHODS

A systematic review was performed by searching five electronic databases for peer-reviewed studies that assessed injection treatments for VVA.

RESULTS

Eight studies (7 observational and 1 randomized) with 236 women were included. Assessed injection materials were: autologous platelet-rich plasma (PRP) + hyaluronic acid (HA), not cross-linked HA plus calcium hydroxyapatite (NCLHA + CaHA), micro-fragmented adipose tissue (MFAT), hyaluronan hybrid cooperative complexes (HCC), crosslinked HA, microfat and nanofat grafting + PRP, and PRP alone. Improvement in GSM symptoms after treatment was assessed through Visual Analogic Scale (VAS) for GSM symptoms or patient satisfaction, several validated questionnaires (FSFI, VHI, FSD, SF12, ICIQ UI SF, PGI-I, FSDS-R, VSQ), symptoms severity, changes in vaginal mucosa thickness, flora, pH, and expression on vaginal mucosal biopsies of Procollagen I and III and ki67 immunofluorescence or COL1A1 and COL3A1 mRNA. Injection treatments showing significant improvement in GSM-related symptoms were: (i) HCC in terms of VAS for GSM symptoms and FSFI score; (ii) Crosslinked HA in terms of VAS for GSM symptoms, FSFI and VHI score, COL1A1 and COL3A1 mRNA expression on vaginal mucosal biopsies; (iii) NCLHA + CaHA in terms of FSFI score; (iv) PRP + HA in terms of VHI, FSD and SF12 score; (v) microfat and nanofat grafting + PRP in terms of VHI score and FSDS-R score; (vi) PRP alone in terms of VHI and VSQ scores.

CONCLUSIONS

All assessed injection treatments except for MFAT seem to lead to significant improvement in VVA symptoms on validated questionnaires. Further studies are necessary in the field.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Genitourinary Syndrome of Menopause: A Narrative Review Focusing on Its Effects on the Sexual Health and Quality of Life of Women

Genitourinary syndrome of menopause (GSM) is a progressive condition due to a hypoestrogenic state affecting perimenopausal and menopausal women. GSM was previously known as urogenital syndrome, vulvovaginal atrophy, or atrophic vaginitis. The term vulvovaginal atrophy did not encompass the symptoms of the urinary tract like incontinence, urgency, and discomfort, or allude that it is due to a hypoestrogenic state. Although a significant segment of the population is affected by GSM, it is very sparsely studied, detected, and treated. GSM affects the quality of life and sexual health of most menopausal women suffering from it. Only a few healthcare providers ask about the symptoms of GSM and a tiny percentage of women seek consultation for it. This may be because they are either embarrassed or believe it to be a part of the natural process of aging. As the life expectancy of women has increased in general, the prevalence of GSM has also risen, while it still remains underdiagnosed and untreated. Properly educating women so that they can seek consultation regarding symptoms of GSM, and training healthcare professionals about communicating with the patient, as well as correctly identifying, diagnosing, and managing the patient are all important to overcome this communication barrier. Once we cross the barrier of diagnosing patients with GSM, we still have to manage the patients with tailor-made prescriptions according to the severity of the symptoms and their preferences. While there are various treatment options, the most effective one is low-dose topical estrogen therapy. In this review, we intend to explore the existing knowledge about GSM and its effect on the quality of life and sexual health of women along with the treatment options for managing and reversing the effects of GSM.

The Comparative Study of the Administration of the Combination Preparation of Isoflavones and Hyaluronic Acid in Menopausal Women for the Treatment of the Symptoms of Menopause, Urogenital Atrophy and Oteoporosis in Relation to Existing Hormone Replacement Therapies

Background

Menopause is characterized by a series of symptoms and effects from the various systems and organs, for which, the decline in estrogen production from the ovaries is considered responsible.

Objective

The aim of this study was to make comparative study of the administration of the combination preparation of isoflavones and hyaluronic acid in menopausal women for the treatment of the symptoms of menopause, urogenital atrophy and osteoporosis in relation to existing hormone replacement therapies.

Methods

In this five-year, double-blind, placebo-controlled clinical study, a total of 274 postmenopausal women were enrolled and classified into three groups. Participants in group A, were 96 women who did not receive Hormone Replacement Therapy (HRT), in the second group, 92 received daily treatment with tibolone (2.5 mg) as monotherapy, and in the third group, 86 received treatment with a pharmaceutical formulation of hyaluronic acid 120 mg and isoflavones. MF11RCE 80 mg.

Results

In the postmenopausal women of our study, a significant reduction of postmenopausal symptoms was found in both groups B and C of participants who received hormone replacement preparations compared to group A who did not receive HRT. Furthermore, no difference in efficacy was observed between the administered preparations of isoflavones and tibolone.

Conclusion

The combination of isoflavones and hyaluronic acid has the same efficacy as tibolone in menopausal symptoms.

A practical guide to managing genitourinary syndrome of menopause in primary care

ABSTRACT

Females spend a third to half of their life in menopause, and the number of US females in menopause is growing. A high percentage of postmenopausal females experience bothersome, sometimes debilitating genitourinary symptoms, which can affect quality of life. The genitourinary syndrome of menopause (GSM) describes the condition previously referred to as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. Of concern, many patients with symptoms of GSM have never been asked about nor have they initiated conversations about these concerns with a healthcare provider. This article addresses the need to improve screening, identification, and patient-centered management in primary care of females with GSM.

Unlocking the Potential of Mesenchymal Stem Cells in Gynecology: Where Are We Now?

Stem cells, with their remarkable capacity for differentiation into diverse cell types, are vital for the development as well as maintenance of health and homeostasis. Two unique abilities set them apart from other cells: self-renewal and the capacity for differentiation. They play important roles in embryogenesis, development, regeneration, and various other processes. Over the last decade, there has been increased interest in their potential use in the treatment of numerous diseases and disorders across multiple fields of medicine in acute, chronic, innate, and acquired diseases. Stem cells are key to maintaining the body's homeostasis and regulating growth and tissue functions. There are several types of stem cells-embryonic, adult, and human-induced pluripotent cells. Currently, mesenchymal stem cells are of great interest due to their regenerative, immunomodulatory, analgesic, and antimicrobial (anti-inflammatory) effects. Recent studies have shown the potent regenerative effect of stem cell therapy in gynecologic diseases such as infertility, Asherman syndrome, lichen sclerosus, polycystic ovary syndrome, premature ovarian insufficiency, genitourinary syndrome of menopause, and rectovaginal fistulas. Moreover, the successful isolation of oogonial stem cells could lead to a revolution in the field of gynecology and the potential treatment of the conditions discussed. This review aims to provide a better understanding of the latest therapeutic options involving stem cells and raise awareness of this promising yet not widely known topic in gynecology and medicine in general.

Management of perimenopausal and menopausal symptoms

Most women worldwide experience menopausal symptoms during the menopause transition or postmenopause. Vasomotor symptoms are most pronounced during the first four to seven years but can persist for more than a decade, and genitourinary symptoms tend to be progressive. Although the hallmark symptoms are hot flashes, night sweats, disrupted sleep, and genitourinary discomfort, other common symptoms and conditions are mood fluctuations, cognitive changes, low sexual desire, bone loss, increase in abdominal fat, and adverse changes in metabolic health. These symptoms and signs can occur in any combination or sequence, and the link to menopause may even be elusive. Estrogen based hormonal therapies are the most effective treatments for many of the symptoms and, in the absence of contraindications to treatment, have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause. Non-hormonal treatment options are also available. Although a symptom driven treatment approach with individualized decision making can improve health and quality of life for midlife women, menopausal symptoms remain substantially undertreated by healthcare providers.

Cellular and extracellular vaginal changes following murine ovarian removal

Loss of estrogen as a result of aging, pelvic cancer therapy, genetics, or eating disorders affects numerous body systems including the reproductive tract. Specifically, a chronic hypoestrogenic state fosters debilitating vaginal symptoms like atrophy, dryness, and dyspareunia. Current treatment options, including vaginal estrogen and hyaluronan (HA), anecdotally improve symptoms, but rectifying mechanisms are largely understudied. In order to study the hypoestrogenic vaginal environment, in particular the extracellular matrix (ECM), as well as understand the mechanisms behind current treatments and develop new therapies, we characterized a reliable and reproducible animal model. Bilateral ovariectomies (OVX) were performed on 9-week-old CD1 mice. After 1 month of estrogen loss due to ovarian removal, a phenotype that is similar to human vaginal tissue in an estrogen reduced state was noted in mice compared to sham-operated controls. The uterine to body weight ratio decreased by 80% and vaginal epithelium was significantly thinner in OVX compared to sham mice. Estrogen signaling was altered in OVX, but submucosal ERα localization did not reach statistical differences. HA localization in the submucosal area was altered and CD44 expression decreased in OVX mice. Collagen turn-over was altered following OVX. The inflammation profile was also disrupted, and submucosal vaginal CD45+ and F4/80+ cell populations were significantly reduced in the OVX mice. These results show altered cellular and molecular changes due to reduced estrogen levels. Developing new treatments for hypoestrogenic vaginal symptoms rely on better understanding of not only the cellular changes, but also the altered vaginal ECM environment. Further studies using this mouse model has the potential to advance women's vaginal health treatments and aid in understanding the interplay between organ systems in both healthy, aged, and diseased states.

New Possibilities for Hormonal Vaginal Treatment in Menopausal Women

Hormonal vaginal therapy is an effective treatment option for women who experience vaginal symptoms related to hormonal changes. Estrogen and prasterone are widely used as vaginal treatments, particularly for urogenital atrophy. These symptoms may include vaginal dryness, itching, burning, and pain during sexual intercourse, all of which can significantly affect a woman's quality of life. Previous studies have indicated that such treatment improves tissue elasticity, moisturizes the vagina, and can have a substantial impact on urine incontinence and vaginal microflora and decreases dyspareunia. Hormonal therapy is also useful and commonly used before vaginal surgical treatment. Prasterone is quite a new option for vaginal therapy in Poland and is mainly recommended for dyspareunia in menopausal women. The study related to prasterone therapy emphasizes its effectiveness and safety, making it advantageous to explore its beneficial impact. This paperwork aims to summarize the mechanism of action as well as the effects of both drugs and their beneficial action during vaginal treatment.

Impact of Menopausal Status and Recurrent UTIs on Symptoms, Severity, and Daily Life: Findings from an Online Survey of Women Reporting a Recent UTI

Introduction: Current UKHSA UTI diagnostic guidance advises empirical antibiotics if two of the following symptoms are present: cloudy urine, dysuria, and new onset nocturia. Hormonal changes during menopause may impact UTI symptoms, and qualitative studies suggest women with recurrent UTIs may present with different UTI symptoms. This study aims to assess whether menopausal status and the presence of recurrent UTIs impact UTI symptoms in women. Methods: An e-survey was conducted between 13 March 2021 and 13 April 2021. Women aged 16 years or older with a history of a UTI in the last year were eligible for inclusion. We defined menopause as those aged 45-64 years; pre-menopause as those less than 45 years; and post-menopause as those 65 years and older. Recurrent UTIs were defined as three or more UTIs in the last year. The data were weighted to be representative of the UK population. Crude unadjusted and adjusted odds ratios were estimated using logistic regression. Results: In total, 1096 women reported a UTI in the last year. There were significant differences in UTI symptoms based on menopausal status and the presence of recurrent UTIs. Post-menopausal women self-reported more incontinence (OR 2.76, 95% CI 1.50,5.09), whereas menopausal women reported more nocturia. Women with recurrent UTIs reported less dysuria, more severe symptoms (OR 1.93 95% CI 1.37,2.73) and a greater impact on daily life (OR 1.68, 95% CI 1.19,2.37). Conclusions: This survey provides evidence that acute UTIs present differently based on menopausal status and in women with recurrent UTIs. It is important that healthcare professionals are aware of these differences when assessing women presenting with an acute UTI and, therefore, further research in this area is needed.

Emergency Gynecologic Considerations in the Older Woman

As women mature through menopause, they will experience normal physiologic changes that can contribute to emergency complaints specific to this patient population. Reviewing the expected physiologic changes of menopause and correlating these normal processes to the development of specific pathologic conditions offers a framework for emergency physicians and practitioners to use when evaluating older women for breast, genitourinary, and gynecologic symptoms.

Complex vulvar and vaginal disease in menopause

PURPOSE OF REVIEW

Menopause is a time of vulvar and vaginal changes that are physiologic and are often symptomatic. These changes can impact up to 50% of women in menopause. There are also several vulvar dermatoses that are more common after menopause and should be recognized early to allow for symptomatic treatment. Some of these conditions can lead to squamous cell carcinoma over time, and early recognition and appropriate treatment reduce this risk. Treatment for women with symptomatic vulvar and vaginal conditions is important for maintaining the quality of life.

RECENT FINDINGS

There are multiple review articles, small case series, and small comparative trials, but definitive trials are unavailable for most of these conditions.

SUMMARY

Current research on pathophysiology and treatment is limited to all of these conditions, and more focus on these life-altering conditions is warranted.

Urban-rural differences in epidemiology and risk factors of menopause syndrome in middle-aged Chinese women

OBJECTIVE

To compare the prevalence and severity of menopausal symptoms and investigate their associated factors among rural and urban middle-aged Chinese women.

METHODS

A descriptive, cross-sectional study of 4,580 urban and 2,729 rural randomly sampled participants aged 40 to 55 years in Gansu Province, China, was conducted. Questionnaires assessing the sociodemographic information and menstrual and reproductive histories of the participants were administered. The modified Kupperman scale was used to assess the presence and severity of menopausal symptoms. Binary and ordinal logistic regression analyses were performed to identify factors associated with the occurrence and severity of menopausal syndrome, respectively, according to the modified Kupperman Menopausal Index score rank.

RESULTS

The natural menopausal age of the rural women was significantly lower than that of the urban women (rural: 47.22, urban: 47.98; P < 0.05). Furthermore, rural women had a higher prevalence (rural: 56.35%, urban: 43.47%) and severity (rural: 11.40%, urban: 6.61%) of menopausal syndrome than the urban women ( P < 0.05). For both the urban and rural women, the prevalence and severity of most menopausal symptoms increased as menopause progressed. The three most prevalent symptoms in both the urban and rural women were fatigue (rural: 70.43%, urban: 68.19%), muscle/joint pain (rural: 62.84%, urban: 59.32%), and vertigo (rural: 57.42%, urban: 47.44%). Positive associations between menopausal symptoms and age, residence, body mass index, level of education, time of pregnancy, menstrual cycle, and presence of chronic diseases were observed.

CONCLUSIONS

Rural women experience more frequent and severe menopausal syndrome than do urban women.

Intravaginal Drug Delivery Systems to Treat the Genitourinary Syndrome of Menopause: Towards the Design of Safe and Efficacious Estrogen-loaded Prototypes

Estrogens locally delivered to the vagina by tablets, capsules, rings, pessaries, and creams are the most common and highly recommended platforms to treat the genitourinary syndrome of menopause (GSM). Estradiol, an essential estrogen, is routinely administered alone, or in combination with progestins, to effectively alleviate the symptoms associated with moderate to severe menopause when non-pharmacological interventions are not indicated. Since the risk and side effects of estradiol use depends on the administered amount and duration of use, the lowest effective dose of estradiol is recommended when long-term treatment is required. Although there is a wealth of data and literature comparing vaginally administered estrogen-containing products, there is a lack of information revealing the effect of the delivery system used and formulation constituent's attributes on the efficacy, safety, and patient acceptability of these dosage forms. This review therefore aims to classify and compare various designs of commercially available and non-commercial vaginal 17β-estradiol formulations and analyze their performance in terms of systemic absorption, efficacy, safety, and patient satisfaction and acceptance. The vaginal estrogenic platforms included in this review are the currently marketed and investigational 17β-estradiol tablets, softgel capsules, creams, and rings for the treatment of GSM, based on their different design specifications, estradiol loads, and materials used in their preparation. Additionally, the mechanisms of the effects of estradiol on GSM have been discussed, as well as their potential impact on treatment efficacy and patient compliance.

Modulation of vulvovaginal atrophy (VVA) by Gelam honey in bilateral oophorectomized rats

INTRODUCTION

Vulvovaginal atrophy (VVA) is a common condition in post-menopausal women. Symptoms of VVA include dyspareunia, vaginal dryness, vaginal and/or vulvar itching, burning and soreness, dysuria and vaginal bleeding accompanying sexual activity. These symptoms are physiological responses to hypoestrogenicity, inducing atrophy of the vagina epithelia and sudden reduction in mucous production. Prevailing therapy for VVA is hormone replacement therapy (HRT), notably estrogen, progesterone or a combination of the two. However, using HRT is associated with an increased incidence of breast and endometrial cancer, venous thromboembolism in the lungs and legs, stroke and cardiovascular complications.

METHODS

This study evaluated Malaysian Gelam honey as a nutraceutical alternative to estrogen HRT (ERT) in alleviating VVA. A total of 24 female 8-weekold Sprague Dawley rats underwent bilateral oophorectomy. A minimum of 14 days elapsed from the time of surgery and administration of the first dose of Gelam honey to allow the female hormones to subside to a stable baseline and complete recovery from surgery. Vaginal tissues were harvested following a 2-week administration of Gelam honey, the harvested vagina tissue underwent immunohistochemistry (IHC) analysis for protein localization and qPCR for mRNA expression analysis.

RESULTS

Results indicated that Gelam honey administration had increased the localization of Aqp1, Aqp5, CFTR and Muc1 proteins in vaginal tissue compared to the menopause group. The effect of Gelam honey on the protein expressions is summarized as Aqp1>CFTR>Aqp5>Muc1.

DISCUSSION

Gene expression analysis reveals Gelam honey had no effect on Aqp1 and CFTR genes. Gelam honey had up-regulated Aqp5 gene expression. However, its expression was lower than in the ERT+Ovx group. Additionally, Gelam honey up-regulated Muc1 in the vagina, with an expression level higher than those observed either in the ERT+Ovx or SC groups. Gelam honey exhibits a weak estrogenic effect on the genes and proteins responsible for regulating water in the vaginal tissue (Aqp1, Aqp5 and CFTR). In contrast, Gelam honey exhibits a strong estrogenic ability in influencing gene and protein expression for the sialic acid Muc1. Muc1 is associated with mucous production at the vaginal epithelial layer. In conclusion, the protein and gene expression changes in the vagina by Gelam honey had reduced the occurrence of vaginal atrophy in surgically-induced menopause models.

Level of Psychological and Somatic Symptoms Predict Perimenopausal Syndrome Severity Better Than Obstetric and Psychiatric History Do Among Korean Women

OBJECTIVE

Menopause symptoms can vary in type, duration, and severity. The purpose of this study was to investigate the key factors predicting severe symptoms among Korean perimenopausal women with various demographic data, obstetric and psychiatric histories, and menopausal symptoms screening scale scores.

METHODS

Data were collected from 1,060 women, and 4 latent classes were identified using latent profile analysis, with 6 major categories of menopausal complaints. Among the 4 classes, we selectively used data from the "all unimpaired" and "all impaired" groups. Menopause rating scale (MRS), sociodemographic, obstetric, and psychiatric factors were assessed, and hierarchical logistic regression analyses were conducted with the "all impaired" group as a dependent variable.

RESULTS

Marital status and scores on the psychological and somatic subscales of the MRS were statistically related to being in the "all impaired" group. Otherwise, family history of menopausal symptoms, menarche age, and history of other psychiatric disorders were not statistically significant predictors of being in the "all impaired" group.

CONCLUSION

The psychological and somatic subscales of the MRS predict the severity of perimenopausal syndrome better than obstetric and psychiatric history do among Korean perimenopausal women. Psychological and somatic symptoms as well as genitourinary symptoms in menopausal patients should be closely evaluated.

A multicenter, randomized, open, controlled trial to evaluate the efficacy of Honglilai Vaginal Cream and Premarin Vaginal Cream for Genitourinary Syndrome of Menopause in different subgroups of Chinese postmenopausal women

AIM

In a randomized, multicenter, open, controlled trial, we compared the effects of Honglilai Vaginal Cream and Premarin Vaginal Cream in different age subgroups and menopausal year subgroups (trial registration numbers: 02003L00493).

METHODS

Postmenopausal women with Genitourinary Syndrome of Menopause (GSM) were divided into Honglilai group (n = 319) and Premarin group (n = 116), while subgroups were divided according to their different characteristics of age and menopausal years. Honglilai Vaginal Cream (0.625 mg/g) or Premarin Vaginal Cream (0.625 mg/g) once daily for 3 weeks.

RESULTS

In the subgroup of participates >60 years, there were no significant differences of Vaginal Cell Maturation Index (VMI) between the two groups after treatment (p = .171). In the subgroup of 50-59 years, the VMI of Honglilai group was significantly lower than Premarin group (Honglilai group: 74.37 ± 22.76; Premarin group: 80.06 ± 16.15; p = .02). There were no significant differences of Vaginal symptom scores between Honglilai group and Premarin group in every sub-group (p > .05).

CONCLUSIONS

Honglilai Vaginal Cream had comparable efficacy with Premarin Vaginal Cream in Chinese women older than 60 years.

Estradiol inhibits HIV-1BaL infection and induces CFL1 expression in peripheral blood mononuclear cells and endocervical mucosa

An inhibitory effect of estradiol (E2) on HIV-1 infection was suggested by several reports. We previously identified increased gene expression of actin-binding protein cofilin 1 (CFL1) in endocervix in the E2-dominated proliferative phase of the menstrual cycle. Actin cytoskeleton has an integral role in establishing and spreading HIV-1 infection. Herein, we studied in vitro effects of E2 on HIV-1 infection and on CFL1 expression to gain insight into the mechanism of HIV-1 inhibition by E2. E2 dose-dependently inhibited HIV-1_BaL infection in peripheral blood mononuclear cells (PBMCs) and endocervix. In PBMCs and endocervix, E2 increased protein expression of total CFL1 and phosphorylated CFL1 (pCFL1) and pCFL1/CFL1 ratios. LIMKi3, a LIM kinase 1 and 2 inhibitor, abrogated the phenotype and restored infection in both PBMCs and endocervix; inhibited E2-induced expression of total CFL1, pCFL1; and decreased pCFL1/CFL1 ratios. Knockdown of CFL1 in PBMCs also abrogated the phenotype and partially restored infection. Additional analysis of soluble mediators revealed decreased concentrations of pro-inflammatory chemokines CXCL10 and CCL5 in infected tissues incubated with E2. Our results suggest a link between E2-mediated anti-HIV-1 activity and expression of CFL1 in PBMCs and endocervical mucosa. The data support exploration of cytoskeletal signaling pathway targets for the development of prevention strategies against HIV-1.

Comparing the effect of education based on PRECEDE - PROCEED model in person-centered and supportive group methods on women's psychological well-being in the menopausal period

BACKGROUND

Positive psychology introduce mental health as a positive psychological functioning and represent it as well-being psychology. From this point of view, psychological health is more supposed to be known as having positive characteristics such as self-esteem, positive social relationships, and satisfaction. This study was conducted to compare the effect of education in two methods of person-centered and supportive group based on the PRECEDE-PROCEED model on women's psychological well-being during menopause.

MATERIALS AND METHODS

The present study was a clinical trial. One hundred and ten menopausal women have been placed in two groups (tests and control). The training program was designed according to the PRECEDE-PROCEED model. The educational intervention was implemented for two groups (person-centered and the supportive group) and the control group did not receive any training. Data analysis was used by descriptive statistics and in the case of normal distribution of alternative tests such as Kruskal-Wallis test, Man-Whitney test, Wilcoxon, spearman correlation, Spearman correlation was used.

RESULTS

Results of variance analysis showed that awareness, attitude, self-efficacy, enabling factors, reinforcement, support, behavioral environment, six psychological well-being factors were significantly different from the individual group and control group. Furthermore, the overall score of the psychological well-being was significantly higher than the control group.

CONCLUSIONS

As a result of the design and deployment of health care monitoring system, building and reform of community beliefs toward women's status in decision making and their role in menopause, the design and development of support group meetings in women's health care system and enhancing women's access to specialist and heterogeneous health services tailored to the needs of the menopause.

Repercussões da eletroestimulação circulatória na qualidade de vida, lubrificação e musculatura pélvica: um estudo piloto

Resumo Introdução: O climatério constitui um dos períodos de transição no ciclo vital da mulher entre a fase reprodutiva e a não reprodutiva, caracterizado por várias alterações metabólicas e psicológicas, seja por distúrbios psíquicos ou disfunções sexuais, promovendo alterações na qualidade de vida. Objetivo: Analisar as repercussões da eletroestimulação na qualidade de vida, lubrificação e atividade mioelétrica dos músculos do assoalho pélvico em mulheres menopausadas. Métodos: Trata-se de um estudo piloto no qual a amostra foi composta por dez voluntárias em menopausa com idade entre 48 e 60 anos. Para avaliar a melhora da lubrificação foi utilizado o questionário Female Sexual Function Index. Quanto à qualidade de vida, utilizou-se o questionário WHOQOL-bref. Já para a avaliação dos músculos do assoalho pélvico, utilizou-se a eletromiografia com eletrodo intracavitário. O protocolo utilizado foi: contração fásica avaliada por três contrações de dois segundos e seis de repouso; três contrações tônicas sustentadas por dez segundos com repouso de dez segundos; endurance durante trinta segundos. A intervenção foi realizada por outra pesquisadora, através de estimulação circulatória com o aparelho Dualpex 961 Quark®. Resultados: A eletromiografia pós-estimulação circulatória obteve resultados significativos, com aumento na Fast Fourier Transform nas contrações tônicas e fásicas, obtendo efeito positivo na percepção e conscientização das contrações devido ao aumento do fluxo sanguíneo. Houve, também, melhora na lubrificação e na qualidade de vida em todos os domínios. Conclusão: A estimulação circulatória apresentou repercussões nos músculos do assoalho pélvico em mulheres menopausadas tanto na fisiologia muscular quanto na lubrificação, influenciando a qualidade de vida das voluntárias.

Repercussions of circulatory electrical stimulation on quality of life, lubrication and pelvic floor muscles: a pilot study

Abstract Introduction: The climacteric is one of the transition periods in the life cycle of women between the reproductive and non-reproductive phase, and it is characterized by various metabolic, psychological and social changes, either by psychic disorders or sexual dysfunctions promoting changes in quality of life. Objective: To analyze the repercussions of electrical stimulation on quality of life, lubrication and myoelectric activity of pelvic floor muscles in postmenopausal women. Methods: This was a pilot study in which the sample consisted of ten menopausal volunteers aged 48-60 years. We used the Female Sexual Function Index questionnaire to determine the improvement in lubrication and the WHOQOL-BREF questionnaire to assess quality of life. The pelvic floor muscles were evaluated by electromyography with an intracavitary electrode. The protocol used was: phasic contraction evaluated by three contractions of two seconds and six of rest; three tonic contractions for ten seconds with ten-second rest; and endurance for thirty seconds. The intervention was performed by another researcher, through circulatory stimulation with the Dualpex 961 Quark®. Results: Electromyography after circulatory stimulation showed statistically significant results with an increase in Fast Fourier Transform in tonic and phasic contractions, obtaining a positive effect on the perception and awareness of contractions due to increased blood flow. Also, there was improvement in lubrication and quality of life in all areas. Conclusion: Circulatory stimulation had repercussions on pelvic floor muscles in menopausal women in both muscle physiology and lubrication, with an influence on the quality of life of volunteers.

Microablative Fractional Radiofrequency as a Therapeutical Option for Genitourinary Syndrome of Menopause: Perspectives

The genitourinary syndrome in menopause can occur at different stages of life, with different causes or triggering factors, such as prolonged use of antiestrogens, chemotherapy, radiotherapy, and extensive vaginal surgeries, which can alter vascularization, hydration, collagen quality, and tissue elasticity. Despite hormonal therapy being considered the best evidenced treatment for genitourinary syndrome of menopause (GSM), there are limitations concerning the latter. Thus, alternative, complementary, or even substitutive treatments have emerged, such as energy use, promoting thermal tissue stimulation to improve tropism. Due to its practicality and feasibility, the micro ablative fractional radiofrequency (MAFRF) has gained space among these energies. It uses high-frequency electromagnetic waves and promotes thermal micro points in the superficial and deep dermis. The safety of these energies limits thermal action laterality and depth. Laterally, it is essential for an adequate regenerative effect without scarring marks or sequelae; the appropriate depth is important for stimulating the obligatory tissue repair response with the production and reorganization of collagen, elastic fibers, increased vascularization and hydration, and the consequent improvement in tropism. In gynecology, the MAFRF is used with therapeutic indication and functional improvement; it is applied to the entire length of the vaginal walls, the vulvar vestibule, urethral meatus, labia minora, clitoris prepuce, labia majora, perineum, and perianal region. The MAFRF has been proved to be an effective and safe treatment for GSM, with long-lasting effects, significantly reducing symptoms and improving vaginal tropism. This review aims to analyze the MAFRF as a non-hormonal therapeutic option for GSM.

Female chronic posterior urethritis is underestimated in patients with lower urinary tract symptoms

Background

As one of the causes of urethral symptoms, female chronic posterior urethritis is a common and distressing disease; however, it is often neglected and misdiagnosed as overactive bladder (OAB) or interstitial cystitis/bladder pain syndrome (IC/BPS). Currently, little is known about the urothelium and lamina propria of the bladder neck and proximal urethra. Thus, identifying urethral lesions is necessary for the diagnosis and treatment of female chronic posterior urethritis. Transurethral electroresection is an effective and safe approach for treating female chronic posterior urethritis. This study sought to determine if urethral lesions are necessary for the diagnosis and treatment of female chronic posterior urethritis, and evaluate the efficacy and safety of the transurethral electroresection of mucosa and submucosa in treating female chronic posterior urethritis.

Methods

A single-center, retrospective, observational study was conducted at a teaching and referral hospital. A total of 147 female patients who had been diagnosed with chronic papillary urethritis underwent transurethral electroresection between 2015 and 2018. Each patient underwent a follow-up examination. A chart review was also performed.

Results

Patients had a mean age of 54 years (range, 23–82 years), and the average follow-up period was 54.8 months (range, 6–600 months). Urinary frequency and urgency (51.7%) were the most common clinical manifestations of chronic posterior urethritis. Forty-two-point two percent of patients had positive urine culture results, most commonly with Mycoplasma genitalium. The cystoscopic findings revealed that chronic posterior urethritis has tuft-like, pseudopodia-like, finger-like, and follicular-like polyps and villi, and a pebble-like appearance with mucosal hyperemia. The success rate of the transurethral electroresection was 88.6%, and patients showed no apparent or serious complications.

Conclusions

This study showed that female chronic posterior urethritis is a cause that contributes to LUT symptoms. Its characteristic cystoscopic appearance and biopsy play a vital role in its diagnosis. The transurethral electroresection of urethral lesions is simple, effective, and minimally invasive without any apparent complications.

Managing female sexual dysfunction

OBJECTIVE

Provide an overview of sexual dysfunction in female urologic cancer patients, approaches for assessing sexual problems, and interventions to treat sexual dysfunction in this patient population.

METHODS

A review of the literature in urologic oncology was conducted. Research on other female pelvic cancers with similar treatments was also reviewed.

RESULTS

Sexual health is an important element of women's quality of life that is often not discussed and problems remain unaddressed. Urologic cancer treatments commonly result in sexual dysfunction (e.g., dyspareunia, vaginal dryness, problems with orgasm) in female patients, although more research is necessary to understand the impact of non-surgical treatments (e.g., radiation, chemotherapy, immunotherapy). As such, provider teams should complete necessary screening for sexual dysfunction during and after treatment. The 5 A's model (i.e., Ask, Advise, Assess, Assist, Arrange Follow-Up) provides a helpful guide for communicating about and addressing sexual health concerns with patients during the screening process. If it is determined that referral for further assessment and treatment of sexual dysfunction is needed, a number of non-pharmacologic (e.g., pelvic floor physical therapy; psychosexual counseling) and pharmacologic treatment approaches are available.

CONCLUSION

Sexual dysfunction is common in female urologic cancer survivors. Routine assessment and appropriate referral are essential for high quality patient care.

Menopause preparedness: perspectives for patient, provider, and policymaker consideration

OBJECTIVE

The aim of the study was to identify priorities to address unmet needs in clinical care, education, and access to treatment to improve quality of life for individuals during the menopause transition.

METHODS

The Society for Women's Health Research convened a working group of 13 experts to discuss updates in research, clinical practice, and policy on menopause. Participants included patient advocates, policy leaders, and clinical specialists and researchers from gynecology, reproductive endocrinology, psychiatry, and epidemiology. Overarching themes and recommendations for improving menopause care were identified and determined by consensus agreement of the participants at the conclusion of the meeting.

RESULTS

The Society for Women's Health Research Menopause Working Group identified gaps in clinical care, policy, and patient and provider education. Limited understanding of menopause by patients and clinicians contributes to delays in recognizing the menopause transition and engaging in symptom management. Recent studies on hormone therapy and alternative treatment options provide evidence to inform updates on existing policy recommendations and coverage.

CONCLUSIONS

To improve care and quality of life for individuals during the menopause transition and after menopause, the working group recommends developing a more standardized approach to menopause preparedness that includes education for both patients and providers, as well as considering policy solutions to address regulatory barriers to care. Providers also need to factor in the diverse needs of individuals experiencing menopause in the development of their personalized care.

Carbon Dioxide Laser Vulvovaginal Rejuvenation: A Systematic Review

Genitourinary syndrome of menopause (GSM) causes significant symptomatic aggravation that affects the quality of life (QoL). Vulvovaginal atrophy (VVA), the hallmark of GSM, is managed with topical non-hormonal therapy, including moisturizers and lubricants, and topical estrogen application. Patients not responding/being unsatisfied with previous local estrogen therapies are candidates for a noninvasive modality. Carbon dioxide (CO2) laser therapy, especially the fractionated type (FrCO2), has drawn considerable attention over the past two decades as a non-invasive treatment for GSM. This systematic review describes the accumulated evidence from 40 FrCO2 laser studies (3466 participants) in GSM/VVA. MEDLINE, Scopus and Cochrane databases were searched through April 2021. We analyze the effects of FrCO2 laser therapy on symptoms, sexual function, and QoL of patients with GSM/VVA. As shown in this review, FrCO2 laser therapy for GSM shows good efficacy and safety. This modality has the potential to advance female sexual wellness. Patient satisfaction was high in the studies included in this systematic review. However, there is a lack of level I evidence, and more randomized sham-controlled trials are required. Furthermore, several clinical questions, such as the number of sessions required that determine cost-effectiveness, should be addressed. Also, whether FrCO2 laser therapy may exert a synergistic effect with systemic and/or local hormonal/non-hormonal treatments, energy-based devices, and other modalities to treat GMS requires further investigation. Lastly, studies are required to compare FrCO2 laser therapy with other energy-based devices such as erbium:YAG laser and radiofrequency.

Intravaginal 6.5 mg prasterone administration in postmenopausal women with overactive bladder syndrome: A pilot study

OBJECTIVE

The aim of this study was to evaluate the impact of vaginally prasterone administration on postmenopausal women with genitourinary syndrome of menopause (GSM) affected by overactive bladder syndrome (OAB). A secondary aim of this study was to assess the efficacy of prasterone on VVA and quality of life (QoL).

STUDY DESIGN

Thirty-two postmenopausal women with GSM and referred OAB symptoms received treatment with daily intravaginal prasterone 6.5 mg. We assessed urinary symptoms through approved ICIQ-OAB and ICIQ-UI questionnaires on incontinence. Women were also screened by the Vaginal Health Index (VHI) to investigate the vulvovaginal atrophy (VVA). Quality of life (QoL) was assessed by the SF-12 Health Survey. Each questionnaire was administrated at baseline (T0) and after a 12-week treatment (T1).

RESULTS

Incontinence questionnaires showed improvement at T1 (from 7.8 ± 2.7 to 2.7 ± 2.2, p < 0.001). Even if women referred an improvement of daily urine although the women reported improvement in daily urine leaks, their urine leak amount did not improve statistically significant [T0 (28.6%) Vs T1 (14.3%), p < 0.16]. Prasterone therapy improved significantly the VHI [T1(21 ± 3.7) Vs T0 (10.8 ± 4.1), p < 0.001]. Finally, women had a statistically significant improvement both in Mental [T1(49.9 ± 11.2) Vs T0 (42 ± 9.2), p < 0.009],) and Physical Health [T1(47.1 ± 9.1) Vs T0 (38.6 ± 8.4), p < 0.006], domains of the SF-12 questionnaire. No women referred side effects.

CONCLUSION

Prasterone is an inactive precursor converted into estrogens and androgens into vaginal tissue. It leads to positive effects on VVA through the activation of the vaginal androgen and estrogen receptors. Empirical evidence in this study suggests that intravaginal 6.5 mg prasterone administration could be an effective treatment for postmenopausal women with GMS affected by OAB.

The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society

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.

Modern management of genitourinary syndrome of menopause

The genitourinary syndrome of menopause (GSM) is the accepted term used to describe the broad spectrum of genitourinary tract symptoms and signs caused by the loss of endogenous sex steroids that occurs at the time of and after the menopause. Global improvements in healthcare have resulted in an ageing population. Today, women are spending 40% of their lives in the postmenopausal state, and with 50–70% of postmenopausal women reporting symptomatic GSM, safe and efficacious treatments are needed for this troublesome condition. This article reviews current evidence for non-pharmacological and pharmacological treatments with a focus on novel and minimally invasive procedures such as energy-based devices (CO₂ laser, YAG laser), hyaluronic acid, dehydroepiandrosterone, and selective oestrogen receptor modulators.

Genitourinary syndrome of menopause in Chinese perimenopausal and postmenopausal women

OBJECTIVE

The aim of this study was to investigate genitourinary syndrome of menopause (GSM) in a large cohort, analyzing the dependency on age and menopausal status and possible differences between non-hysterectomized and hysterectomized women.

METHODS

Data were assessed by validated questionnaires, collected over 2 years for all eligible women attending our 'Menopause Clinic' from 31 Chinese provinces. Simple and unconditional logistic regression analysis was used with adjustments by all analyzed factors.

RESULTS

A total of 4063 women (mean age 50.53 ± 6.57 years), 2107 perimenopausal and 1956 postmenopausal, were included. Almost all GSM symptoms were more frequent and severe in postmenopausal women. GSM was more frequent in hysterectomized women compared to non-hysterectomized women. Independent of menopausal status, low sexual interest (92.78%), urinary incontinence (91.65%) and vaginal dryness (91.60%) were the top three GSM symptoms. Most severe were low sexual interest (21.01%), vaginal pain (20.10%) and decreased sexual pleasure (17.13%). Prevalence and severity of GSM were not related to age, but were related to menopausal status and increased with time since menopause.

CONCLUSIONS

Within 2 years, more than 4000 women with GSM traveled from all over China to our specialized clinic, indicating the great importance of GSM. Hysterectomy can increase the risk of GSM, and GSM symptoms increase from perimenopause to postmenopause and with an increase of time since menopause, pointing to the dependency on the loss of ovarian function.

The therapeutic effect of dehydroepiandrosterone (DHEA) on vulvovaginal atrophy

Vulvovaginal atrophy (VVA) is a chronic disease that mostly occurs in postmenopausal women. After menopause, insufficient sex hormones affect the anatomy of the vagina and cause drastic physiological changes. The main histopathological studies of VVA show that postmenopausal estrogen deficiency can lead to the increase of intermediate/parabasal cells, resulting in the loss of lactobacillus, elasticity and lubricity, vaginal epithelial atrophy, pain, dryness. Although the role of estrogen hormones in the treatment of VVA has always been in the past, it is now widely accepted that it also depends on androgens. Estrogen drugs have many side effects. So, Dehydroepiandrosterone（DHEA）is promising for the treatment of VVA, especially when women with contraindications to estrogen have symptoms. This review is expected to understand the latest developments in VVA and the efficacy of DHEA.

The genitourinary syndrome of menopause

ABSTRACT

Genitourinary syndrome of menopause (GSM) refers to a collection of symptoms resulting from diminished hormonal, primarily estrogenic stimulation to the vulvovaginal or lower urinary tract and may affect up to 50% of postmenopausal women. Symptoms, which are typically progressive and unlikely to resolve spontaneously, may include, but are not limited to, vulvovaginal dryness, burning or irritation, dyspareunia, or urinary symptoms of urgency, dysuria or recurrent urinary tract infection. These symptoms are typically progressive and unlikely to resolve spontaneously. Diagnosis is clinical. Telemedicine may play a role in diagnosis, initiation of treatment, and follow-up of women with GSM. Effective treatments include moisturizers and lubricants, local hormonal therapy with estrogen or dehydroepiandrosterone, and oral selective estrogen receptor agonists. Laser or radiofrequency procedures, although currently utilized, are being studied to comprehensively understand their overall effectiveness and safety. Additionally, the influence and effect of the vaginal microbiome, as well as potential of treatment via its manipulation, is being studied. We performed a literature search of PubMed, Google Scholar, and Ovid with search terms of vulvovaginal atrophy and GSM and reviewed major US Society Guidelines to create this narrative review of this topic. The literature suggests that healthcare providers can make a significant impact of the health and quality of life of women by being proactive about discussing and providing interventions for GSM. A systematic approach with consideration of current guidelines and attention to developing protocols for interventions should be employed.

Genitourinary syndrome of menopause: the unmet need

ABSTRACT

Genitourinary syndrome of menopause (GSM) is a highly prevalent and progressive condition of postmenopausal women that has significant negative effects on vulvovaginal health, sexual health, and overall quality of life. Despite many available safe and effective therapies, GSM often goes undiagnosed and untreated. This Practice Pearl addresses the pathophysiology of GSM and reviews available treatment options.