Author(s): Brinderjeet Kaur
Genitourinary Syndrome of Menopause (GSM) is a term used to define the group of symptoms including vaginal pain, vaginal dryness, itching, pain during sexual intercourse as well as urinary symptoms including urinary frequency, urgency, incontinence, blood in urine (haematuria) and recurrent urinary tract infections (UTI) that occur due to lack of estrogen hormone. These symptoms can have a significant negative impact on psychosexual issues, sexual function and quality of life in postmenopausal women .
Traditionally such menopausal symptoms have been treated by estrogen creams to suffice for decreased estrogen. Increasing awareness and concern of women towards menopausal symptoms and increasing life span of population has lead to availability of plethora of treatment modalities instead of only estrogen creams and moisturizers. Yet, there is no consensus on how to use them. It is a therefore vital that a well-designed assessment tool is available to precisely evaluate the severity of GSM and its improvement when using any treatment, through either subjective or objective tools. In the absence of a disease specific quality of life questionnaire, a look out for a validated scale is required. The article discusses various assessment tools in an effort to study symptoms, emotions, life impact and sexual impact of GSM in postmenopausal women.
Genitourinary Syndrome of Menopause (GSM) is the term used to define the group of symptoms including vaginal pain, vaginal dryness, itching, pain during sexual intercourse, as well as urinary symptoms including urinary frequency, urgency, incontinence, blood in urine (haematuria) and recurrent urinary tract infections that occur due to lack of estrogen hormone [1, 2].
The post-menopausal women vaginal microenvironment differs from that of women in premenopausal status. This is due to changes on account of lack of estrogen [3, 4]. In premenopausal women, presence of estrogen not only cause proliferation of the vaginal epithelium cells but also causes production of glycogen, an essential factor for the growth of vaginal lactobacilli. This vaginal lactobacilli play an important role for a healthy vaginal epithelium by maintaining an acidic Ph by producing lactic acid and H2O2 and offering competitive activity to other pathogens, thereby preventing growth of pathogens [5-8].
In postmenopausal women, decrease or absence of estrogen results in decrease in lactobacilli species, rise in vaginal ph above 4.5 and thereby loss of local vaginal defense mechanism against bacterial pathogens. Thus predisposing these women to local inflammation and infections [9, 10]. Disturbance or decrease in Lactobacilli flora results in the increase in pathogenic organisms like Gardnella Vaginalis, Trichomonas Vaginalis, Enterococci, group B Sreptococci, Escherichia coli [11]. As a result, infections like asymptomatic bacteruria and recurrence of UTI in postmenopausal women is a rampant problem.
The international society for the study on woman’s sexual health and the North American Menopause society in 2014, proposed the term GSM replacing earlier terminology of Vulvo vaginal atrophy (VVA) [12, 13]. VVA do occur in non-menopausal hypoestrogenic states like chemotherapy, breast-feeding and pelvic radiation, where at times it resolves spontaneously and therefore labeling them as GSM could result in inappropriate treatment [14-16].
Traditionally such menopausal symptoms have been treated by estrogen creams to suffice for decreased estrogen. Increasing awareness and concern of women towards menopausal symptoms and increasing life span of population has lead to availability of plethora of treatment modalities instead of only estrogen creams and moisturizers. Yet, there is no consensus on how to use them [17]. It is a vital issue to acquire well designed assessment tools to precisely evaluate the severity of GSM and its improvement when using any treatment, through either subjective or objective tools. In the absence of a disease specific quality of life questionnaire, a look out for a validated scale is required. The article discusses various assessment tools in an effort to study symptoms, emotions, life impact and sexual impact of GSM in postmenopausal women.
Signs of GSM include atrophic changes of the external and internal female genitalia, regression and thinning of the labia minora, retraction of the introitus and prominence of urethral meatus [18]. Tissue changes also occur at a histological level, suggesting thinning of the stratified squamous epithelium, decreased glycogen stores in the epithelial cells and loss of vascularity and dermal papillae [19].
The classical diagnostic modality for GSM has been a ‘clinical diagnosis’ including clinical suspicion when women in menopausal status present symptoms e.g burning, dryness and dyspareunia in the genital tract and confirmed clinically observing a pale and dry vulvovaginal mucosa with petechiae occasionally. It is essential to differentiate from other bothersome vaginal conditions such as vaginal lichen sclerosis, vaginal lichen planus, hyperkeratosis, contact dermatitis, vulvar cancer, vulval intraepithelial neoplasm, extramammary paget disease and vaginal infections [3].
Over the years, diagnosis of GSM has been under diagnosed, underreported probably due to unawareness and neglect of women. The logical treatment of GSM is use of estrogen products to palliate lack of estrogen. Today, novel therapies such as vaginal laser, prasterone or ospemifene have made way, however no consensus have been made on how to use them due to absence of assessment tools to precisely evaluate the severity of GSM. The implementation of reliable assessment tools would ultimately bring consistency across scientific evaluation of GSM, allowing regulating the various new treatment options.
Vaginal health as measured in women with GSM using a variety of validated tools. Depending on the target for each assessment tool, a classification of objective (Table-1) outcomes and subjective (Table-2) outcomes may be prepared. It has been seen assessment tools that considered subjective outcomes, influenced by the patient perception of the complaint, are the most widely used in scientific evaluation of GSM (Table-3)
Table 1: Potential Assessment Tools (Objective Tools)
| 1. | Vaginal epithelial thickness on Biopsy (VTB) |
| 2. | Vaginal lamnia propria characteristic on biopsy (VLP)- suggesting increased number of fibroblasts, collagen, vascularization and increased Ki 67 |
| 3. | Vaginal Thickness on abdominal ultrasound measure (VTU) |
| 4. | Vaginal Compliance on Biopsy (VC) - Assess tensile strength |
Table 2: Questionnaires used in Non-Surgical Procedures to Treat GSM
| Questionnaire | Validated | Aim of Questionnaire |
|---|---|---|
| Female Sexual distress Scale Revised (FSDS-R) | Yes | Distress with sexual function |
| Female Sexual Function Index (FSFI) | Yes | Multiple Domain of sexual function |
| Vulvovaginal symptom questionnaire (VSQ) | Yes | Quality of life impact from vulvovaginal symptoms, emotional and sexual concerns |
| Urogenital Distress Inventory (UDI -6) | Yes | Assess frequency of micturition, urgency, incontinence |
| Incontinence Impact Questionnaire (IIQ-7) | Yes | Impact on urinary leakage on quality of life |
| Sexual Satisfaction Questionnaire (SSQ) | No | Sexual Satisfaction |
| Vaginal Laxity Questionnaire | No | Degree of patient reported vaginal laxity |
Table 3: Summary of Current and Potential Assessment Tools
| Subjective Tools | Objective Tools | Both Subjective & Objective |
|---|---|---|
| DIVAS | VAS | SF 2 |
| FSF1 | VHI | |
| VSQ | VMI | |
| PISQ12 | Cotton swab test | |
| PROM |
There is a possibility that some therapies present only subjective improvement that if not evaluated result in proclaiming the treatment option as a placebo effect. Therefore, the use of assessment tools to measure the efficacy, safety, success or benefits of a treatment remain a hot topic, underlying the lack of consensus among researchers on how we are assessing clinical relevant changes in women with GSM.
On account of paucity of assessing GSM, different methods of assessment of GSM need to be explored to understand the outcome and credibility of plethora of modalities of treatment in the market. There is a possibility that some therapies present subjective improvement. The article emphasis the need of evaluation of both subjective and objective tools to assess improvement in symptoms of GSM, thereby opening the door to complementary unconventional therapies.
Conflict of Interest: Nil
Sources of funding: Nil
