Reproductive · Year 2 · from Reproductive
Case 2: Genitourinary Syndrome of Menopause
Clinical Image
Source: Wikipedia - Atrophic vaginitis - CC BY-SA 3.0
Case Presentation
A 62-year-old woman presents with vaginal dryness, painful intercourse, and recurrent urinary tract infections. She went through menopause at age 51 and had mild hot flashes that resolved within a few years without treatment. Over the past 3 years, she has developed progressive vaginal dryness causing significant dyspareunia. She and her husband have essentially stopped having intercourse due to her discomfort. She has also had 4 UTIs in the past year despite adequate hydration. Physical examination reveals pale, thin vaginal epithelium with loss of rugae, petechiae, and a vaginal pH of 6.0 (normal premenopausal pH is 3.5-4.5). The urethral meatus appears prominent. She has no history of breast cancer and her mammograms have been normal. She declines systemic hormone therapy as she has no vasomotor symptoms. The diagnosis is genitourinary syndrome of menopause (GSM). She is counseled that unlike hot flashes, GSM is progressive and will not resolve without treatment. She is started on vaginal estrogen cream (conjugated estrogens 0.5 g intravaginally twice weekly). At 12-week follow-up, she reports marked improvement in vaginal comfort and has resumed sexual activity. The vaginal epithelium appears healthier, and pH has decreased to 4.5. No UTIs have occurred since starting treatment.
Key Learning Points
- Genitourinary syndrome of menopause (GSM) affects approximately 50% of postmenopausal women and includes vaginal dryness, dyspareunia, urinary urgency/frequency, and recurrent UTIs
- Unlike vasomotor symptoms, GSM is progressive and does not resolve spontaneously; treatment is required to prevent progression
- Low-dose vaginal estrogen is the most effective treatment for GSM with minimal systemic absorption; it is safe even in many women with contraindications to systemic HT
- Alternative treatments include vaginal DHEA (prasterone), the oral SERM ospemifene, and non-hormonal vaginal moisturizers and lubricants