Systematic Review Examines Treatments for Genitourinary Syndrome of Menopause and Highlights Need for Long-Term Safety Data

Core Concepts

Commonly used therapies, including vaginal estrogen, vaginal dehydroepiandrosterone (DHEA), and oral ospemifene, are likely effective for relieving symptoms of genitourinary syndrome of menopause, particularly vaginal dryness and painful intercourse, but long-term safety data is lacking.

Abstract

This article summarizes the findings of a systematic review published in Annals of Internal Medicine that examined the effectiveness and safety of various treatments for genitourinary syndrome of menopause (GSM), a condition that can lead to vaginal dryness, painful intercourse, and recurrent urinary tract infections (UTIs) in postmenopausal women.
The review included 46 randomized controlled trials evaluating vaginal estrogen, other hormones (such as vaginal oxytocin or testosterone), vaginal moisturizers, and combination treatments. The key findings are:

Hormonal treatments, including vaginal estrogen, vaginal DHEA, and oral ospemifene, were associated with reduced pain during intercourse and decreased vaginal dryness.
Vaginal moisturizers were linked to reduced vaginal dryness.
Vaginal estrogen did not reduce pain during intercourse as consistently as DHEA or oral ospemifene, possibly due to differences in study design and sample size.
Few studies examined the impact of these treatments on other GSM symptoms, such as vaginal itchiness or urination difficulties.
The review found no evidence for the benefit of oral DHEA, raloxifene, bazedoxifene, vaginal oxytocin, or vaginal testosterone for GSM treatment.
The authors noted that most studies were short-term (12 weeks or less), so the long-term safety of these treatments, particularly the risk of uterine cancer with extended use, remains unclear.
The patient populations in the included studies were not diverse, and the exclusion criteria often excluded women with cardiovascular risk factors or a history of cancer, leaving a gap in understanding the safety of these treatments in higher-risk populations.
The article also highlights the connection between GSM and recurrent UTIs, which can be a serious complication of the condition. Experts emphasize that hormonal treatments may be necessary for decades to reduce the risk of UTIs in some women, further underscoring the need for long-term safety data.

Stats

"The main finding is that commonly used therapies are likely to be effective for the common symptoms people have for GSM, particularly vaginal dryness and painful intercourse."
"Most of the trials included in the analysis studied treatment periods of 12 weeks or less, so the safety of long-term use is unclear."
"One question that hasn't been answered yet in clinical trials is whether there could be a risk of uterine cancer with extended use of any of these treatments."
"The maximum follow-up was 1 year, and study participants had a low risk for cancer to begin with."

Quotes

"Women might not bring it up or think there's a treatment that can work."
"Genitourinary syndrome of menopause is not just a little bit of vaginal dryness that can be cured with moisturizers and lubricants, but the syndrome can lead to recurrent urinary tract infections, which are extremely harmful and dangerous to our patients and cost the healthcare system a lot of money."
"Recurrent urinary tract infections occur because of GSM, because of the lack of hormones to the tissue, sometimes when a woman is in her 60s or 70s and thinks menopause is long over."

Key Insights Distilled From

Review Provides Look at Treatments for Menopause Symptoms

by Marcus A. Ba... at www.medscape.com 09-11-2024

https://www.medscape.com/viewarticle/remedies-menopause-symptoms-show-short-term-benefit-need-2024a1000gg9

Deeper Inquiries

What are the potential long-term risks of using hormonal treatments, such as vaginal estrogen or ospemifene, to manage genitourinary syndrome of menopause, and how can these risks be mitigated?

The potential long-term risks associated with hormonal treatments for genitourinary syndrome of menopause (GSM), particularly vaginal estrogen and ospemifene, primarily revolve around the possibility of stimulating the growth of the uterine lining, which could increase the risk of uterine cancer. Although current studies have not shown a significant increase in uterine cancer risk with short-term use, the lack of long-term data raises concerns, especially for women who may require these treatments indefinitely. Additionally, there are uncertainties regarding the safety of these treatments in women with pre-existing conditions such as cardiovascular issues or a history of cancer, as these populations were often excluded from clinical trials.
To mitigate these risks, clinicians should adopt a cautious approach by closely monitoring women who are on long-term hormonal therapy for GSM. This includes regular gynecological evaluations and discussions about the benefits and risks of continued treatment. Furthermore, healthcare providers should consider individual patient risk factors, such as family history and personal medical history, when prescribing these treatments. Engaging in shared decision-making with patients can also empower them to make informed choices about their treatment options, balancing the relief of GSM symptoms with potential long-term risks.

How can the diversity and representation of participants in clinical trials for GSM treatments be improved to better understand the safety and efficacy of these treatments in a wider range of patient populations?

Improving diversity and representation in clinical trials for GSM treatments is crucial for understanding the safety and efficacy of these therapies across different demographics. One approach is to implement inclusive recruitment strategies that actively seek participants from various racial, ethnic, and socioeconomic backgrounds. This can be achieved by collaborating with community organizations, healthcare providers, and advocacy groups that serve underrepresented populations.
Additionally, trial designs should consider the inclusion of women with comorbidities, such as cardiovascular disease or a history of cancer, to better reflect the general population of postmenopausal women. Researchers can also utilize stratified sampling methods to ensure that diverse groups are adequately represented in the study population. Furthermore, providing culturally sensitive education about the trials and their importance can help to alleviate concerns and encourage participation among diverse groups. By prioritizing diversity in clinical trials, researchers can generate more comprehensive data that informs treatment guidelines and improves outcomes for all women experiencing GSM.

Given the connection between GSM and recurrent UTIs, what other non-hormonal interventions or strategies could be explored to help manage the urinary symptoms associated with GSM?

In addition to hormonal treatments, several non-hormonal interventions and strategies can be explored to manage urinary symptoms associated with genitourinary syndrome of menopause (GSM) and reduce the risk of recurrent urinary tract infections (UTIs). These include:

Lifestyle Modifications: Encouraging women to adopt healthy lifestyle changes, such as maintaining proper hydration, practicing good hygiene, and avoiding irritants like caffeine and alcohol, can help reduce urinary symptoms and the risk of UTIs.

Pelvic Floor Exercises: Kegel exercises can strengthen pelvic floor muscles, improving bladder control and reducing urinary incontinence, which may be exacerbated by GSM.

Dietary Adjustments: Incorporating a diet rich in antioxidants and probiotics may support urinary tract health. Foods such as cranberries, which are known for their potential to prevent UTIs, can be beneficial.

Topical Moisturizers and Lubricants: While not hormonal, vaginal moisturizers and lubricants can alleviate dryness and discomfort during intercourse, indirectly supporting urinary health by reducing irritation.

Alternative Therapies: Some women may benefit from acupuncture or herbal remedies, although these should be approached with caution and discussed with a healthcare provider to ensure safety and efficacy.

Education and Awareness: Increasing awareness about the connection between GSM and urinary symptoms can empower women to seek timely treatment and adopt preventive measures.

By exploring these non-hormonal strategies, healthcare providers can offer a more comprehensive approach to managing urinary symptoms associated with GSM, ultimately improving the quality of life for affected women.