Genito Urinary Syndrome of Menopause (GSM) or Vulvo-vaginal Atrophy (VVA) an Unspoken Sorrow

Abstract

GSM includes wide spectrum of vulvovaginal Symptoms and urinary troubles replacing the term vulvovaginal atrophy (VVA). It is a silent epidemic condition affecting 50-60% postmenopausal women. Estrogen withdrawal causes thinning, narrowing, tissue loss & reduced blood supply in vulvo-vaginal area, which results GSM. GSM causes burning in vagina, dyspareunia, urinary urgency, repeated UTI. Dyspareunia affects all the domain of sexual function and deteriorates the quality of life. Irony is, women are oblivious to share and doctors are reluctant to discuss. So women keep continue suffering without knowing the restorative treatment. Repercussion of GSM/VVA intensifies the sorrows, distress and sufferings. It has profound effect on relationship and psychology and quality of life of women. Good history taking and clinical examination do diagnosis. Investigations are done to exclude other causes. Treatment is challenging. Maintenance of optimum body weight, exercise, regular coitus, quitting smoking & excessive alcohol intake are the key factors. Vaginal moisturizers are recommended as 1st line therapy for mild to moderate VVA or women who can't take estrogen. Ideal moisturizers should have similarity with vaginal secretion of osmolality, pH and composition. Meta analysis shows local estrogen therapy is effective. It restores vaginal pH and maturation index. Systemic absorption is minimal so progesterone needs not to be added. Testosterone improves dyspareunia, sexual desire, lubrication and satisfaction. DHEA (Prasterone) penetrates vaginal wall better. It increases elasticity and vascularity of vagina. RCTs have not shown benefits of it's systemic therapy. But local daily administration of DHEA reduces dyspareunia and GSM so improves the quality of life. Ospemifene is well tolerated. It's agonist effect on vaginal mucosa and antagonist effect on endometrium and breast, makes it promising. Lasofoxifene, third generation SERM, is also very effective but it needs FDA approval. Laser is widely being used and very effective. It is simple, faster, painless procedure. It activates dominant fibroblasts, proteoglycans, hyaluronic acid, thereby improves GSM & sexuality. Black cohosh, Botox, G-shot, probiotics, gabapentin are not yet evidence based. Still there is significant unmet need for medical treatment. Women reports GSM but that is only tip of iceberg. Good communication and optimum treatment only can break the sorrows GSM/VVA.