32 | Nursing in Practice | Winter 2022
HOW TO …
Manage
genitourinary symptoms of menopause
GP specialist in women ’ s health Dr Rebecca Smithson explains how genitorurinary problems can affect women during the menopause and provides an update on management options
What is the menopause ? Menopause occurs when the menstrual cycle ceases as a result of loss of ovarian function . The time leading up to a natural menopause , when hormone levels are changing , is termed the perimenopause , and postmenopause is the time after the last period . This can be timed precisely after a surgical menopause , but in a natural menopause can only be defined in retrospect when 12 months have passed since the last menstrual period ( LMP ). The average age of the menopause in the UK is 51 ; menopause is considered to be early if it occurs between the ages of 40 and 45 . If it occurs before the age of 40 , it is termed premature ovarian insufficiency . 1
What effect does the menopause have on the genitourinary system ? There are oestrogen and progesterone receptors in the vagina , urethra , bladder and pelvic floor muscles . As hormone levels fall , tissues become thinner , drier and less elastic . This can lead to a variety of symptoms and signs , which are collectively known as genitourinary syndrome of menopause ( GSM ). 2 Common signs and symptoms are outlined in Box 1 . 3
More so than some menopausal symptoms , such as vasomotor symptoms , GSM symptoms tend to increase over time , and may last for years after the menopause . 1
How might patients present ? It is not uncommon for patients to present with symptoms of burning and itching , which can be mistaken for candida infections . However , recurrent infections – including vaginal and urinary tract infections – are common with the menopause , due to an increase in the vaginal pH as oestrogen levels fall . 1 Patients may attend with discharge , or even bleeding , which of course must be investigated to exclude any other underlying cause . Nurses may pick up signs of vaginal dryness or atrophy at a routine smear test , with tissues looking pale and friable ; this can be a chance to discuss symptoms opportunistically . Some patients may not realise their symptoms are caused by hormonal
ONLINE Scan the QR code to access the full Nursing in Practice clinical archive , or visit nursinginpractice . com / clinical changes , or they may feel inhibited from discussing genitourinary symptoms with their healthcare provider . While 40 % or more of those going through the menopause will experience GSM , only 25 % will seek help for those symptoms . 1
What treatments are available ? Treatments for GSM can be grouped into hormonal and non-hormonal .
Hormonal treatments for GSM Hormonal treatment is mostly oestrogen based , although some women may find testosterone is helpful for low sexual desire . Oestrogen may be delivered systemically as hormone replacement therapy ( HRT ), locally , or both . It is important to note that some patients on systemic HRT may still require local oestrogen , and NICE supports the use of local oestrogen in addition to systemic HRT for women with GSM for as long as is required to relieve symptoms . 4 Low-dose vaginal oestrogens may be used in some patients in whom systemic HRT is contraindicated , but this should be under the guidance of a menopause specialist . 1 Examples of local oestrogens are outlined in Box 2 , on page 34 . 1
Box 1 Common signs and symptoms of GSM 3
Genital Vaginal dryness Irritation / burning / itching Vaginal / pelvic pain or pressure Vaginal prolapse
Sexual Dyspareunia Dryness / lack of lubrication Postcoital bleeding Reduced arousal / desire Anorgasmia / dysorgasmia
Urinary Dysuria Urgency Incontinence – stress and / or urge Recurrent urinary tract infections Urethral prolapse Ischaemia of vesical trigone
Other Other pelvic organ prolapse ( cystocoele , rectocoele , uterine prolapse )
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