By Rebecca Bowers

EXECUTIVE SUMMARY

Sexual function often decreases for women because of the genitourinary syndrome of menopause (GSM). This condition includes the physical changes of the vulva, vagina, and lower urinary tract that result from estrogen deficiency.

  • Although about one-third of midlife and older women report dryness and pain with intercourse, few consult their clinicians about GSM. Women will seek care for vasomotor symptoms associated with menopause, but those with GSM allow symptoms to progress without treatment.
  • For women who wish to use nonhormonal options, regular use of long-acting vaginal moisturizers and lubricants can aid in decreasing friction. Two low-dose estradiol creams, a vaginal ring, and a tablet are available for GSM treatment.

Sexual function often decreases for women because of the genitourinary syndrome of menopause (GSM). What treatment options are available to help women stay sexually active?

Previously known as vulvovaginal atrophy, this new term expands the areas of concern to include not only the physical changes that occur in the vulva and vagina but also those in the lower urinary tract that result from estrogen deficiency.1 This deficiency may cause the vagina to shorten and narrow, the introitus to contract, the vaginal epithelium to become thin, and sebaceous gland secretions to diminish. Lubrication from sexual stimulation may be delayed, as well as decreased.1

“Fortunately for women who have suffered with GSM, including women who have undergone cancer treatments, there are more options than ever before for maintaining a healthy sex life,” says Jan Shifren, MD, director of the Midlife Women’s Health Center in the Department of Obstetrics & Gynecology at Massachusetts General Hospital in Boston. Shifren presented information on treatment options at the recent North American Menopause Society annual meeting.2

Although about one-third of midlife and older women report dryness and pain with intercourse, few seek help for GSM.1 Women will seek care for vasomotor symptoms associated with menopause, but those with GSM often allow symptoms to progress without treatment.

“It is important for women, as well as their healthcare providers, to understand the information because sex shouldn’t hurt at any age,” says JoAnn Pinkerton, MD, NCMP, North American Menopause Society executive director.

Examine the Choices

For women who wish to use nonhormonal treatment options, using long-acting vaginal moisturizers and lubricants regularly can aid in decreasing friction, notes Shifren. Over-the-counter, water-based or silicone-based vaginal lubricants for sexual activity may be appropriate. Topical lidocaine also can help decrease the pain of penetration, she says.

For some women, introital–vaginal contraction or vaginismus may prevent penetration. By using graduated vaginal dilators facilitated by physical therapists specializing in pelvic floor disorders, women may be able to resume or initiate comfortable sexual activity. Starting low-dose vaginal estrogen therapy may aid progress.3

Clinicians also may offer various approved hormone therapies. These include vaginal use of low-dose estrogen therapy, which represents a highly effective treatment for symptomatic GSM.1 Low-dose tablets, a vaginal ring, and creams have comparable efficacy in treating vulvovaginal symptoms, data indicate.4 Research suggests that vaginal estradiol may reduce the risk of recurrent urinary tract infections and overactive bladder symptoms in menopausal women.3 The low-dose vaginal ring is approved to treat urinary urgency and dysuria.3 Creams may be applied not only intravaginally, but digitally to the vestibular tissues-introitus as well.

Systemic hormone therapy also offers an effective option in treating symptoms of genitourinary atrophy. However, research indicates that 10-15% of women will experience vulvovaginal symptoms during use. These symptoms become more likely when using doses that are lower than the standard.3 Low-dose vaginal estrogen can be added in these cases.

Other Treatment Options

Another drug option for treating GSM is ospemifene, a systemic estrogen agonist-antagonist. Research indicates that hot flushes were reported by 7.2% of participants randomized to ospemifene at 60 mg compared with 2.0% of those randomized to placebo.5 In 2013, the Food and Drug Administration (FDA) approved ospemifene 60-mg oral tablets for treating dyspareunia in postmenopausal women.

Intrarosa is an intravaginal therapy that relies on the vaginal epithelium to locally convert dehydroepiandrosterone (DHEA) into estrogen to treat women experiencing moderate to severe pain during sexual intercourse due to menopause.

Research regarding the use of vaginal testosterone is limited. More robust studies are needed to assess efficacy and safety.

REFERENCES

  1. Kaunitz AM, Manson JE. Management of menopausal symptoms. Obstet Gynecol 2015;126:859-876.
  2. Shifren JL. Treatment options for sexual problems resulting from genitourinary syndrome of menopause. Presented at the 2018 North American Menopause Society Pre-Meeting Symposium. San Diego; October 2018.
  3. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013;20:888-902.
  4. Rahn DD, Carberry C, Sanses TV, et al. Vaginal estrogen for genitourinary syndrome of menopause: A systematic review. Obstet Gynecol 2014;124:1147-1156.
  5. Simon JA, Lin VH, Radovich C, Bachmann GA; Ospemifene Study Group. One-year long-term safety extension study of ospemifene for the treatment of vulvar and vaginal atrophy in post-menopausal women with a uterus. Menopause 2013;20:418-427.