Genitourinary Syndrome of Menopause

Hormonal changes beginning in perimenopause significantly influence the vaginal microbiome, causing a collection of symptoms affecting the genitourinary system. Vaginal dryness is the most common symptom, but it’s just the beginning of the issues that can arise in menopause.

Today’s article will take a deep dive into the genitourinary syndrome of menopause, its causes, symptoms, and most importantly, effective solutions. If you’ve been suffering and haven’t spoken to your gynecologist yet, we’re here to tell you that you’re not alone and that you don’t have to suffer any more.

Keep reading as we explore:

• The vaginal microbiome
• Estrogen’s role in the genitourinary system
• How everything changes in perimenopause and menopause
• The genitourinary syndrome of menopause
• Integrative solutions for vaginal, vulvar, and urinary tract health

The Vaginal Microbiome

You’re likely familiar with the gut microbiome, the trillions of organisms inhabiting the digestive tract. Over a half billion years, we’ve co-evolved with the microbiome in a mutually beneficial relationship. We provide a home for the microbes, and they provide us with immune and anti-inflammatory protection, metabolic health, essential nutrients, hormone balance, and more.

The vaginal microbiome is a similar microecosystem living in the vagina but with a different microbial profile. Lactobacillus species are the most common bacteria in the vaginal microbiome, producing antimicrobial compounds that protect against pathogenic infections, including bacterial vaginosis. They are also critical for keeping a healthy acidic vaginal pH lower than 4.5.

Interestingly, the vaginal microbiome responds to hormonal fluctuations, changing with different phases of the menstrual cycle and throughout life. For example, the microbial composition changes during pregnancy and shifts again with perimenopause and menopause.

Like the gut microbiome, the vaginal microbiome is sensitive to environmental factors, including antibiotics, toxins, and stress.

The Role of Estrogen

Estrogen plays a crucial role in the health of the vaginal microbiome and tissues of the genitourinary system. Estrogen binds to estrogen receptors in the vaginal tissue, allowing for lubrication, collagen production, and blood vessel health to maintain tissue structure and integrity. It also stimulates cells to produce sugars that feed lactobacillus, allowing for all their benefits, including the maintenance of the vaginal pH.

It's the decline in estrogen in the vaginal tissues in perimenopause and menopause that leads to genitourinary syndrome of menopause.

Perimenopausal and Menopausal Changes

Declining estrogen in late perimenopause and post-menopause leads to changes in the structure and function of the vaginal and surrounding tissues: levels of collagen and elastin proteins decline, which leads to decreased thickness of the labia, vulva, and vaginal tissues, along with declining elasticity. The skin can become thin and more fragile. Blood flow, pelvic floor strength, and lubrication also decline.

As mentioned, changes in the vaginal microbiome, including a reduction of lactobacillus, result from declining estrogen. The microbiome changes make women more prone to vaginal and urinary tract infections. Changes in the microbiome are also associated with increased inflammation.

Genitourinary Syndrome of Menopause

Formerly called vaginal atrophy, genitourinary syndrome of menopause was defined in 2014 and affects 50% of women. It’s underdiagnosed and undertreated, even with many practical and effective solutions available.

While many perimenopausal symptoms, such as hot flashes, decline in the post-menopause phase of life, genitourinary syndrome typically doesn’t improve. In the low estrogen state, genitourinary syndrome is chronic and progressive, worsening as time goes on.

Genitourinary syndrome of menopause is a collection genital, urinary, and sexual symptoms. Vaginal dryness is the most common symptom, affecting 93% of postmenopausal women. Other symptoms may include:

• Vulvar itching, burning, and irritation
• Pelvic pain and pressure
• Decreased arousal, pleasure, and orgasm
• Reduced lubrication
• Painful sex (dyspareunia)
• Bleeding after sex
• Increased urinary frequency and urgency
• Stress incontinence
• Increased urinary tract infections (UTIs)
• Increased vaginal infections
• Pelvic organ prolapse (vagina, uterus, rectum, urethra)

Early menopause, smoking, cancer treatments, poor lifestyle habits, and other factors can make symptoms worse. The good news is there are effective and safe treatments for genitourinary syndrome.

Integrative Solutions

As Generation X and Millennials enter perimenopause and transition to menopause, the conversation is changing. Women today are more open to talking about their symptoms, with their girlfriends and healthcare team. They aren’t willing to suffer in silence, especially when simple interventions can make a significant difference in symptoms and health outcomes.

It’s important to work closely with your gynecologist for a proper diagnosis and to rule out other issues that could be causing your symptoms. If your doctor is dismissive of what you are experiencing, which unfortunately is common, look for a provider who will listen and take your symptoms seriously. At TārāMD, when a woman says she’s having dryness and discomfort, we believe her and support her long-term health goals.

Many options may help address genitourinary symptoms. An integrative approach offers a personalized plan for each woman, often containing several helpful interventions for symptom relief and preventing future problems. Some helpful approaches include:

• Simple hygiene and self-care: The vagina is self-cleaning, and you don’t need to wash it internally. Avoid harsh, irritating soaps. Choose breathable, organic cotton underwear. Urinate after sex.

• Foundations of health: Eat a nutritious diet, prioritize sleep, move your body, manage stress, and find joy in your life.

• Vaginal lubricants and moisturizers: Lubricants and moisturizers are first-line non-hormonal options and can also be used along with hormone therapies and other interventions. Choose natural products, avoiding fragrances and other ingredients that might be irritating or contain toxins.

• Hormone therapy: The North American Menopause Society recommends local hormone support, either low-dose vaginal estrogen or DHEA. Systemic estrogen therapy is also an option, and women may use both local and systemic options to address symptoms and long-term health. Dr. Fenske is certified by the North American Menopause Society and is current on the latest research and evidence-based recommendations.

• Sexual stimulation: Either alone or with a partner, stimulation brings blood flow to the area, increases lubrication, and supports skin elasticity and muscle tone.

• Personalized integrative therapies: Phytoestrogens and SERMs (selective estrogen receptor modulators), including Ospemifene medication, may be options for some women. Vaginal laser therapy shows promise in some research, and pelvic floor physical therapy is a wonderful addition to any treatment plan.

Knowledge is power, and our hope is this information empowers you to talk with your healthcare team or see us at TārāMD if (or when) you notice a change in vaginal health during perimenopause and into the post-menopause years. Just because symptoms are common doesn’t mean you have to live with them. Simple interventions are incredibly effective and can improve the quality of life for millions of women.

References

1. Chen, X., Lu, Y., Chen, T., & Li, R. (2021). The Female Vaginal Microbiome in Health and Bacterial Vaginosis. Frontiers in cellular and infection microbiology, 11, 631972.
2. Angelou, K., Grigoriadis, T., Diakosavvas, M., Zacharakis, D., & Athanasiou, S. (2020). The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus, 12(4), e7586.
3. Byrne, E. H., Song, H., Srinivasan, S., Fredricks, D. N., Reed, S. D., Guthrie, K. A., Wu, M., & Mitchell, C. M. (2024). Association between vaginal microbiota and vaginal inflammatory immune markers in postmenopausal women. Menopause (New York, N.Y.), 31(7), 575–581.
4. Marino J. M. (2021). Genitourinary Syndrome of Menopause. Journal of midwifery & women's health, 66(6), 729–739.
5. Cox, S., Nasseri, R., Rubin, R. S., & Santiago-Lastra, Y. (2023). Genitourinary Syndrome of Menopause. The Medical clinics of North America, 107(2), 357–369.
6. The NAMS 2020 GSM Position Statement Editorial Panel (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause (New York, N.Y.), 27(9), 976–992.
7. Da Silva, A. S., Baines, G., Araklitis, G., Robinson, D., & Cardozo, L. (2021). Modern management of genitourinary syndrome of menopause. Faculty reviews, 10, 25.