Questions and Answers About Menopause Therapy with Dr. Denise Black

By Denise Black, MD, FRCSC

Assistant Professor,
Department of Obstetrics, Gynecology and Reproductive Sciences,
University of Manitoba

 

What vaginal health issues do women commonly face following menopause?

Up to 50% of post-menopausal women will experience genitourinary symptoms of estrogen deficiency, with a resulting negative impact on quality of life. These symptoms do not improve over time, and in fact get worse. Despite this, only one quarter of affected women will initiate this discussion with their healthcare provider.

The vagina, lower urinary tract, and pelvic floor all contain estrogen receptors, and all undergo atrophy after menopause. Women may experience symptoms of vulvovaginal dryness, itching or burning, as well as dyspareunia, urgency, nocturia, and recurrent urinary tract infection (UTI). This constellation of symptoms is referred to as genitourinary syndrome of menopause (GSM). This is the preferred terminology, replacing the antiquated “vulvovaginal atrophy.”

Can estrogen help relieve symptoms of GSM?

Women already taking systemic hormone therapy for management of other symptoms of meno­pause may experience some relief of these symptoms, but as many as 40% of these women do not get adequate effect on the vaginal mucosa. For women experiencing GSM, use of topical (vaginal) estrogen is considered the gold standard of treatment. Other non-hormonal therapies exist (e.g., vaginal lubricants and moisturizers) but these do not reverse the basic tissue pathophysiology and are considered less effective.

Vaginal estrogen doses are microscopic, and an entire year of vaginal therapy has the dosing equivalency of a single 1-mg oral estradiol tablet. Because of this low dosing, systemic absorption is minimal and no endometrial stimulation is seen. Concomitant use of progesterone for endometrial protection is not necessary. There have not been concerns with venous thromboembolism or adverse cardiovascular effects.

The Society of Obstetricians and Gynecologists of Canada (SOGC) 2014 Managing Menopause document stated that vaginal estrogens are recommended as effective therapy for vaginal atrophy, and that they may be recommended for management of urge incontinence and prevention of recurrent UTI in post-menopausal women.


References

1. Reid R, Abramson BL, Blake J, et al. Managing menopause. J Obstet Gynaecol Can 2014; 36(9):830-8.

2. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013; 20(9):888-902.

3. Portman DJ, Gass ML, et al. 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. Climacteric 2014; 17(5):557-63.

Development of this article was sponsored by Merck Canada Inc. The author had complete editorial independence in the development of this article and is responsible for its accuracy. The sponsor exerted no influence in the selection of content or material published.