Genitourinary Syndrome of Menopause: Why Vaginal Dryness, UTIs, and Pain Are Not 'Just Part of Aging
The vagina, vulva, urethra, bladder, and pelvic floor muscles are loaded with estrogen receptors. When estrogen declines, these organs and tissues are no longer exposed to estrogen. Women wind up with vaginal atrophy, loss of elasticity, thin tissue, changes in vaginal pH, and changes in the vaginal microbiome.
As a result, women begin to experience increased frequency of urination, decreased sexual arousal, vaginal discomfort, vaginal dryness, pain with intercourse, and changes in vaginal discharge. While some perimenopausal and menopausal symptoms are transient and may improve over time, vaginal symptoms often persist unless treated and can significantly impact a woman’s quality of life.
The most common symptoms include:
Vaginal dryness, loss of lubrication
Pain with sex
Painful urination
Recurrent urinary tract infections (UTIs)
Bladder urgency
Bladder leaking/incontinence (leaking when you sneeze or laugh)
Loss of libido, arousal, or orgasm
Vaginal/vulva burning, pain, dryness, irritation, or itching
Increase in vaginal yeast infections or other vaginal infections
Nutrition and lifestyle
Avoid/reduce known bladder irritants which can exacerbate urinary symptoms. These include sugar, coffee, black tea, carbonated drinks, alcohol, certain acidic fruits like oranges, grapefruits, lemons, and limes due to the citric acid, vinegar, spicy foods, tomato-based products, and chocolate (yes, all of the fun stuff!)
Maintain optimal body weight. Obesity has been identified as a significant independent risk factor for urinary incontinence in postmenopausal women. It has been identified as the most significant attributable risk factor for daily urinary incontinence.[1]
Optimal levels of Vitamin D are needed to support pelvic floor muscle strength.[2] Studies show that Vitamin D levels below 30 ng/mL are associated with urinary incontinence and poorer pelvic floor strength.[3]
Pelvic floor exercises can be beneficial to improve GU symptoms.
Pelvic floor exercises and/or Pilates
Seek out a Pelvic Floor Specialist
Refrain from high-intensity exercises such as running and jumping if you experience issues, as these can worsen bladder symptoms and leakage
Supplements, products & Resources
Vaginal moisturizers and lubricants can improve symptoms but must be used regularly to experience consistent benefit.
Hyaluronic acid such as Revaree, BioNourish, or Good Clean Love
Gynotrof is a combination formula with both hyaluronic acid and Vitamin E
Julva Vaginal Cream (contains DHEA)
Bezwecken has an entire lineup of vaginal/menopause support products
Probiotics that specifically include the strains L. rhamnosus and L. reuteri support vaginal pH and the vaginal microbiome. Seed recently came out with VS-01, a new vaginal synbiotic that, in a clinical trial, converted 90% of participants to an optimal vaginal microbiome within 21 days and was superior to both a leading oral probiotic for vaginal health and a placebo.
D-mannose may be considered to prevent urinary tract infections in women who experience persistent UTIs.
The Honey Pot Company is a plant-based feminine care company that carries a beautiful lineup of washes, wipes, incontinence products, and more that are vagina friendly.
JoyLux uses red light therapy and other technology to help improve vaginal wellness.
Interlude - Telehealth vaginal estrogen and other products
Testing your vaginal microbiome
Recurring yeast infections, bacterial vaginosis, and other infections are quite common. You can test your microbiome with something like Juno or Evvy.
Medications
Many anticholinergic medications on the market work by controlling muscle spasms in the bladder. Oxybutynin is an FDA-approved treatment for overactive bladder that has also been shown to reduce hot flashes and night sweats in menopausal women. The downside? In randomized clinical trials, over 50% of women who use this treatment report dry mouth, which is already a problem for many midlife women.[4]
Hormone replacement therapy
Vaginal estradiol or estriol (estriol directly placed into the vagina) improves vaginal atrophy[5], pain with intercourse[6], urinary symptoms, and quality of life in women with overactive bladder[7].
Typical dosing for Estradiol cream is 0.01% (0.1mg/g), 1 g per application = 0.1mg applied vaginally nightly for 2-3 weeks, reducing to 2-3 treatments per week ongoing, or until symptoms resolve without treatment. Typical dosing for Estriol is .03-2 mg applied vaginally nightly for 2-3 weeks, reducing to 2-3 treatments per week ongoing, or until symptoms resolve without treatment.
Studies confirm that low-dose vaginal estrogen does not cause endometrial hyperplasia (i.e., excessive growth of the uterine lining) even without progesterone and is a safe and effective treatment for symptoms of vaginal atrophy in women who are not candidates for systemic hormone replacement therapy.[8]
Estrogen replacement therapy used systemically can often relieve/reduce GU symptoms. Some women may find that a combination of both systemic estrogen replacement therapy and vaginal estrogen (estriol) is needed to reduce/relieve symptoms.
Vaginal DHEA - While oral DHEA is available over the counter, it has not been shown to address vaginal dryness or atrophy. Vaginal DHEA is a different story and has been shown to reduce vaginal dryness, improve vaginal pH, strengthen the vaginal musculature, decrease pain during intercourse, and increase sexual arousal and libido. This is only available by prescription under the brand name Intrarosa (prasterone) and can be inserted into the vagina at bedtime.
Testosterone replacement - Testosterone has a significant impact on vaginal and bladder/urethral health. Testosterone replacement can be a game-changer in saving you all those nighttime trips to the bathroom, issues with urinary leakage and urgency, and can help boost libido.[9] Testosterone can only be obtained by prescription.
Warning: As always, be sure to check with your physician or licensed healthcare practitioner before trying any new supplements.
Important medical disclaimer
The contents of this blog are for informational purposes only and are not a substitute for professional medical advice. None of the recommendations, suggestions, or written information provided is intended to replace a one-on-one relationship with a qualified health care professional. The information presented is not intended to diagnose, treat, cure, or prevent any disease but rather as a sharing of knowledge and information from the research and experience of Jill Chmielewski, RN, BSN. You are encouraged to make your own health care decisions based on your research and partnership with a qualified healthcare professional of your choosing.
References
[1] Ballard, Alicia C, and Holly E Richter. “The Impact of Obesity and Weight Loss on Urinary and Bowel Incontinence Symptoms in Women.” Menopausal medicine: for clinicians who provide care for women vol. 19,3 (2011): S1-S7.
[2] Aydogmus, H, and U S Demirdal. “Vitamin D Deficiency and Lower Urinary Tract Symptoms in Women.” European journal of obstetrics, gynecology, and reproductive biology vol. 228 (2018): 48-52. doi:10.1016/j.ejogrb.2018.06.009
[3] Badalian, Samuel S, and Paula F Rosenbaum. “Vitamin D and pelvic floor disorders in women: results from the National Health and Nutrition Examination Survey.” Obstetrics and gynecology vol. 115,4 (2010): 795-803. doi:10.1097/AOG.0b013e3181d34806
[4] Simon, James A et al. “Extended-release oxybutynin therapy for vasomotor symptoms in women: a randomized clinical trial.” Menopause (New York, N.Y.) vol. 23,11 (2016): 1214-1221. doi:10.1097/GME.0000000000000773
[5] Marnach, Mary L, and Rochelle R Torgerson. “Vulvovaginal Issues in Mature Women.” Mayo Clinic proceedings vol. 92,3 (2017): 449-454. doi:10.1016/j.mayocp.2016.10.031
[6] Murina, Filippo et al. “Coital pain in the elderly: could a low dose estriol gel thrill the vulvar vestibule?.” European journal of obstetrics, gynecology, and reproductive biology vol. 207 (2016): 121-124. doi:10.1016/j.ejogrb.2016.10.016
[7] Matarazzo, Maria Grazia et al. “Does vaginal estriol make urodynamic changes in women with overactive bladder syndrome and genitourinary syndrome of menopause?.” European journal of obstetrics, gynecology, and reproductive biology vol. 222 (2018): 75-79. doi:10.1016/j.ejogrb.2018.01.002
[8] Rueda, C et al. “The efficacy and safety of estriol to treat vulvovaginal atrophy in postmenopausal women: a systematic literature review.” Climacteric : the journal of the International Menopause Society vol. 20,4 (2017): 321-330. doi:10.1080/13697137.2017.1329291
[9] Islam, Rakibul M et al. “Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data.” The lancet. Diabetes & endocrinology vol. 7,10 (2019): 754-766. doi:10.1016/S2213-8587(19)30189-5