Genitourinary Syndrome of Menopause
Vaginal dryness, although it is more common in the menopause, is a problem that can affect a woman in any phase of life (due to the use of contraceptives, breastfeeding, after childbirth, peri and post-menopause). In fact, more than half of women who suffer from this disorder are under 50 years-old; in whom secondary irritations associated with the use of soaps and shower gels, detergents and softeners to wash underwear, lotions and perfumes can occur. Certain medications or hormones used in the treatment of endometriosis, uterine fibroids or infertility, as well as others used for the treatment of breast cancer and radiotherapy in the pelvic area or chemotherapy can cause vaginal dryness, lack of elasticity of the vulva and vagina and discomfort-pain during sexual intercourse (dyspareunia).
Reasons for which it is more common post-menopause are derived from the lack of oestrogen, as there are two basic causes for which this syndrome appears: Alterations in the constitution and functioning of the vaginal mucosa and alterations in the vaginal microbiota (microorganisms that normally live in the vagina)
Functions of oestrogen in the vagina:
- Lubrication: Due to its stimulus, the vaginal mucosa produces a transparent lubricant fluid which prevents the dehydration and dryness of the mucous membranes; in addition, during sexual intercourse, its increase means that these are more comfortable due to the reduction in friction and micro-traumas.
- Regeneration: The vagina is covered by an epithelium that is regenerated due to the stimulation of oestrogens and, when its levels are reduced during the menopause, this proliferation process is decreased meaning that the urovaginal epithelium becomes thinner and, as the nerve endings are found near the surface, sensitivity is increased and this can cause pain.
- Alteration in normal microorganisms (vaginal microbiota): Oestrogen influences the pH of the vaginal epithelium which contributes to maintaining the vaginal microbiota in balance, and to lowering oestrogen levels, good bacteria are reduced and this promotes infections.
It was initially thought that the only problem after the menopause was vaginal dryness, and that is why previously only vaginal atrophy was described. Today we know that this is only one of the symptoms since it is an even more complex syndrome, which is why we currently talk about genitourinary syndrome of menopause (although it also occurs outside the menopause in the situations previously stated).
The range of symptoms can go from some small discomforts, to impeding significantly the personal, social and work performance of a woman.
Within the most frequent symptoms we have:
- Burning sensation, irritation or itchiness in the genital area that can generate great discomfort and pain.
- Burning feeling when urinating.
- Abnormal vaginal discharge (due to appearance or smell).
- Appearance of small cracks most notably in the lower end of the vulva (vulvar fork) or in the walls of the vagina.
- Pain during sexual intercourse due to limited lubrication and lack of elasticity that makes penetration difficult, meaning that these are little or not at all pleasurable or even painful.
- Light bleeding, spotting or abrasions after sexual intercourse.
- Carrying out a gynaecological examination can be uncomfortable or painful.
- The vulva can become so sensitive that it can be difficult to sit down, to walk or run a lot or even to practise some sports.
- Vaginal atrophy makes a woman more prone to contracting vaginal infections caused by bacteria or fungi (due to imbalance or absence of the vagina's natural flora).
- In its chronic form it can cause ulcers, cracks or adhesions to the walls of the vagina.
- Significant impact on the relationship with her partner, especially if there is not adequate communication due to the alterations that it causes in a woman's sex life.
For the treatment, there are several alternatives depending on the severity and frequency of the symptoms. Some of these can be used in an escalated form.
These are used when extra lubrication is required during sexual intercourse to minimise friction, irritation, dryness and pain. The most recommendable lubricants are those which have a base of water or silicone, given that they are easier to remove afterwards by washing. It should be applied inside and around the vagina the number of times necessary.
Lubricants containing scents or perfumes should be avoided, since they can be irritating, as should petroleum jellies, because they can stick to the vaginal mucosa and alter it, promoting the development of fungi.
- Moisturising creams
These are applied in the vagina several times a week. They fix to the vaginal epithelium, retaining the water from the vagina, maintaining its hydration and elasticity. In addition, they reduce pH levels in the vagina with which, as there is greater acidity, there is better control of the bacterial growth. You can also find substances with a regenerative effect of the epithelium and antipruritics to relieve the itch.
- Local hormone therapy
It is used to treat the symptoms of vaginal atrophy when they are moderate or severe. Low doses of local oestrogens are administered, applied directly in the area in the form of vaginal ovules or tablets, vaginal creams and silicone rings. With its use, it is possible to normalise the acid pH, increase the blood supply of the epithelium and to improve the lubrication response of the vagina, reducing vaginal dryness.
- Non-Hormonal Oral Therapy
It uses a drug called Ospemifene. This is an oral treatment that does not contain hormones, but replicates the effects of oestrogen in certain body parts such as the vulva and the vagina. It is indicated in women during the post-menopause period for whom local oestrogen treatment is not suitable.
- Hormone Replacement Therapy
It uses hormone therapy with oestrogens combined with progesterone in the form of a patch or skin sprays or a pill that is taken orally. The risks and benefits of their use should be taken into account.
- Laser Therapy
It is an outpatient, minimally invasive technique which uses heat to stimulate the production of collagen of the cells of the vaginal area and to replace the driest layers of the skin with new cells, reorganising and rebalancing the different components of the vaginal mucosa.
- Injection of Hyaluronic Acid
It is a minimally invasive treatment that consists of injecting via the intradermal/intramucosal vaginal route, a preparation based on reticulated hyaluronic acid and mannitol to biostimulate, improve the elasticity, re-hydrate and re-tone the female intimate area.
There are a series of measures that can help to prevent vaginal dryness.
- Drink enough water throughout the day to improve body hydration.
- Avoid tobacco and alcohol because these reduce oestrogen levels and increase vaginal dryness.
- Avoid intimate hygiene products (soaps, lotions, perfumes and vaginal douches) with a fragrance or drying agents.
- Use hypoallergenic soaps and soaps that respect the skin's pH.
- Assess the use of some drugs: Antidepressants, antihypertensive agents, antiulcer drugs, antihistamines and some medications for common colds that can contribute to vaginal dryness due to their mechanism of action.
- Enjoy a full sex life since having sexual intercourse on a regular basis can help to prevent dryness.
And, lastly, don't forget that it is important to consult with the gynaecologist to define the most appropriate treatment to improve the symptoms of each particular patient.