Which treatments are effective for treating genitourinary syndrome of menopause?

Postmenopausal vulvovaginal, urinary and sexual symptoms (called genitourinary syndrome of menopause [GSM]) affect approximately 50%-to-70% of postmenopausal women, but only about half of symptomatic women discuss their symptoms with a clinician. Bothersome GSM symptoms, such as vulvovaginal dryness or dyspareunia, can affect quality of life and may prompt women to seek treatment with prescription, over-the-counter, and/or complementary and alternative medicines.1 Unlike vasomotor menopausal symptoms, which typically improve over time without treatment, GSM symptoms typically do not improve without treatment and worsen over time.2 Two systematic reviews recently evaluated the available evidence on GSM treatments.1,3Hormonal treatments and vaginal moisturizers The systematic review of hormonal treatments and vaginal moisturizers for GSM evaluated 46 randomized controlled trials that examined vaginal estrogen, nonestrogen hormones (vaginal dehydroepiandrosterone [DHEA]; systemic DHEA; vaginal testosterone; vaginal oxytocin; and the oral selective estrogen receptor modulators ospemifene, raloxifene and bazedoxifene), vaginal moisturizers or multiple interventions. The review concluded that there is a low certainty of evidence that vaginal estrogen may improve vaginal dryness or dyspareunia compared to placebo or no treatment. Compared with placebo, all with a low certainty of evidence, vaginal DHEA may improve vulvovaginal dryness and dyspareunia; ospemifene may improve dryness and dyspareunia; and vaginal moisturizers may improve dryness.1 Either no benefit or uncertain benefit, with very low certainty of evidence, was noted for vaginal testosterone, systemic DHEA, vaginal oxytocin, raloxifene or bazedoxifene.1 No serious adverse effects were identified with any of the treatments, but the short duration of the studies limited evaluation of long-term harms, and none of the studies were sufficiently large to assess serious, but infrequently occurring harms.2Complementary and alternative therapiesThe review of complementary and alternative therapies for GSM identified 57 randomized controlled trials that examined 39 distinct complementary and alternative therapies for GSM. Most of these trials investigated over-the-counter products, such as herbal or botanical supplements (e.g., phytoestrogens), probiotics or vitamins, whereas others reported on mind–body practices or educational interventions.3The authors were unable to determine whether any of the reported studies identified effective interventions, the magnitude of any effect, or the certainty of the findings. The authors concluded that given study size and duration, as well as the variability in patient symptoms, interventions, comparisons and outcomes, plus challenges in ensuring specific herbal product quality, it is unlikely that high-certainty evidence exists regarding complementary and alternative therapies to enable making recommendations that can be applied to patient care.3CommentaryAn accompanying editorial points out that these two reviews document how stunningly little we know about GSM, a condition that affects most postmenopausal women. Much work needs to be done to enable definitive conclusions to inform patient care.2 The two reports also stimulate several questions. For example, what GSM definition should clinical trials use? Only half of the included trials evaluating hormonal treatments and vaginal moisturizers required participants to have moderate to severe symptoms of GSM, and there was highly variable reporting of objective verification of vaginal atrophy with pH or vaginal cytology.2 Also troubling is that participants in most studies were generally healthy; women with risk factors for venous thromboembolism, cardiovascular disease and cancer were mostly excluded. As 80% of women in the United States aged 55 years or older have at least one chronic condition, and 50% have two or more chronic conditions, currently available trials provide information on a population that largely does not represent the women with GSM that clinicians see. Furthermore, the studies were short in duration, and adverse event reporting was limited in duration, leaving lingering questions about long-term safety.2 Also concerning is the fact that there have been no head-to-head comparative efficacy trials to determine whether one treatment may be more effective than another, or whether one treatment is more effective in certain populations. Such data could help with individualization of therapy.2 Overall, the editorial concludes that trials of GSM treatments need to include populations with chronic medical conditions and a history of cancer, report on longer-term serious adverse events, and employ head-to-head comparisons of different therapies in order to improve the care of all women with GSM.2References:Ullman KE, Diem S, Forte ML, et al. Complementary and alternative therapies for genitourinary syndrome of menopause. An evidence map. Ann Intern Med 2024; published online September 10, 2024. (accessed September 12, 2024).Faubion SS. Why do we know so little about genitourinary syndrome of menopause (editorial)? Ann Intern Med 2024; published online September 10, 2024. doi:10.7326/ANNALS-24-01693. Danan ER, Sowerby C, Ullman KE, et al. Hormonal treatments and vaginal moisturizers for genitourinary syndrome of menopause. A systematic review. Ann Intern Med 2024; published online September 10, 2024. (accessed September 12, 2024).

Which treatments are effective for treating genitourinary syndrome of menopause?

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