Menopausal Genitourinary Syndrome (GSM) is a chronic, progressive condition that results from declining estrogen levels, primarily after menopause, but also due to other causes of estrogen deficiency. It affects the vulva, vagina, and lower urinary tract, leading to a variety of uncomfortable symptoms. Previously known as vulvovaginal atrophy (VVA) or atrophic vaginitis, the term GSM was introduced to encompass the broader range of changes affecting the vulva, clitoris, vagina, urethra, and bladder, recognizing that it's not just a vaginal issue. Causes: The primary cause of GSM is the decline in estrogen levels, which leads to thinning, drying, and inflammation of the tissues in the genitourinary tract. While primarily associated with menopause, other conditions can also cause estrogen deficiency.

Menopause: The natural cessation of menstrual periods, leading to a significant drop in ovarian estrogen production.
Surgical Menopause: Bilateral oophorectomy (removal of both ovaries).
Medical Treatments:
- Chemotherapy: Can induce temporary or permanent ovarian failure.
- Radiation Therapy: Especially pelvic radiation, can damage ovarian function.
- Anti-estrogen Drugs: Such as aromatase inhibitors used in breast cancer treatment (e.g., anastrozole, letrozole, exemestane) or tamoxifen.
- GnRH Agonists: Used to treat endometriosis or fibroids (e.g., leuprolide) by suppressing ovarian function.
Lactation: Breastfeeding can cause a temporary estrogen deficiency.
Certain Autoimmune Conditions: Can sometimes affect ovarian function.
Disorders of the Pituitary Gland: Affecting hormone production.

Symptoms: Symptoms of GSM can vary in severity and may affect one or more areas of the genitourinary tract. They tend to worsen over time if left untreated.

Vaginal Symptoms:
- Vaginal Dryness: The most common symptom, leading to discomfort.
- Vaginal Burning: A persistent sensation.
- Vaginal Itching: Can range from mild to severe.
- Dyspareunia: Pain or discomfort during sexual activity due to dryness and thinning of tissues.
- Decreased Vaginal Lubrication: During sexual arousal.
- Vaginal Bleeding: Especially after intercourse due to fragile tissues.
- Shortening and Narrowing of the Vagina: Over time, if untreated.
Urinary Symptoms:
- Urinary Urgency: A sudden, strong need to urinate.
- Dysuria: Pain or burning during urination.
- Recurrent Urinary Tract Infections (UTIs): Due to changes in the urethra and bladder lining.
- Nocturia: Waking up at night to urinate.
- Stress Urinary Incontinence: Leaking urine with coughing, sneezing, or laughing.
Vulvar Symptoms:
- Vulvar Dryness, Itching, or Burning.
- Changes in Vulvar Appearance: Loss of labial fullness, thinning of pubic hair.

Diagnosis: Diagnosis of GSM is primarily clinical, based on a woman's symptoms and a physical examination. There are no specific lab tests required for diagnosis, though some may be done to rule out other conditions.

Medical History: The healthcare provider will ask about symptoms, menstrual history, menopausal status, sexual activity, and any relevant medical conditions or medications.
Physical Examination:
- Pelvic Exam: The provider will visually inspect the vulva and vagina for signs of atrophy, such as pallor, loss of rugae (vaginal folds), thinning, redness, and dryness.
- Assessment of Vaginal pH: Atrophic vaginal tissue often has a higher (more alkaline) pH.
- Evaluation of Vaginal Maturation Index (VMI): A microscopic examination of vaginal cells to assess the proportion of superficial, intermediate, and parabasal cells, reflecting estrogen status.
Urine Test: To rule out a urinary tract infection if urinary symptoms are present.
Other Tests (less common): Occasionally, blood tests for hormone levels might be considered, but they are not typically necessary for GSM diagnosis.

Treatment: Treatment for GSM aims to alleviate symptoms and improve the health of the genitourinary tissues. Treatment options range from non-hormonal lubricants to hormonal therapies.

Non-Hormonal Treatments (First-line for mild symptoms):
- Vaginal Moisturizers: Regular use (2-3 times per week) to hydrate vaginal tissues and maintain moisture. Examples include Replens, Hydralin, or over-the-counter options.
- Vaginal Lubricants: Used at the time of sexual activity to reduce friction and discomfort. Water-based or silicone-based lubricants are generally recommended.
- Regular Sexual Activity: Can help maintain vaginal elasticity and blood flow.
Local Estrogen Therapy (Low-dose vaginal estrogen):
- Considered the most effective treatment for moderate to severe GSM symptoms. Directly targets the vaginal and vulvar tissues with minimal systemic absorption.
- Vaginal Cream: Applied with an applicator (e.g., Estrace, Premarin).
- Vaginal Tablet/Pessary: Inserted into the vagina (e.g., Vagifem, Imvexxy).
- Vaginal Ring: A flexible ring inserted into the vagina that releases estrogen consistently for three months (e.g., Estring).
Systemic Estrogen Therapy:
- Oral pills, patches, gels, or sprays. Primarily used to manage other menopausal symptoms like hot flashes, but can also improve GSM symptoms. Typically prescribed when other systemic menopausal symptoms are also bothersome.
Selective Estrogen Receptor Modulators (SERMs):
- Ospemifene (Osphena): An oral SERM that acts like estrogen on vaginal tissue, improving dryness and dyspareunia.
- Prasterone (Intrarosa): A vaginal insert containing DHEA (dehydroepiandrosterone), which is converted to estrogens and androgens within the vaginal cells.
Laser Therapy: Emerging treatments like CO2 laser therapy are being explored, though long-term efficacy and safety are still under investigation.

Management of GSM is often ongoing. It's crucial for women to discuss their symptoms with a healthcare provider to receive an accurate diagnosis and appropriate treatment plan.

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Menopausal Genitourinary Syndrome (GSM)

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