Genitourinary Menopause Symptoms and Treatments

Lesson 2

Welcome to our second video in this series. If you haven't seen it, our first video really was an overview of menopause. What's happening to your body, why do you get the symptoms that you're experiencing, what those symptoms might be, and what are some of the hidden symptoms that you may not realize are associated with menopause? So if you haven't had a chance to watch that video, I would encourage you to do so.

In this second video, we're going to be looking at the symptoms of menopause in more detail, in particular the genitourinary symptoms of menopause. And I'm going to review with you some of the solutions that are available. And by the end of this video, I hope that you'll feel more informed about not only what's happening to your body, but what solutions are available for you out there.

What are the most common genitourinary symptoms of menopause?

As a gynecologist, the most common symptoms that my patients come to talk to me about related to their genitourinary health would be vaginal dryness, number one, the most common and how it's affecting their intimacy. Other symptoms that patients are experiencing that they may not realize are associated with this dramatic drop in estrogen related to menopause are things like vulvar itch that can keep them up at night. And so it's disturbing their sleep and affecting everything else that they're doing. Things like stress urinary incontinence, having to wear a pad to go to the gym when they never had to before or that sense of urge incontinence, that feeling that you've got to go and you've got to go right away.

Are menopause symptoms the same for everyone?

Every woman's experience through menopause is going to be individualized. Some women go through menopause and don't have any hot flashes, don't notice problems with vaginal dryness, for example, for years afterwards and other women the day after their last period, that is the first day of their first hot flash. And so everybody's different in their experience. Women who are quite thin and have a low body mass index are going to have usually more symptoms of menopause. And that's because fat cells produce a very weak estrogen called estrone. And, of course, women who have a higher body mass index are going to be producing more of that estrone, mitigating some of those symptoms related to estrogen loss.

What causes vaginal itching or burning?

The reason that women are experiencing vaginal itching or burning or vulvar burning or itching is related to the changes in the structure of the skin, the skin lining the vagina or the skin on the vulva. That normal architecture that supports healthy skin, collagen, elastin, those tissues are now becoming thinner. The collagen and elastin levels go down. The cells that produce normal vaginal lubrication are much fewer, and it's through the treatments that we're going to discuss later in this video that we can actually bring those cellular structures back, make for new collagen, make for new elastin, bring back those cells that create normal lubrication.

Why can sex be so painful after menopause?

Menopause can lead to painful intercourse, not necessarily immediately after you go through menopause, but usually within two to four years of experiencing menopause. Those low levels of estrogen are going to deplete the cellular structure that creates normal lubrication inside the vagina. That cellular structure is going to be lost, the walls of the vagina become very, very thin without that normal structure that supports the vagina. With a thinner vaginal wall without normal lubrication, that's going to cause pain and with pain that leads to decreased interest and can impact relationships. A lot of women don't realize that with that dramatic decrease in estrogen, not only does it affect their sexual health and their vulva and vaginal health, but it also affects the bladder. The bladder anatomically sits right in front of the vagina, just below your pubic bone. And so the lack of estrogen in that area, it affects the architecture that holds up the bladder and gives your bladder normal tone. That's why things like stress incontinence become much more common because the normal architecture supporting the bladder has changed over time. It doesn't change overnight. We can repair that structural change surgically, but we can also repair it just with simple things like medications and/or MonaLisa Touch.

What does vaginal atrophy or vaginal laxity mean?

When you're online and you're looking around and you're trying to find solutions to the symptoms that you're having, come across different terms such as vaginal atrophy, vaginal laxity. These are all terms that relate to what, medically, we now call the genitourinary symptoms of menopause. The term genitourinary symptoms of menopause, we believe is a better term to encompass not just what's happening around the vagina leading to abnormal lubrication for intercourse, but for everything that's happening in your pelvis. So those other symptoms like vulvar itch or stress incontinence or urge incontinence, that whole area of your pelvis, that genitourinary area of your pelvis is being affected. But you will see these other terms like vaginal atrophy and they essentially relate to one component of the genitourinary symptoms of menopause.

When should I talk to my doctor about menopause?

For women who are experiencing the perimenopause or pre-menopause time, it's really important to start the conversation with your doctor or nurse practitioner at that time, not only from an education point of view, but you can get a plan in place so that you feel ready to address the symptoms that you're experiencing as they're happening and not have to suffer through them for years before you start looking for solutions. For lots of women before they actually go through menopause, their periods will become irregular and/or heavy. By communicating with your family doctor and nurse practitioner or your gynecologist at that time, not only can you address those symptoms, but you can then become more educated and informed about, okay, what's coming next? How do we deal with that? How do we get ahead of those symptoms so that I don't have to suffer?

Do some menopause symptoms require surgery to treat?

For some women, their dominant symptom, whether it's before menopause or after menopause, is related to their bladder function, in particular leakage of urine with activity. Now before we talk about surgical options with those symptoms, there are other options such as changing their fluid intake and things like coffee and caffeines that act as diuretics and make you go to the bathroom are often where we can do things like physiotherapy and there are trained professionals in pelvic physiotherapy who can help retrain the muscles to support the bladder. But there are also some surgical options where the architecture of the bladder or the bladder neck, the urethra (the tube that you urinate through) can be changed or altered to allow for better bladder function.

What is hormone therapy and how does it work?

When you're learning about menopause, many times you'll hear about this concept of hormone replacement therapy. So the hormones that we're talking about that are getting replaced in that setting it's predominantly estrogen. And for women who have not had a hysterectomy and who have a uterus in place, we also need to give them progesterone as well because estrogen being exposed to the uterus without the other counter-affecting hormone called progesterone can lead to overstimulation of the lining of the uterus and, rarely, in time that can lead to changes in the cellular structure of the uterus and lead to things like endometrial cancer or cancer of the uterus. So to counteract that, when women are taking estrogen to treat their symptoms of menopause, we also need to be using this other hormone that's naturally produced by your body before menopause called progesterone. By giving women estrogen and progesterone, we're replacing what their body was producing normally, but at a fraction of the level before menopause, just enough of these hormones to make those symptoms go away.

Is hormone therapy effective for treating the genitourinary symptoms of menopause?

Estrogen is pretty good at treating the genitourinary symptoms of menopause. But the studies would tell us that about 40% of women who are getting relief of their hot flashes are still having issues with normal lubrication or other symptoms like a vaginal or vulvar itch, or bladder problems. There's lots of different ways to get hormones back into your body to aleviate, your symptoms of menopause. You can take tablets, you can use an estrogen gel or creamon your skin, you can use a patch, there's a ring that's can be inserted into the vagina. These are all different mechanisms to get these hormones back into your body. They're all effective ways of getting that back into your body. Reasons why you might choose one over the other: Some people find it difficult to remember to take a tablet every day.

An alternative like the patch, where you only have to change it once every couple of days might be more effective for you or the insertion of a vaginal ring where you have to change it even less often might be a better option for you. 

Are there any risks with hormone therapy?

Using any medication or going through any medical treatment of course, is associated with some risk. For the right candidate, hormone replacement therapy in the form of estrogen and progesterone is a very low risk option. Some of the risks that can be associated with these medications are a local reaction. For example, if you're using a patch, you're not reacting to the hormones in there, but you might react to the adhesive that keeps the patch on your arm. We are concerned about the use of estrogens in women who are smokers. We know that smoking brings an increased risk of cardiovascular disease and the combination of smoking and estrogens is not a great idea. We currently believe that using hormone replacement therapy for a relatively short period of time to get through the common symptoms like hot flashes, is a safe and effective treatment. The current recommendation is treatment for up to five years. After that time the ongoing use of hormone replacement therapy should be individualized. Looking at your risks for things like cardiovascular disease, your bone health, and the severity of your menopausal symptoms.

Is vaginal estrogen an effective treatment for the genitourinary symptoms of menopause?

Vaginally, we can treat the genitourinary symptoms of menopause using creams, ointments, vaginal suppositories that dissolve inside the vagina, or a vaginal ring. The concept is that we're introducing very low levels of estrogen to the genitourinary area to solve the common symptoms of dryness with intercourse, lack of lubrication, vulvar itch, bladder health, recurrent urinary tract infections. The upside to those medications is if you're only using that form of estrogen, that dose is so low that you don't also have to be taking progesterone. The downside is that because the dose is low, many women will not get full relief of their symptoms, specifically around lubrication. They may notice some improvements, but approximately 40% of women will still have ongoing issues with dryness. And we'll be looking for other solutions. Maybe that's using lubricants, or maybe it's considering a longer-lasting treatment like the MonaLisa Touch. For women who are considering the use of vaginal estrogen, one of the challenges is that if you're using creams or suppositories it can be messy. They do not have a long lasting effect, so you have to be applying these things on a very regular basis. Using the vaginal ring can be less messy and it can last longer, but women have to feel comfortable inserting the ring, removing the ring, and replacing it at the right time.

Are there any natural menopause treatments that are effective?

When women are looking for solutions to their genitourinary symptoms of menopause, they immediately go to the internet and start searching and on the internet you'll find all kinds of suggestions for the treatments of your genitourinary symptoms of menopause. Things like vitamins, creams, herbal remedies, etc. The reality is that when those remedies are tested in an appropriate fashion using scientific structure and appropriate evaluation techniques, there really are no good herbal remedies or other over the counter remedies that will effectively treat your genitourinary symptoms of menopause. There are things like lubricants that can help for dry vagina. Some women find that they are producing enough estrogen on their own and, with lubricants, that sex can be satisfactory and they no longer have troubles with dryness and pain. But for the most part, you're either looking at some version of estrogen or what we're going to be talking about in one of our future videos: The MonaLisa Touch.

Are there any non-hormonal alternative treatments for menopause symptoms?

There are some alternatives to hormone replacement therapy, but those alternatives are primarily focused on the primary symptom of menopause, being hot flashes. Those include things like serotonin reuptake inhibitors and other medications in different classes that look to treat the source of the hot flashes or the symptoms related to the hot flashes in a non hormonal fashion. Your healthcare provider would be familiar with those options and if you were considering using one of those other non-hormonal options to treat particularly hot flashes, then sit with your healthcare provider and go through the pros and cons of those options.

What are some other non-hormonal and non-surgical treatments for the genitourinary symptoms of menopause?

So there are some other non-surgical non-hormonal treatments that are now available for treatment of specifically the genitourinary symptoms of menopause. These use either radio frequency, heat generation or laser light therapy. So in general, these non-hormonal non-surgical treatments use either radio frequency, generation of heat or laser light therapy to stimulate your body's natural response to minor injuries, to bring in new blood flow, stimulate growth of new collagen and the structures that support the vagina and bladder as well as bring in those cells that create normal lubrication.

Are these new types of treatments safe and effective?

When we talk about some of these new treatments, whether they be radio-frequency based or whether they be laser light based, people are always curious about, well, when something's new, how well has it been evaluated? Does it really work? And to date, specifically looking at the MonaLisa Touch, there have been over 30 studies published that relate not only to evaluating what's happening right at the tissue level, when there have been biopsies of the vaginal tissue before and after treatment showing these dramatic changes within just a couple of treatments. But also functionally, so looking at symptoms like what's happened to lubrication, what's happening to vulvar itch, what's happening to burning, what's happening to that sense of pressure in your pelvis and, reliably, study after study is showing a really positive effect such that about 90% of women are getting the long lasting solution that they're looking for.

Why haven't I heard more about these treatments?

A lot of women will ask "if this is so new and exciting, why haven't I heard about this before?", and I think the reason is that that first of all, there are so many new advances in medicine, it's hard for any doctor to keep up with all the different changes, primarily when this treatment is not life saving, but it's life changing. So your healthcare provider may be focused on those life saving issues that they have to keep on top of whether it's impact on risk for stroke or heart disease. But just as importantly, we need to stay informed as healthcare providers about these life changing options. But many times it takes a little while for this new information to percolate, not just to the healthcare providers, but to the women themselves.

What's Next?

Thanks for watching this video, the second in our series. In the next video, I'm going to talk to you specifically about one of the treatments that's now available, non-hormonal non-surgical, called the MonaLisa Touch. It's been used to treat millions of women around the world and change their quality of life.