During menopause, the female pelvic organs undergo a variety of hormonal and physiological changes. Most often we think of the typical menopause symptoms as hot flashes, mood swings and sleeplessness, but around 60% of women will notice changes to their bladder and vagina.
GSM refers to a group of changes within these areas, including bladder irritation, vaginal dryness and painful sex. This is due to a drop in oestrogen supply to the pelvic area, which causes bladder and vaginal muscle atrophy as well as tissue fragility.
Bladder Changes
Less muscle bulk around the bladder means it is harder to contract the urethral sphincters with enough strength to remain continent. The bladder itself also becomes less elastic, which means women can also notice more urgency. Overall, this leads to an increase in both stress and urge urinary incontinence in post-menopausal women.
Vaginal Changes
As the vaginal tissue atrophies and the vulval skin thins, women may notice more sensitivity or even pain around the area. Oestrogen is also important for your body’s natural lubrication, so a drop in oestrogen supply means the vagina can become drier and more prone to chafing. This may result in discomfort or pain with penetrative sex.
Vaginal muscle atrophy also may lead to changes in your arousal and ability to orgasm, as you require good muscle tone to aid in stimulation of clitoral and vaginal nerve receptors.
Treating GSM
Medical
There is a lot that can be done to treat GSM – and speaking to your GP can be a great first step. Confirming menopausal status is important so that we are ruling out other causes for your symptoms. Once this has happened, your GP can help you find the right management.
Hormone Replacement Therapy (HRT) is the most common form of medical management, prescribed as either a tablet, patch or cream. HRT can assist with management of general menopause symptoms by:
● Reducing hot flashes
● Improving sleep
● Preventing of GSM atrophy
● Preserving good cholesterol
● Preventing bone loss
However, HRT does increase your risk of uterine hyperplasia and cancer, and increases your relative risk of breast cancer, ovarian cancer, thromboembolism, stroke, and coronary heart disease1. HRT can’t be prescribed if you have or have had breast cancer, endometrial cancer, deep vein thrombosis (DVT)/pulmonary embolism (PE), liver disease, unexplained vaginal bleeding and coronary heart disease.
Low-dose topical oestrogen cream is a safe alternative form of hormone treatment for GSM. It is applied topically to the vulval skin and/or internally, and has been shown to:
-
Increase local blood flow
-
Reverse vaginal muscle atrophy
-
Bulk the bladder, vaginal and vulval tissue
-
Increased natural lubrication
-
Improve bladder urgency/irritation symptoms
Because of its low dose, topical oestrogen is absorbed locally and has very minimal systemic uptake, meaning that there is less change of side effects. It also means that, while there is still a mild increased risk of DVT, it does not carry any of the other risks of HRT1.
Pelvic Physiotherapy
Studies have shown that completing daily pelvic floor exercises can help reduce GSM. A study by Mercier et. al. (2020) found that after a 12-week individualised pelvic floor training program, women had better blood flow to the pelvic tissue, tissue elasticity and muscle relaxation with an increased amount of muscle bulk and strength/tone.
Put simply, pelvic floor exercises can help to reduce symptoms that cause painful sex and can improve your sensation, stimulation, and orgasm during sex! It can also reduce bladder irritation to reduce discomfort, urgency, and bladder leakage.
It is important that your pelvic floor exercises be specific, challenging (yet doable!) and progressed. Seeing a Pelvic Physio is the best way to ensure you are doing the right kind of exercise and getting the most benefit out of a pelvic floor strengthening program.
Menopause is an important milestone for every woman, but it does not have to be a negative experience! Growing old is a privilege – you get to apply the knowledge you gained from youthful misadventures to enjoy your life with family and friends. That’s not to say that some aspects don’t suck, but not everything has to. If you are experiencing bother with any aspects of menopause, please know there is help available and the team at FPC are ready to help you in any way we can.
Liz – FPC Physio
References
Farrell Am E. (2017). Genitourinary syndrome of menopause. Australian family physician, 46(7), 481–484.
Kim, H. K., Kang, S. Y., Chung, Y. J., Kim, J. H., & Kim, M. R. (2015). The Recent Review of the Genitourinary Syndrome of Menopause. Journal of menopausal medicine, 21(2), 65–71. https://doi.org/10.6118/jmm.2015.21.2.65
Mercier, J., Morin, M., Tang, A., Reichetzer, B., Lemieux, M. C., Samir, K., Zaki, D., Gougeon, F., & Dumoulin, C. (2020). Pelvic floor muscle training: mechanisms of action for the improvement of genitourinary syndrome of menopause. Climacteric : the journal of the International Menopause Society, 23(5), 468–473. https://doi.org/10.1080/13697137.2020.1724942