Genitourinary Syndrome of Menopause (GSM) its more than just dryness

Dr. Sameena Rahman [: 00:00:00

Hey, y'all, it's doctor Samina Rahman, Gyno girl. I'm a board certified gynecologist, a clinical assistant professor of Ob GYN at Northwestern Feinberg School of Medicine, and owner of a private practice for almost a decade that specializes in menopause and sexual medicine. I'm a south asian american muslim woman who is here to empower, educate, and help you advocate for health issues that have been stigmatized, shamed, and perhaps even prevented you from living your best life. I'm better than your best girlfriend and more open than most of your doctors. I'm here to educate so you can advocate. Welcome to Gyno girl presents sex, drugs, and hormones.

Dr. Sameena Rahman [: 00:00:46

Let's go. Hey, y'all, it's me, doctor Saminurman Gynel girl. Welcome to Gyne girl presents sex, drugs, and hormones. Thank you for listening to my podcast. Please like and subscribe. Please write a review. Please give me some five stars. And hopefully, you know, more people can listen and more people can get engaged and know that I'm out here trying to give some good information, evidence based information based on my years of experience and, you know, my knowledge.

Dr. Sameena Rahman [: 00:01:17

I'm a board certified ob GYN in downtown Chicago. My specialties are in menopause and sexual medicine. I'm a part of the International Society for the Study of Women's Sexual Health ishwish as well as menopause society. And I'm a menopause certified physician. And today I want to talk to you about a topic that, you know, I talk about a lot, I lecture on a lot, and I just realized I haven't done a podcast on it yet, even though we've mentioned it before in other ways. But to specifically talk about hormone deficiencies when it comes to our genitourinary health. And that's really what I want to get into a little bit today for you guys to understand what I want to ask you guys. And just imagine what you think of when you hear the term atrophy.

Dr. Sameena Rahman [: 00:01:59

Like, if someone says your muscles are atrophic or your skills have become atrophied or whatever, what do you think about? It's really a wasting away. It's a wasting away of either body part or an organ or a tissue. And to hear that your vagina is atrophied has to be one of the most disturbing things to hear for a midlife patient or, you know, patients that are affected by other hormone deficiencies. So I want to just want you guys listen to that term for a second, just like, if you're told, you know what? Your vagina is atrophic. Your vagina has atrophy. That literally means that your vagina is wasting away, right? So I start with this because, you know, we've gone away from using that term, but it wasn't until around 2014 when that happened. In 2014 ish wish and the Menopause society and other societies came together and were like, hey, you know what? You know, in the 1990s, we quit calling it impotence, right? We never, back in the day when men couldn't get an erection, they called it impotence, that they were impotent. And, you know, we would, we did away with that.

Dr. Sameena Rahman [: 00:03:16

We started calling it erectile dysfunction. You know, because words matter. I say this all the time to my kids. I say this to patients all the time. When you hear something and you're described something and it's, you know, told to you or you're called something, these words matter, right? So if you're sitting here telling and your doctor saying, or your clinician, whoever you see is saying, hey, you know what? I'm sorry, your vagina is atrophic, just wasting away. You know, it's just not the most pleasant thing. So in 2014, the, these, the consensus became that we should refer to the changes specifically in midlife when it comes to hormonal deficiency as the genitourinary syndrome of menopause. Because it's not just about vaginal dryness.

Dr. Sameena Rahman [: 00:03:57

And I think that is something, if you learn nothing from me and anything that I say, I want you to learn that progenitorinary syndrome, menopause, is not just about vaginal dryness. It is about, you know, the vagina changing. But it is a genitourinary syndrome. Remember, when we talk about menopause, we're talking about a hormone deficient state. And it's not just estrogen that's deficient, it's testosterone. And, you know, newsflash, you have testosterone receptors in your vagina, your clitoris, your vulva, and your, you know, vest, your vulvar vestibule, which I've talked about. So when we talk about the fact that you now are having a vaginal dryness, it's just not this feeling of discomfort and dryness and, like, weird, you know, lack of frictiony kind of stuff. It really is more of a profound state.

Dr. Sameena Rahman [: 00:04:48

It is a syndrome, right, related to hormone deficiency. And it means that in our genitals, in our labia, in our vulva, we might have some shrinkage. You might have shrinkage of your clitoris. It might become, as they used to say, atrophic wasting away. Clitoris is good, no good for anybody. So we don't want that to happen. So, you know, there's that. There's the vulva changing.

Dr. Sameena Rahman [: 00:05:10

There's the vagina changing. There's changes in your vagina in that, you know, as you lose estrogen, as you lose testosterone, it changes the ph of your vagina, right? So the ph of the vagina is usually between three and a half and four and a half, roughly. It's acidic. We like it to be acidic. We like that vaginal microbiome, these little critters, the bacteria, the fungus, all the things that actually are housed in the vaginal tissue to be in a state that is consistent with harmony. We want the vagina to have more lactobacillus, so that lactobacillus species can create more lactic acid, which makes the vagina acidic, which allows the vagina to keep its moisture. But it also allows the vagina, you know, as estrogen becomes deficient, we lose our basis for collagen, right? Just like we lose collagen in our face, which nobody wants. You lose collagen in the vagina and you lose elasticity.

Dr. Sameena Rahman [: 00:06:06

You lose all of that in the vulva as well. So we have all these changes in the vagina and the vulva that then results in this discomfort. And so when I talk about the genital urinary syndrome and menopause, I'm referring to, it's a condition that affects at least half of post menopausal or perimenopausal women, but more about closer to probably 75% to 80%. Okay, so that's one thing. Just true story. You guys may have heard that Halle Berry came out recently in the media saying that, you know, she was misdiagnosed about her menopause symptoms. She was told that she likely had genital herpes, and it turned out to be the genital urinary syndrome and menopause. She had burning after intercourse.

Dr. Sameena Rahman [: 00:06:49

She had all this discomfort. She had painful sex. And her doctor actually said, you have herpes. And then when he did a swab, it was negative. And she's very outspoken about this. She's spoken about this on multiple media platforms. And she was told that she has herpes, and she goes home thinking she has herpes after having some sexual encounter and whatever. Later, you know, it was discovered that she did not have herpes, but in fact, the genital urinary syndrome in Memphis.

Dr. Sameena Rahman [: 00:07:14

And one thing I want you guys to understand it is a chronic progressive state, meaning it doesn't get better without treatment. And if you stop treatment, it gets worse. So when we talk about treatment, which I'll do, you know, I consider this, as my friend Doctor Rachel Rubin says, till death to you part. It should just be a part of your regimen. I talk about this all the time with my menopausal patients when we are brushing our teeth and washing our face and putting our, you know, face regimen on. We should then just, you know, if you're using systemic hormones, put on your patch, take your progesterone right before you go to sleep, and then, hey, guess what? Stick whatever you need to in the vagina to make sure that you're getting it, you know, treated and better. So it's a chronic, progressive treatment. And, you know, about less than a quarter of women actually discuss it with the patient, with their clinicians or doctors, and most cases are not treated, and many people don't recognize it.

Dr. Sameena Rahman [: 00:08:07

But it is not just about vaginal dryness, as I said earlier. It is about these changes that happen in the vulva and the vagina. The vulva, like I said, the clitoris shrinks, the labia minora might shrink and become smaller, the urethra might become more proliferate, and the genitourinary syndrome and menopause. The urinary part of that is symptoms such as pain with urination, urinary frequency, urinary urgency. I got to go. I got to go. I got to go. I leak.

Dr. Sameena Rahman [: 00:08:32

Recurrent urinary tract infections, you know, symptoms that might mimic something like an irritable bowel syndrome. And then, you know, the general side, vaginal dryness, vaginal pain, pain with initial insertion, with sex, that can sometimes lead to a more worsening consequences. Because if, you know, when I talk about vestibulodynia and that pain at the vulvar vestibule, remember, the vulvar vestibule is that little slither of tissue from the inner labia minora to the hymen remnant extending up to the urethra and down to the perineum. And that's that little slither of tissue that you have to pass through to get into the vagina, just like you have to pass through a vestibule to get into a large, fancy room or a church or whatever. And so that vestibule is really consistent with the same tissue as the outer part of the urethral opening. And it's so it comes from embryologically. For those medical people listening, the endodermal tissue of your germ cell layers, and it is very much concentrated with estrogen and androgen receptors. And the androgen receptors are very critical to this.

Dr. Sameena Rahman [: 00:09:37

The testosterone needs to get there. Remember, when you go through menopause, you lose 50% of your testosterone production, which can then lead to that, you know, low desire, low arousal, as well as painful sex, because you're losing the testosterone that's needed at the vulvar vestibule. So you got these symptoms known as the genital urinary syndrome and menopause, we're not calling it vaginal atrophy anymore. And what we have is all of these symptoms and a constellation of symptoms. And the other thing we have is recurrent urinary tract infections. Yes, that's right. You heard me right. People get recurrent utis from that lack of estrogen, okay? 10% of women over the age of 65 and a third of women over the age of 85 have at least one UTI a year, okay? And there are 7 million UTI hospitalizations annually.

Dr. Sameena Rahman [: 00:10:29

The UTI valuation and treatment burden is up to $2 billion a year. And they're harder to diagnose in older women because when you get a UTI, you have the possibility of getting urocepsis. That's when the bacteria from the urethra or the urinary tract gets into your blood. You can get kidney infections, you can get bladder infections, you can get confused and delirious, and you can get septic. So about a quarter of all hospitalizations in the geriatric community are related to urocepsis in the ICU, and about 6% of those patients die. So I do not say this lightly when I say the treatment for genitourinary syndrome of menopause being some form of vaginal estrogen or vaginal dheA, which I'll talk about in more detail with the. What the options are available is life savings. Okay? Is life saving when you are, you know, in that age range and you're getting UTi and then it develops into euro sepsis, and then you become septic in the ICU.

Dr. Sameena Rahman [: 00:11:32

That means the bacteria is in your blood and you're in the ICU and you're delirious and you might be intubated and whatever. I've seen it myself. I've seen it with family members who've stopped using vaginal estrogen, and all of a sudden they became septic. In fact, true story, when this happened to somebody that I know and love, they ended up in the ICU. I was in the ICU asking for this person to have their estrogen ring placed while they were getting better. And the ICU residents were really like, why? Why would I do that? Why is that important right now? What's the deal with the vaginal dryness? And then I had to teach them that recurrent utis are reduced dramatically with the use of vaginal estrogen. Okay. And then vaginal estrogen, therefore, can reduce utis and save lives.

Dr. Sameena Rahman [: 00:12:23

So I did convince them at that juncture to do that again. Vaginal estrogen is the prime treatment for genital urinary syndrome or menopause. So I was saying earlier when I was talking about the vulvar vestibule and causing pain, when you have pain at the vulvar vestibule area, you know, it's usually insertional pain. But over time, what happens is when you're in pain, what do you do? You clench. When you're anxious, what do you do? You clench. This persistent clenching leads to pelvic floor hypertonicity and dysfunction. And when you have pelvic floor dysfunction, essentially you then can have this hypertonic floor that causes more pain with sex and more burning at the vestibule. Right.

Dr. Sameena Rahman [: 00:13:06

We talked about, one of the causes of vestibulodynia is hypertonic pelvic floor. So now you're exacerbating that pain, and then you may actually develop like a form, secondary vaginismus. Cause now you're involuntarily contracting all the time because you think this penetration is going to hurt, whether or not it's an exam in the office, whether or not it's with their toy, whether or not it's what significant other. It's going to hurt. I'm going to. And you automatically start involuntarily contracting. And so then you actually, every one of my patients with general urinary syndrome, menopause, usually have to get pelvic floor physical therapy, and many of them are using dilators because of that involuntary contraction of the pelvic floor, that vaginismus that develops. We have to use dilators to desensitize the muscles.

Dr. Sameena Rahman [: 00:13:52

And then we do pelvic floor therapy, sometimes botox, to help reduce that hypertonicity. And as we treat it with vaginal estrogen or DHEA, the muscles get better, the vaginal skin gets better, and we have an improvement over time. So remember, that lack of estrogen causes a change in the ph of the vagina. Your vagina becomes basic. It goes from acidic to basic. And when you have more of a basic vagina, the ph is more basic, you end up having more of the bad bacteria that start developing in the vagina, the ones that can cause BV or yeast can overgrow. And so with that, you can get these infections, and then that same bacteria can jump on into the urethra, because now the urethra is so prominent and the vagina has shrunk and it's lacking elasticity and it's smaller, and you're having what Doctor Lawrence Stryker has always referred to as sandpaper sex. All of a sudden, all of these things in combination then cause significant more discomfort and pain.

Dr. Sameena Rahman [: 00:14:53

And, you know, then the UtIs come. So this is what I. What is referred to as the genitourinary syndrome and menopause. I think anyone of any age, you know, that is postmenopausal, I'll start them on it. In fact, when I see a perimenopausal or midlife patient and she talks about her mom with me, I always ask, is your mom on vaginal estrogen? And if she's not, you know, get her on it, because that is one thing we can do to help prevent urinary frequency, urgency and recurrent utis. So treatment wise, what do we do with treatment? We do a local vaginal estrogen. Right. And so what are the different forms of estrogen? There is estrogen cream in the form of what's known as estrace or premarin.

Dr. Sameena Rahman [: 00:15:39

I do not work for any of these pharmaceutical companies. So I'm just telling you the things that I tell my patients for FDA approved options that are available. That means they've been studied and they're heavily regulated by the government. So what I tend to do is tell my patients about estrogen cream, which is estrace or premarin or just estradiol cream. And they use about, you know, a gram a night for two weeks and then twice weekly till you die. So those are the things that we could start with. And the estrace is kind of nice for some patients because they can apply it to the vulvar vestibule. Other patients do not like the messiness of cream.

Dr. Sameena Rahman [: 00:16:17

They are not happy doing that. So we offer them like, an estrogen suppository, like invexi, which is an estradiol suppository, has like a nice moisturizing cover with coconut oil, again, every night for two weeks, and then twice weekly till the end. There is an estradiol pill that you put in the vagina known as uv or vagifim. It comes in a pre loaded applicator. So you're getting all these applicators that end up on in the trash. So just contributing to our issue with the environment. But it is. Some people prefer that because it's preloaded.

Dr. Sameena Rahman [: 00:16:56

It's a small little tablet. You just put it in again every night for two weeks as you start it, and then twice weekly till the end. There is also an estrogen ring. That is a local estrogen ring called estring. E S t r I n g. You put it in, you leave it in for three months. I like it a lot for my elderly patients who don't, you know, want to change it out themselves. And so they actually come see me every three months if they can get their insurance to pay for it, which is sometimes a challenge.

Dr. Sameena Rahman [: 00:17:26

And so the estrogen ring, you leave it in for three months. Do not confuse that with fem ring. Fem ring is a systemic estrogen. You do get a two for one. You get that topical local estrogen, and you do get systemic estrogen, which, you know, you might need progesterone then in the form of a pill or an IUD or a synthetic form if you have a uterus. But that is the estrogen ring. And then we have. My favorite, actually, is vaginal dhea, which is known as intrarosa.

Dr. Sameena Rahman [: 00:17:55

I like that one the best because it's dhea. You put it in the vagina every night. Basically, it converts into estrogen and testosterone. Remember, we have receptors for both. And there have been some studies that showed that have shown that, you know, Doctor Goldstein in San Diego, they did a study looking at vestibulodynia when it comes to using intrarosa, this prosterone, or vaginal dhea. You put it in the vagina over about a six month period of time, it starts leaking. You know, it'll leak into the vulvar vestibule, and you get a little improvement of that in the process. Because sometimes that vestibular pain is the worst when it comes to general urinary syndrome or menopause.

Dr. Sameena Rahman [: 00:18:32

So then you do get that treatment as well, which is very helpful. And so that is the vulmar vestibule with DHEA that I. That's why I like it, especially for my patients who are having significant sexual pain. And then there is ospimafeme, or osphena, which is an oral selective estrogen receptor modulator, a cirm. And so it is for the treatment of genital urinary syndrome, menopause. It's really good for people that just don't like doing anything down there. I have patients that are like, I'm not touching down there. I'm not doing down there.

Dr. Sameena Rahman [: 00:19:02

I'm not doing it. So they'll take an oral pill every day, which will improve their symptoms. And those are the ones that I use that are FDA approved. Every once in a while, I have someone with a really, really inflamed vestibule. Think, man, you know, to get to wait that three to six months for the DHEA to work, why don't we go ahead and start treating that vestibule separately? And just like with hormonally mediated vestibulodynia, which I've talked about before, where the vestibule is in pain because of lack of hormones, we will do an estrogen, testosterone, from a pharmacy that we can trust in a gel form, in a methocellulose base. And patients will use that and they'll get great relief. And then as their DHEA will start working, then over time, they won't necessarily need that anymore. Oftentimes I get asked, and, you know, I did actually, years ago when the Mona Lisa first came out.

Dr. Sameena Rahman [: 00:19:56

And at the time, you know, it was not well accepted that breast cancer and other patients can utilize vaginal estrogen, which they can. The one key thing to remember about vaginal estrogen, by the way, is that there is no systemic absorption. There's no rise in your blood levels of estrogen. So it is completely safe from the majority of women. So we have really no excuses. Even the oncology community is now on board with giving it to breast cancer survivors and other survivors. So what I was saying is there is a carbon dioxide based laser called the CO2 laser, which is known as the Mona Lisa touch, that has been studied to be effective, not more effective than vaginal estrogen, but some people prefer to have it done because they don't want to keep up with the uptake, and they don't want to use a vaginal estrogen as consistently. So it is a CO2 layer, just like CO2, how it works on your face.

Dr. Sameena Rahman [: 00:20:52

It increase fibroblasts, it increase blood flow, and it increase glycogen storage, which will then facilitate more lactobacillus to develop the vagina and improve the ph of the vagina. And so some studies have demonstrated, you know, pretty good effectiveness with a CO2 fractionated laser, such as the Mona Lisa touch. Those are some of the options for treatment when it comes to actually treating the tissue. Remember, vaginal moisturizers and lubricants are great, and I will talk about them separately, but they will not change the tissue, right. You're just treating the symptoms. You're not trying to get a more youthful vagina. I hate the term vaginal rejuvenation. I do not use it.

Dr. Sameena Rahman [: 00:21:36

But if you're thinking about rejuvenating your vagina, the best form of vaginal rejuvenation, the best form of female viagra, is really in the form of vaginal estrogen or vaginal dHea. So I think that is really important to remember. But I want to give another word of caution regarding all of this stuff and how most people think it's just a peri or postmenopausal issue. It is not. It actually should be referred to as the genitourinary syndrome of hormone deficiency because there are multiple times in a woman's life where she will be vulnerable to hormone changes, fluctuations, and deficiencies. And so it may be that you enter perimenopause and menopause naturally, and that is the cause of your genital urinary syndrome or menopause. That is the cause of your vaginal dryness, your sexual pain, your frequency, urgency, and utis. But other stages of hormone deficiency exist, such as lactation after women have babies and they're breastfeeding, they are in an estrogen deprived state.

Dr. Sameena Rahman [: 00:22:47

So guess what happens. Guess why postpartum and four fourth trimester women have so much sexual dysfunction. It's not just because you can't sleep at night because the baby's up. It's not just because your hormones have diminished and now you're crying and maybe you have, unfortunately, postpartum blues or depression, which is pretty rampant. It's not just because your vagina tore from top to bottom and you had a horrible tear and you're healing, and now you know you can't have sex because it hurts. I will say every patient in the fourth trimester in the postpartum period should be having pelvic floor therapy, just as my patients who have genital urinary syndrome or menopause have pelvic floor therapy as one of their treatment options. But all of these things happen. The lack of sleep happens, the lack of desire happens.

Dr. Sameena Rahman [: 00:23:37

You know, you don't feel like yourself. You feel like a foreigner in your body postpartum until probably at least a year after you deliver. And so all of this is very bothersome to a lot of patients. But you can't deny the hormone deficiency related to lactation in that postpartum period. And it creates a genital urinary syndrome of hormone deficiency or lactation. And again, it's just not about vaginal dryness. So that happens to women in the postpartum. What do you think happens to patients who have gotten cancer treatment whose hormones have been forced to decline, patients who have gone through infertility treatment, and they have to take, like, lupron and put themselves in this, like, temporary state of menopause to downregulate only so they could upregulate their hormones later.

Dr. Sameena Rahman [: 00:24:26

What about patients who have had their ovaries removed and abruptly entered a surgical menopause that is horrendous? Surgical menopause is horrendous because you're losing that testosterone immediately. You're losing that estrogen immediately. And so the vagina takes a hit for that. And these cancer therapies are sometimes anti hormonal. The aromatase inhibitors, the tamoxifens, the selective estrogen receptor modulators, all of these are very important for the treatment, but really put a number on your vulva and vagina. All of these things put a hit to your vagina and your vulva and your vestibule and your clitoris. And they create a lot of havoc for patients. That's not just vaginal dryness.

Dr. Sameena Rahman [: 00:25:12

That includes urinary symptoms, and that includes pain and discomfort. I would rebrand it and call it the genital urinary syndrome of hormone deficiency if I could. And that's what I usually refer to it as with my patients here. We have a syndrome which is a constellation of symptoms that are due to something, and it's due to hormone deficiency. And as my menopausal member and friend Rossio Selas Whalen says, as an endocrinologist, she treats every hormone deficiency, whether or not it's insulin, whether or not it's thyroid, or whether or not it's anything else. And she just said, why is it that we don't treat the hormone deficiencies around menopause and perimenopause the same way? We don't. People are very hesitant to do it. We know that there's a lot to unpack their misogyny and patriarchy and all the things, but this is something very simple.

Dr. Sameena Rahman [: 00:26:07

I think if you're a clinician listening to it, there are estrogen based products you can be utilizing to help your patients and to prevent disease in them. If you are a patient, you can understand what's happening to your body, the sexual pain, the urinary frequency, urgency, recurrent utis, the pelvic floor dysfunction, the overall pain in the vulvar vaginal area and the dryness, maybe recurrent BV infections, if you're sexually active or trying to have sex, these things are all, you know, a constellation of symptoms related to, you know, this change that's happening with your hormones. So we should treat it, and we shouldn't be afraid to treat it. Like I said, there's no systemic absorption when it comes to local vaginal products, and so we shouldn't be afraid to utilize it. So that's it, guys. That's my little soapbox about genital urinary syndrome and menopause, general urinary syndrome of lactation, the genital urinary syndrome of hormone deficiency. Again, it's not just about vaginal dryness. It's about a life saving measure.

Dr. Sameena Rahman [: 00:27:09

I always put this slide up in my. In my every talk that I give about GSM, and I give many talks about it, and my slide is how to save a life. And I talk about vaginal estrogen because I've seen it myself, saving some of my elderly patients from getting recurrent utis that then lead to uricepsis that then can lead to death. So that's my soapbox for you for the day. I hope you guys gained a little bit of perspective about what happens to the vulva and the vagina. Please, clinicians, don't call it atrophy. Nobody wants to hear that they're wasting away down there, okay? Women already feel bad enough about themselves. Half the time that this is happening.

Dr. Sameena Rahman [: 00:27:51

They really don't want to hear that they're atrophic on top of that. All right, so that's it. Tune into my next week when I have a guest. You know, I'm here to educate so you could advocate for yourself and be your best advocates. Please join me again next week for another episode of Gyno Girl presents, sex, drugs, and hormones. I'm doctor Samina Rahmandha, board certified gynecologist in downtown Chicago. Please join me. Would love to have you back.

Dr. Sameena Rahman [: 00:28:15

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Dr. Sameena Rahman [: 00:28:26

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Dr. Sameena Rahman [: 00:28:28

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Dr. Sameena Rahman [: 00:28:30

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Dr. Sameena Rahman [: 00:28:34

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Dr. Sameena Rahman [: 00:28:41

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Dr. Sameena Rahman [: 00:29:01

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Dr. Sameena Rahman [: 00:29:03

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