Sadly, as we age, the quality of our skin changes. It becomes drier, less elastic, and more fragile. This is very apparent to us when we inspect our faces, arms, and legs. However, you may not realize that these changes also occur in the vagina, which is lined with cells very similar to our external skin. And, to add insult to injury, when menopause rolls around, the vaginal lining is even more affected. This is because the cells in the vagina and surrounding tissue rely heavily on estrogen to keep them from aging. So starting sometime after age 40, women may begin to notice vaginal dryness, sensitivity, and discomfort with intercourse. Other problems ensue such as urinary leakage and a tendency to get vaginal and bladder infections. This array of symptoms has been officially recognized and is now referred to as the genitourinary syndrome of menopause, or GSM. This name was chosen to more accurately reflect the spectrum of changes that occur in the vaginal area and surrounding tissues because of a lack of estrogen.
Many women don’t seek treatment for these problems because they are either embarrassed, or don’t realize that there are treatments available to help alleviate these symptoms. I recently attended the 2022 annual conference of the North American Menopause Society (NAMS) where these issues were discussed, and in this blog I am going to update you on some of the information that was presented.
Moisturizers and lubricants
Moisturizers and lubricants have been around a long time and there are many products available. In fact, at the NAMS conference I was blown away by the multitude of vendors demonstrating the newest array of these OTC products. Moisturizers are agents designed to be used several times per week to help combat vaginal dryness; lubricants are generally used to provide lubrication for intercourse. Moisturizes and lubricants can help women deal with some of the symptoms of GSM, but unlike estrogen treatment, they don’t alter the underlying cell changes causing the problems.
Thank goodness for estrogen
Since it is the loss of estrogen that is mainly responsible for the deterioration of the vaginal cells, it makes sense that replacing estrogen after menopause should help. And, it does. The 2022 position statement from NAMS notes that estrogen remains the most effective treatment for GSM. And fortunately, GSM is one of the few conditions where estrogen treatment is approved by the FDA.
There are two major options for women when it comes to taking estrogen. Women who are having hot flashes generally opt to take estrogen in the form of pills or patches. The dosages of estrogen prescribed are effective for relieving many menopausal symptoms, including GSM. However, for some women, estrogen replacement in this form is either not recommended or not desired. So the other option is to use a very a low-dose estrogen preparation formulated to be inserted into the vagina. These are available in the form of creams, suppositories, and even a long-lasting ring inserted into the vagina. These low-dose estrogen products contain such small amounts of estrogen that very little is absorbed – so negligible amounts get into the blood stream. Thus they are unlikely to cause negative side effects in the rest of the body. Even most women with a history of breast cancer can safely use this form of estrogen. On the flip side, the low doses do very little to help with hot flashes or provide some of the other benefits of estrogen, such as preventing osteoporosis.
Other hormone-like options
Besides vaginal estrogen products, a novel vaginal product designed to help GSM came on the market six years ago. This product, prasterone, consists of DHEA. DHEA is a hormone made by the adrenal glands. When a dose of prasterone is inserted into the vagina, it is converted into both estrogen and testosterone. Thus, the estrogen nourishes the lining cells as discussed above. The testosterone produced is believed to add some additional benefit.
Another pharmaceutical, approved in 2013, is a pill called ospemifene. Ospemifene is not a hormone – rather a selective estrogen receptor modulator (SERM). SERMS are designer chemicals made to have some estrogen-like properties, so ospemifene has estrogen effects in the vagina. The down side is that this drug can worsen hot flashes and increase the risk of blood clots.
How does estrogen work?
Without estrogen the vaginal cells shrink in size, produce less mucous, and stop producing other compounds that keep the vagina resilient. If estrogen is replaced after menopause, the vaginal cells enlarge and behave like they did before menopause. The lining becomes thicker – making it less vulnerable to being irritated and injured. In addition mucous cells are replenished and this increases vaginal moisture. The accompanying picture shows a cross-section of how the vaginal lining appears before and after menopause.
Healthy vaginal cells allow lactobacilli to flourish. Without these “good” bacteria, the acid level in the vagina goes down and this, plus other changes, allow “bad bacteria” (like E.coli) and yeast colonies (like Candida) to take over, leading to infections. Putting estrogen back into the vaginal cells reverses these damaging changes and essentially “rejuvenates” the tissues.
A novel new approach
The most recent development for treating GSM is laser therapy. Lasers are instruments that create powerful beams of light that can alter or remove tissue. Lasers are used in many areas in the medical field – such as destroying skin cancers, reshaping the cornea (like LASIK procedures), or blasting kidney stones. Since a laser is usually used to remove unwanted tissue, using one in the vagina may seem puzzling. So you may be wondering how this works to treat GSM.
The accompanying images illustrate this procedure. Image (A) depicts a laser machine. Light is generated in the machine and channeled down a long tube. At the end of the tube is a specialized probe that looks like a hairbrush. Emanating from the brush are many closely spaced holes which emit tiny laser beams.
The probe is inserted into the vagina (B) and is rotated and the laser beams make hundreds of tiny holes in the vaginal lining.
Image (C) illustrates a diagram of a cross-section of the vaginal lining where the laser has made a series of holes (like pinpricks) in the vaginal wall. After the procedure, as part of the healing process, new cells, collagen, and blood vessels are formed within the vaginal lining. The end result is that the vaginal wall becomes thicker and stronger.
Laser treatment for GSM typically consists of several sessions over a few months followed by “touch-up” procedures every six to 12 months. These treatments are performed in the office and do not require anesthesia.
Many clinics have appeared over the last few years promoting these procedures. However, this treatment is very controversial. In the hands of experienced doctors with the proper equipment, the results have been positive. Under these conditions a few studies have indicated that laser therapy can be as effective as estrogen therapy for GSM. However, other studies have not been conclusive. Although laser machines have been approved by the FDA for many uses, the FDA currently notes “that the safety and effectiveness of energy-based medical devices to manage vaginal symptoms related to menopause or sexual function have not been established, and that these therapies may lead to serious adverse events.”
The most recent position statement from NAMS similarly reads that “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.” What both of these agencies are saying is that more studies are needed before doctors should offer these treatments to patients.
Some gynecologists and other healthcare practitioners don’t agree with this opinion and many clinics continue to promote vaginal laser treatments. If you search the internet, there are a number of direct-to-consumer ads marketing these treatments. Millions of dollars have been invested by some practitioners in the purchase and promotion of these machines.
The bottom line
Many women feel there is nothing to be done and do not seek medical advice for GSM. The purpose of this blog has been to educate you about this condition, describe the options for treatment, and explain how those options work. Having this type of information puts you in the best position to make informed decisions about your medical care.
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