Beyond hot flashes

The menopause symptoms nobody talks about

By Kelly Tull

Women’s Health Nurse Practitioner & Sex Counselor, Venus Collective Women’s
Health and Intimacy

I’m sure you’ve heard of the classic menopause/midlife symptoms like hot flashes, night sweats, and mood swings. These symptoms are real and can be quite distressing for many women starting as early as their late 30s. However, about 75% of women suffer with a cluster of symptoms they often overlook: urinary and vaginal symptoms, known as genitourinary syndrome of menopause (or GSM). The most significant difference between hot flashes and GSM, is that hot flashes can improve over time whereas vaginal dryness and urinary symptoms can continue to worsen over time.

About genitourinary syndrome

So what is genitourinary syndrome of menopause? First, this is a term that was adopted quite recently, just in 2014. This collection of symptoms used to be referred to as vaginal atrophy, and even before that (my personal favorite) senile vagina!

This new terminology is important, because it encompasses more than just changes in the vagina, but all of the genital structures and urinary tract. Words matter, and I don’t know about you, but I would hate for a provider to tell me that my vagina was atrophic, let alone senile.

You may be wondering if you possibly have genitourinary syndrome of menopause. Well, here are the common symptoms that women can experience:

Vaginal symptoms:

Vaginal or vulvar dryness, burning, itching
Painful intercourse/penetration
Light bleeding after intercourse/penetration
Changes in vaginal discharge (color, odor)

Urinary symptoms:

Urinary urgency and frequency
Burning/discomfort with urination
Recurrent urinary tract infections
Urinary incontinence

These symptoms not only impact many women’s quality of life, but also their health. It is estimated that a woman over the age of 50 that has been diagnosed with a UTI has a 55% risk of having another one in the same year! Left untreated or recurring, UTIs can lead to confusion, kidney infection, antibiotic resistance, and even sepsis (a life-threatening bloodstream infection).

So why do all of these symptoms happen? The root cause is the decline and eventual absence of estrogen. Starting in perimenopause (the years leading up to your final period), falling estrogen levels can trigger these symptoms, and they typically worsen after menopause, when estrogen production drops to nearly zero.

Estrogen is important in maintaining elasticity, moisture, and thickness of the genitourinary system. So when estrogen is on the decline, the vaginal tissue becomes thin and fragile (pain and bleeding), the natural pH of the vagina and urinary tract shift (increasing infection risk, vaginal discharge changes), and the urethra, bladder, and pelvic floor lose flexibility (incontinence, urgency, frequency).

There are some women who can experience these symptoms much sooner, including some women on birth control pills for an extended period of time, women who have had both ovaries removed (surgical menopause), who have experienced early menopause, or who have had chemo/radiation.

Unfortunately, most women do not seek help for these symptoms. Of the 75% of women who complain of genitourinary syndrome of menopause, only 25% of them seek help, and less than 10% start treatment. The most unfortunate barrier to treatment is lack of education on both the patient and provider’s side; women are led to believe that these symptoms are just a normal consequence of aging and that treatment is not needed and/or is dangerous.

There is help!

There are many safe and effective treatments available:

Non-hormonal over-the-counter options (first line for mild symptoms): Vaginal moisturizers used regularly, and lubricants used during intercourse. Both are available over the counter without a prescription.
Local vaginal estrogen (first line for moderate/severe symptoms). Forms: vaginal cream, suppository, tablet, vaginal ring. Minimal systemic absorption - this eliminates most risks of vaginal estrogen. Considered safe for most women and there are few contraindications (including women with history of cancer when we consult with their oncologist)
Intrarosa (local vaginal DHEA)Daily vaginal suppository FDA-approved for painful intercourse. Helpful for vaginal symptoms, but less so for urinary ones.
Ospemifene (oral, non-estrogen): FDA-approved for painful intercourse and vaginal dryness. Acts more selectively than traditional estrogen therapy, though it carries a small risk of blood clots and stroke and isn’t right for everyone.
Pelvic floor physical therapy. Especially helpful for urinary symptoms and painful intercourse, and pairs well with any of the above treatments

Don’t suffer in silence

Too many women stay silent about these symptoms. Whether from stigma, lack of education, feeling rushed, or simply not knowing help exists. You deserve to live a full and happy life without vaginal burning and bothersome urinary symptoms.

This may not be something your provider asks about, so be proactive! If you have any of the symptoms above, ask your provider about it at your next visit; tell them that you think you could have genitourinary syndrome of menopause and that you would like treatment. You truly deserve to feel like yourself at every stage of life; and as I love to say, you shouldn’t have to pee your pants or grit your teeth to have sex!

The information in this column is intended for educational purposes only and does not constitute medical advice. Please consult your own healthcare provider before beginning any treatment

Kelly Tull is a Women’s Health Nurse Practitioner and AASECT Certified Sex Counselor at Venus Collective Women’s Health and Intimacy in East Longmeadow, MA. She is a member of the Menopause Society and the International Society for the Study of Women’s Sexual Health (ISSWSH). Kelly specializes in menopause management, women’s pelvic health, and sexual wellness. For more information, visit www.myvenuscollective.com or follow her on Instagram at @myvenus_collective