Genitourinary Syndrome of Menopause (GSM)

Tara Sullivan instructs her course Sexual Medicine in Pelvic Rehab on October 19-20. Her course provides a thorough introduction to pelvic floor sexual function, dysfunction, and treatment interventions of all sexual orientations, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, and multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Menopause is a natural phase in a woman's life, signaling the end of her reproductive years. While many are familiar with common symptoms such as hot flashes, night sweats, brain fog, and mood changes, there is another less-discussed condition that affects many women: Genitourinary Syndrome of Menopause (GSM). GSM encompasses a range of symptoms affecting the genital and urinary systems, profoundly impacting a woman’s quality of life. Understanding GSM is crucial for women entering menopause and healthcare providers, especially pelvic floor specialists.

What is Genitourinary Syndrome of Menopause (GSM)?
Genitourinary Syndrome of Menopause (GSM) refers to a collection of signs and symptoms associated with the changes in estrogen levels that occur during menopause. These hormonal changes affect the tissues of the vulva, vagina, urethra, and bladder, leading to a variety of symptoms that can be both uncomfortable and disruptive.

GSM was formerly referred to as vulvovaginal atrophy, but this term was considered limited because it didn’t encompass the full scope of symptoms women experience, particularly those related to the urinary system. The term "GSM" is now preferred as it better reflects the diverse nature of the condition.

Common Symptoms of GSM

1. Vaginal Dryness and Irritation: One of the most frequently reported symptoms of GSM is vaginal dryness. This occurs because estrogen levels drop, causing the vaginal tissue to become thinner, less elastic, and less lubricated. This dryness can lead to itching, burning, and irritation. 

2. Painful Intercourse (Dyspareunia): Vaginal dryness can make sexual activity uncomfortable or even painful. Women may also experience tearing or bleeding during intercourse due to the thinning of the tissue specifically around the vaginal opening.

3. Urinary Symptoms: GSM can cause a range of urinary issues, including increased frequency of urination, urgency, urinary tract infections (UTIs), and incontinence. Estrogen plays a role in maintaining the health of the urinary tract, so its decline can lead to irritation and increased susceptibility to infections.

4. Pelvic Floor Dysfunction: abnormal tone or weakening of pelvic floor muscles exacerbates urinary symptoms and pain, and contributes to conditions like pelvic organ prolapse.

5. Changes in Vaginal pH: Estrogen plays a critical role in maintaining a healthy vaginal environment. With lower estrogen levels, the vaginal pH becomes less acidic, making the area more susceptible to infections such as bacterial vaginosis and yeast infections.

Causes and Risk Factors
GSM is directly related to the reduction in estrogen production during menopause. Estrogen is responsible for maintaining the thickness, elasticity, and moisture of the vaginal and urinary tissues. As levels drop, these tissues undergo changes that lead to GSM.

While GSM is most commonly associated with natural menopause, it can also occur in women who experience early menopause due to surgery or cancer treatments like chemotherapy and radiation. Women who smoke or have never given birth vaginally are also at a higher risk for developing GSM.

Treatment Options:
The good news is that GSM is treatable. While you might think, systemic hormone replacement therapy (HRT) is enough to resolve GSM, that’s not typically the case. More often, even if one is on already on estrogen HRT, or for those who cannot or will not take systemic estrogen, they can still apply a low dose estradiol cream specifically to the vestibule, urethra, and vaginal opening to target the tissue most affected by GSM. Local topical estradiol cream is considered a safe option. In a recent article, “In a large, claims-based analysis, we did not find an increased risk of breast cancer recurrence within 5 years in women with a personal history of breast cancer who were using vaginal estrogen for genitourinary syndrome of menopause”

However, if one is still opposed to using estradiol, other non-hormonal options are available to treat GSM symptoms:

1. Vaginal Moisturizers and Lubricants: For women experiencing mild symptoms, over-the-counter vaginal moisturizers and lubricants can provide relief from dryness and discomfort. These products can be used regularly to help maintain vaginal moisture and make intercourse more comfortable.

2. Pelvic Floor Physical Therapy: Many women with GSM benefit from pelvic floor physical therapy, which can strengthen the muscles of the pelvic floor, improve bladder control, and enhance sexual function. Physical therapists specialized in pelvic health can provide individualized treatments to address specific concerns.

3. Laser Therapy: A newer, non-invasive option for GSM is laser therapy, such as fractional CO2 lasers. This therapy stimulates collagen production in the vaginal tissues, promoting healing and improving symptoms of dryness, pain, and laxity.

4. Lifestyle Modifications: Quitting smoking, maintaining a healthy weight, and staying sexually active can also help reduce symptoms of GSM. Regular sexual activity increases blood flow to the vaginal area, helping to maintain tissue health.

Our Role as Pelvic Floor Therapist:
Despite affecting up to half of postmenopausal women, GSM remains underdiagnosed and undertreated. Many women may feel uncomfortable discussing these symptoms with their healthcare providers, or they may assume that these changes are a natural part of aging that must be endured. That is where pelvic floor specialists have a unique opportunity to educate these women. We have the luxury of one-on-one time and we are one of the only specialists that fully assess the vulvar tissue, specifically the vestibule and urethral opening where GSM is most identifiable. Understanding the research on estradiol treatment as well as other non-hormonal options can greatly improve our patients' quality of life.

Join Tara Sullivan in her upcoming course to learn more about Sexual Medicine in Pelvic Rehab on October 19-20. Lecture topics include hymen myths, squirting, G-spot, prostate gland, sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm, and function and specific dysfunction treated by physical therapy in detail including vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post-prostatectomy; as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus. 

 Resource:

•  Agrawal P, Singh SM, Able C, Dumas K, Kohn J, Kohn TP, Clifton M. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023 Sep 1;142(3):660-668. doi: 10.1097/AOG.0000000000005294. Epub 2023 Aug 3. PMID: 37535961. https://pubmed.ncbi.nlm.nih.gov/37535961/

AUTHOR BIO:
Tara Sullivan, PT, DPT, PRPC, WCS, IF

Dr. Tara Sullivan, PT, PRPC, WCS, IF (she/her) started in the healthcare field as a massage therapist practicing for over ten years, including three years of teaching massage, anatomy, and physiology. During that time, she attended college at Oregon State University earning her Bachelor of Science degree in Exercise and Sport Science, and she continued to earn her Masters of Science in Human Movement and Doctorate in Physical Therapy from A.T. Still University. Dr. Tara has specialized in Pelvic Floor Dysfunction (PFD) treating bowel, bladder, sexual dysfunctions, and pelvic pain exclusively since 2012. She has earned her Pelvic Rehabilitation Practitioner Certification (PRPC) deeming her an expert in pelvic rehabilitation, treating men, women, and children. Dr. Sullivan is also a board-certified clinical specialist in women’s health (WCS) through the APTA and a Fellow of the International Society for the Study of Women's Sexual Health (IF).

Dr. Tara established the pelvic health program at HonorHealth in Scottsdale and expanded the practice to 12 locations across the valley. She continues treating patients with her hands-on individualized approach, taking the time to listen and educate them, empowering them to return to a healthy and improved quality of life. Dr. Tara has developed and taught several pelvic health courses and lectures at local universities in Arizona including Northern Arizona University, Franklin Pierce University, and Midwestern University. In 2019, she joined the faculty team at Herman and Wallace teaching continuing education courses for rehab therapists and other health care providers interested in the pelvic health specialty, including a course she authored-Sexual Medicine in Pelvic Rehab, and co-author of Pain Science for the Chronic Pelvic Pain Population. Dr. Tara is very passionate about creating awareness of Pelvic Floor Dysfunction and launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

In March 2024, Dr. Tara left HonorHealth and founded her company Mind to Body Healing (M2B) to continue spreading awareness on pelvic health, mentor other healthcare providers, and incorporate sexual counseling into her pelvic floor physical therapy practice. She has partnered with Co-Owner, Dr. Kylee Austin, PT.