Genitourinary Syndrome of Menopause (GSM) refers to a range of signs and symptoms that occur due to low levels of oestrogen in the vulva, vagina and urinary tract. This term replaced the previously used “vulvovaginal atrophy” in 2014, to provide a more all-encompassing description (and, more importantly, to recognise that no one likes to think of their genitals as atrophied). 

More than two thirds of people experiencing these symptoms don’t speak to a health professional, and many doctors do not routinely screen for this incredibly common and easily-treatable condition. I can count on my hands the number of postmenopausal patients I have seen who have answered “no” when asked if they have noticed troublesome vulvovaginal changes. Although these changes are frequently seen in people who have transitioned through menopause, they are not exclusively related to menopause and may be seen in any hypo-oestrogenic state – such as during lactation, and while taking hormonal medications and contraceptives.

The words we use during screening also matter – a patient recently mentioned to me that her Gynae had talked about vaginal dryness a few times, but she had never associated her experience of vulval ‘irritation’ and ‘burning’ with the word ‘dryness’, and therefore never realised that she was suffering from GSM until seeing these terms on social media.

Management is fairly straightforward in patients who have no history of previous breast cancer – but can be more nuanced when it comes to supporting patients who have undergone breast cancer treatment (who often experience menopause earlier and with more severe symptoms than those who have transitioned through natural menopause).

Multiple international guidelines recommend vaginal moisturisers and lubricants as first-line therapy; however, to treat the underlying cause, oestrogen may be required for symptomatic relief. Although systemic oestrogen can improve these symptoms, this is generally contra-indicated in anyone with a history of breast cancer. In contrast, data around the use of local/vaginal oestrogen is very reassuring, and vaginal oestrogen use is not associated with an increase in breast cancer recurrence or mortality in the majority of people. Observational data support the use of vaginal oestrogen in most patients with a history of breast cancer, with the exception of those using aromatase inhibitors where some studies have found an increased risk of recurrence (but not mortality), and guidelines encourage shared decision making with the patient, GP and oncologist.

As health providers, we have a role in screening but also adequately counseling patients on their treatment options and the latest evidence regarding the therapies available to them. Sexual health during menopause is an incredibly complex topic, with factors ranging from midlife relationship changes and career dynamics, to physical symptoms such as poor sleep, to psychological shifts particularly those around self-esteem.

By starting with the basics, and acknowledging the vulnerability it takes to seek help for sexual health concerns, we can ensure that people experiencing challenges during and beyond the menopause can continue to live fulfilled, pleasurable lives. 

References

1. ACOG Clinical Consensus. Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer. December 2021, Number 2. 
2. Agrawal P, Singh SM, Able C, Dumas K, Kohn J, Kohn TP, Clifton M. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023 Sep 1;142(3):660-668. doi: 10.1097/AOG.0000000000005294
3. Cathcart-Rake EJ and Ruddy KJ. Vaginal estrogen therapy for the genitourinary symptoms of menopause: Caution or reassurance? J Natl Cancer Inst 2022 Jul 20; [e-pub]. https://doi.org/10.1093/jnci/djac113
4. Cold S et al. Systemic or vaginal hormone therapy after early breast cancer: A Danish observational cohort study. J Natl Cancer Inst 2022 Jul 20; [e-pub]. https://doi.org/10.1093/jnci/djac112.
5. 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. Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel Menopause. 2014 Oct;21(10):1063-8. 
6. Kingsberg SA, Larkin L, Krychman M, Parish SJ, Bernick B, Mirkin S. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause. 2019 Feb;26(2):124-131. doi: 10.1097/GME.0000000000001194
7. Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med. 2013 Jul;10(7):1790-9. doi: 10.1111/jsm.12190
8. McVicker L, Labeit AM, Coupland CAC, Hicks B, Hughes C, McMenamin Ú, McIntosh SA, Murchie P, Cardwell CR. Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer. JAMA Oncol. 2024 Jan 1;10(1):103-108. doi: 10.1001/jamaoncol.2023.4508.
9. Sund M, Garmo H, Andersson A, Margolin S, Ahlgren J, Valachis A. Estrogen therapy after breast cancer diagnosis and breast cancer mortality risk. Breast Cancer Res Treat. 2023 Apr;198(2):361-368. doi: 10.1007/s10549-023-06871-w.