Menopause news

New Guidelines for Managing Genitourinary Syndrome of Menopause

12 October 2020

The North American Menopause Society (NAMS) has updated and expanded its 2013 position statement on the management of the genitourinary syndrome of menopause (GSM), of which symptomatic vulvovaginal atrophy is a part.

The updated statement was presented at the 2020 Virtual NAMS Meeting by Stephanie S. Faubion, MD, Mayo Clinic, Jacksonville, Florida, and colleagues.

"Healthcare providers should educate women about GSM and the urogenital changes that often occur with menopause," the statement reads. "Many women are unaware that vaginal dryness, recurrent urinary tract infections, discomfort with sexual activity, and other GSM symptoms are a consequence of estrogen deficiency. Unlike vasomotor symptoms that typically improve with time, GSM symptoms often worsen in the absence of treatment."

According to the statement over-the-counter vaginal lubricants and moisturizers may sufficiently manage symptoms for some women with milder symptoms, as well as some approved prescription therapies, including vaginal estrogens, dehydroepiandrosterone (DHEA), systemic hormone therapy, and ospemifene.

"The choice of therapy depends on the severity of symptoms, efficacy, and safety of treatments for the individual woman, and patient preference," the authors stressed.

The recommendations include:

• First-line therapies for women with GSM include nonhormonal lubricants with sexual activity and regular use of long-acting vaginal moisturizers (level A -- supported by sufficient, consistent scientific).


• For women with moderate to severe GSM and those who do not respond to lubricants and moisturizers, several safe and effective options are available, including low-dose vaginal oestrogen therapy (level A), vaginal DHEA (level A), ospemifene (level A), and systemic oestrogen therapy when vasomotor symptoms are also present (level A).


• For women with a history of breast or endometrial cancer, management depends on a woman’s preferences, symptom severity, and understanding of potential risks after consultation with her oncologist (level C -- based primarily on expert opinion).


• Use of a progestogen is not recommended with low-dose vaginal oestrogen therapy, although women at increased risk of endometrial cancer may warrant endometrial surveillance. Endometrial safety clinical trial data are not available for use longer than 1 year, although observational studies are reassuring regarding longer-term use (level B - supported by limited or inconsistent evidence).
  
• Routine endometrial surveillance is not recommended for asymptomatic women using low dose vaginal oestrogen therapy. Transvaginal ultrasound or intermittent progestogen therapy may be considered for women at increased risk of endometrial cancer. (level C).


• Spotting or bleeding in a postmenopausal woman requires a thorough evaluation that may include transvaginal ultrasound and/or endometrial biopsy (level A).


• Energy-based therapies, including vaginal laser and radiofrequency devices, require long-term, sham-controlled safety and efficacy studies before their routine use can be recommended (level C).


• Therapy for GSM should be continued, with appropriate clinical follow up, for as long as bothersome symptoms are present (level C).


"By educating women about GSM, as well as diagnosing and appropriately managing this condition, clinicians can help to resolve many distressing genitourinary symptoms and improve the quality of life of women," the authors concluded.



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