The Genitourinary Syndrome of Menopause

Nancy A. Phillips, MD; Gloria A. Bachmann, MD

Menopause. 2021;28(5):579-588.

Conclusion

Healthcare providers can make a significant impact on the health and quality of life of women by being proactive about discussing and providing interventions for the genitourinary syndrome of menopause, which encompasses vulvovaginal atrophy, as well as all the symptoms related to estrogen deficiency in the vagina, vulva, and lower urinary tract. A systematic approach with consideration of current guidelines and attention to developing protocols of interventions being studied should be employed.

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Funding/support
None reported.

Table 1. Symptoms of the genitourinary syndrome of menopause
Genital symptoms	Vulvovaginal dryness
	Vulvovaginal itching/burning/irritation
	Vaginal discharge
Urinary symptoms	Dysuria
	Nocturia
	Urinary frequency/urgency
	Recurrent urinary tract infection
Sexual symptoms	Decreased lubrication/arousal with sexual activity
	Pain with introital insertion during sexual activity
	Dyspareunia
	Decreased or delayed orgasm
	Postcoital bleeding

Table 2. Genitourinary syndrome of menopause: physical examination findings
Vulva	Thinning/loss of pubic hair
	Thinning or fusion of labia
	Clitoral hood retraction or fusion
	Posterior fissuring
Vagina	Introital retraction
	Pallor or erythema, petechiae
	Loss of rugae
	Loss of hymenal remnants
	Leukorrhea
	pH > 5
	Loss of vaginal and cervical secretions
Urethra	Prominence of urethral meatus/caruncle

Table 3. FDA-approved preparations for vulvovaginal atrophy (VVA): estrogens, DHEA, and ospemifene
Product	Brand names	Route	Dosing
17β estradiol cream (0.1 mg/g)	Estrace (Allerga, Madison, NJ) Estradiol generic also available	Intravaginal cream	Initial: 2–4 g/d for 1–2 wk Maintenance: 1 g/1–3 times/wk
Conjugated estrogen cream (0.625 mg/g)	Premarin (Wyeth, Philadelphia, PA)	Intravaginal cream	VVA: 0.5–2 g/d, 21 d, then off 7 d or twice/week Dyspareunia: 0.5 g/d 21 d, then off 7 d or twice/week
17 β estradiol ring (7.5 μg/d)	Estring (Pharmacia and Upjohn, New York, NY)	Intravaginal ring	Inserted for 90-d intervals without interruption
Estradiol hemihydrate tablet (10 μg/d)	Vagifem (NovoNordisk, Plainsboro, NJ) Yuvafem (Amneal, Bridgewater, NJ)	Intravaginal tablet	Initial: 1 tablet/d for 2 wks Maintenance: One tablet twice/week
Estradiol soft gel insert (4 μg or 10 μg)	Imvexxy (TherapeuticsMD, Inc, Boca Raton, FL)	Intravaginal soft gel insert	Initial: 1 insert/d for 2 wks Maintenance: One insert twice/week
DHEA (Prasterone) (6.5 mg insert)	Intrarosa (Endoceutics Inc, Quebec City, Canada)	Intravaginal insert	One insert into vagina q hs
Ospemifene tablet (60 mg)	Osphena (Shionogi Inc, Florham Park, NJ)	Oral tablet	One tablet by mouth daily

The common clinical dosing for estradiol and conjugated estrogen vaginal creams is 0.5 g twice a week for maintenance.
Premarin, Osphena have FDA approval for both dyspareunia and vulvovaginal atrophy.
Imvexxy and Intrarosa have FDA approval only for dyspareunia due to menopause.
DHEA, dehydroepiandrosterone.

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The Genitourinary Syndrome of Menopause

Conclusion

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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