Genitourinary Syndrome of Menopause: A Consensus Statement From the ISSWSH

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Included in the consensus statement are reasons to include androgen therapy as a way to treat symptoms of vulvovaginal atrophy.
Included in the consensus statement are reasons to include androgen therapy as a way to treat symptoms of vulvovaginal atrophy.

The International Society for the Study of Women's Sexual Health (ISSWSH) convened a panel of 14 researchers and clinicians in order to expand the recommended clinical management of genitourinary syndrome of menopause (GSM) to include androgen therapy.  Outcomes of their assessment were published in Menopause.

The research team found that symptoms of vulvovaginal atrophy (VVA) such as vaginal dryness and urinary frequency/urgency have a marked impact on sexual functioning, emotional health, body image, and relationships with peers. Factors that contribute to an increased risk for these symptoms may include Hispanic ethnicity, obesity, diabetes, depression, and urinary incontinence. Women with ovarian insufficiency or hypoestrogenic amenorrhea, as well as women prescribed ultralow-dose oral contraceptives were also found to be at risk for symptoms of VVA.

The researchers stressed the importance of androgens for women with GSM as they support genitourinary tissue structure and function. In the vagina, androgens and estrogens regulate vaginal mucin production in epithelial cells, and sex steroid hormones may regulate androgen and estrogen expression in genitourinary tissues. Although positive immunostaining for estrogen and androgen has been demonstrated in human vulvar tissue, estrogen was less prevalent and androgen was more prevalent when compared with vaginal tissue. Clitoral hypertrophy is considered one of the most sensitive markers for excess androgen production in women through menopause.

A diagnosis of GSM is confirmed by the presence of a vaginal pH ≥5.0, decreased volume of superficial cells, and increased proportion of parabasal cells. Clinicians should assess menstrual and medication history for women presenting with symptoms of GSM; a pertinent sexual history will assess whether symptoms are associated with sexual activity. External evaluation signs may include thinning or absent pubic hair, diminished elasticity of vulvar skin, introital narrowing and decreased moisture, and fusion or resorption of the labia minora. A thorough physical examination can differentiate GSM from other conditions of the vulva such as lichen sclerosus, lichen planus, or lichen simplex chronicus.

Treatments for GSM should combine both androgenic and estrogenic actions, such as seen with esterified estrogens with methyltestosterone and tibolone, which exerts estrogenic, progestogenic, and androgenic effects. In placebo-controlled clinical trials, daily insertion of dehydroepiandrosterone vaginal ovules decreased vaginal pH, improved the vaginal epithelial maturation index and vaginal epithelial thickness and integrity, and increased vaginal secretions resulting in improvement in dyspareunia. Information related to systemic testosterone therapy and low testosterone therapy for GSM is insufficient; more trials are needed in a postmenopausal population to determine whether testosterone therapies are beneficial.

Reference

Simon JA, Goldstein I, Kim NN, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review. Menopause. 2018;25(7):837-847.

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