Modern management of genitourinary syndrome of menopause

From waste to wellness - what women want: insights into patient perspectives on topical vaginal estrogen applicators and environmental considerations

OBJECTIVE

Environmental consciousness and the role of plastic waste are increasing. Topical vaginal estrogen prescription can be prescribed with one reusable plastic applicator or multiple single-use plastic applicators. User preference about the role of plastic in personal healthcare is not fully understood. This study aimed to explore patients' perspectives on the applicator and environmental considerations.

METHOD

A mixed-methods questionnaire was employed to assess users' experience with topical vaginal estrogen applicators and their views on the environment.

RESULTS

Ninety-two respondents had previously used estriol 0.1% cream and 77 had used estradiol 10 μg vaginal inserts. The mean age of participants was 67.3 years. The mean duration of use was 36.5 months, and the discontinuation rate was 26.1% and 29.9% for estriol 0.1% cream and estradiol 10 μg vaginal insert users, respectively. Satisfaction with applicators and ease of use were similar in both groups. There was a higher report of the product being 'messy' (38.0% vs. 18.2%; p = 0.026) and 'not hygienic' (48.9% vs. 18.2%; p < 0.001) by estriol 0.1% cream users compared to estradiol 10 μg vaginal insert users. Women aged <65 years demonstrated a greater concern about plastic use and the impact on the environment compared to women aged over 65 years (81.0% vs. 56.9%; p = 0.002). The younger cohort showed a preference for reusable applicators (66.2%) compared to single-use applicators (33.8%) (p = 0.005). There was no statistically significant difference in preference for women aged over 65 years.

CONCLUSION

This study demonstrates that younger postmenopausal women showed greater concern for plastic waste and its impact on the environment, with a preference for reusable products. Manufacturers of health products and prescribers should be aware of this growing trend. With similar overall satisfaction and side-effect profiles, users should be made aware of the different types of applicators available to help support an informed decision.

Optimizing the regenerative potential of vaginal fibroblasts: The role of autologous platelet-rich plasma and hyaluronic acid in vitro

OBJECTIVE

Many postmenopausal women suffering from vulvovaginal atrophy are looking for non-hormonal treatments. Platelet-rich plasma (PRP) therapy has emerged as a novel and promising approach for gynecological applications. PRP is an autologous blood product rich in growth factors used to stimulate tissue regeneration. On the other hand, hyaluronic acid (HA) is used as a treatment for vaginal dryness as it improves tissue hydration thanks to its strong capacity to retain water. This study examines the in vitro effects of PRP alone or combined with HA on vaginal fibroblasts (VFs) isolated from mucosal samples of postmenopausal women undergoing surgery for vaginal prolapse.

METHODOLOGY

Vaginal and blood samples were collected from postmenopausal women undergoing pelvic organ prolapse surgery. PRP was prepared alone or combined with HA (PRP-HA) from peripheral blood. Vaginal fibroblasts were isolated via enzymatic dissociation and cultured in 2D and 3D (spheroids) systems. Biological activities were assessed by measuring cell growth, proliferation, senescence, metabolic activity, and collagen accumulation, along with immunocytochemistry for (myo-)fibroblast markers.

RESULTS

VFs cultured with PRP or PRP-HA showed dose-dependent higher proliferation compared with the control condition, with increased S and G2M cell cycle phases correlating with enhanced proliferation. Expression of vimentin, a protein that plays a key role in maintaining cellular structure and function, was stable, while alpha-SMA decreased, indicating a shift from myofibroblasts to fibroblasts. Collagen production, crucial for wound healing and tissue regeneration, increased under PRP or PRP-HA treatment. PRP and PRP-HA also prevented cell senescence in long-term low-density cultures. These findings were consistent across 2D and 3D culture systems.

CONCLUSIONS

This study provides in vitro evidence supporting the potential of PRP and PRP-HA as autologous treatments for vaginal rejuvenation.

Aromatherapy for the Management of Menopause Symptoms: An Updated Systematic Review and Meta-analysis

Introduction

Numerous studies have found aromatherapy beneficial during menopause; however, some of its effects are still unclear in past meta-analyses, and no comprehensive study has consolidated and analyzed grading evidence of its impact on menopausal symptoms. Therefore, the present meta-analysis aimed to determine and update the impact of aromatherapy on the management of menopausal symptoms.

Methods

We conducted a comprehensive literature search using PubMed, Web of Science, Scopus, and the Cochrane Library until January 20, 2024, without any limitations on language, time, or region to find randomized clinical trials. To evaluate the included trials' methodology, we used version 2 of the Cochrane Handbook's risk-of-bias assessment, as well as GRADEpro GDT (Guideline Development Tool) for quality evidence and Review Manager software (RevMan version 5.1) for analysis.

Results

We conducted a meta-analysis of 13 randomized controlled trials (RCTs) with mixed quality from 15 trials with 1217 participants. Compared to the control group, aromatherapy reduced physical (SMD -0.93, 95% CI -1.19 to -0.67, P<0.00001), psychological (SMD -0.83, 95% CI -1.13 to -0.54, P<0.00001), and overall symptoms (SMD -1.51, 95% CI -2.11 to -0.90, P<0.00001), enhanced sexual function (MD 5.58, 95% CI 0.98 to 10.17, P=0.02), and the quality of sleep (MD -4.51, 95% CI -7.45 to -1.57, P=0.003). The evidence grading for physical symptoms was moderate, and other variables were low to very low.

Conclusion

Aromatherapy is efficacious for managing the symptoms of menopause. However, there is insufficient high-quality evidence for some outcomes, indicating the necessity for additional research.

Beyond the discomfort: understanding and managing sexual pain in women, a comprehensive case-based discussion

INTRODUCTION

Sexual pain has a profound impact on individuals, regardless of their sexual orientation or gender identity, and affects women more often than men. It adversely affects both sexual function and interpersonal relationships. Despite its prevalence, sexual pain in women often remains unaddressed and untreated. Various underlying causes contribute to sexual pain, sometimes involving multiple factors. We explore treatment options and offer clinical insights into the evaluation and management of 4 common conditions which cause sexual pain in women. In this article, we use the term "women" to indicate cisgender women.

OBJECTIVES

Our aim is to highlight the most common clinical scenarios of sexual pain and provide comprehensive discussions on each, to improve patient care and outcomes in the management of sexual pain.

METHODS

We conducted a comprehensive review of literature and clinical cases to explore the various causes and management strategies for sexual pain in women. We systematically searched databases such as PubMed, Google Scholar, and relevant medical journals. We included peer-reviewed articles, case studies, and clinical trials published between 2000 and 2023. Additionally, we analyzed real-life cases from our clinical practice at our academic institution.

RESULTS

Our review identified various factors contributing to sexual pain in women, ranging from hormonal imbalances to neuroproliferative and inflammatory conditions affecting the genitourinary system. Each case should be approached individually to offer optimal management strategies accordingly.

CONCLUSION

The management of sexual pain in women requires a comprehensive approach that addresses the multifactorial nature of the condition. Patient education and counseling play a crucial role in the management of sexual pain, empowering individuals to advocate for their own health and well-being. The collaboration between healthcare providers and patients can improve our understanding and management of this complex condition.

Understanding the Interplay Between Premenstrual Dysphoric Disorder (PMDD) and Female Sexual Dysfunction (FSD)

Premenstrual dysphoric disorder (PMDD) is a severe variant of premenstrual syndrome (PMS), categorized as a mood disorder due to marked symptoms of depression and anxiety, compounded with severe physical symptoms. Female sexual dysfunction (FSD) can manifest as low libido, difficulty achieving sexual pleasure, and dyspareunia, causing functional and psychological distress. PMDD and FSD are globally prevalent conditions with postulated biological, psychological, and social associations between them. Nevertheless, sexual dysfunction in PMDD is an important aspect of women's health that has been understudied and has notable methodological limitations. In this narrative review, we summarize the existing literature on sexual function in women with PMDD and PMS, specify the distinctions between PMDD and other general symptoms of PMS, highlight the significance of understanding sexual dysfunction in the female population, and outline some available therapeutic options. Studies show that women frequently experience debilitating sexual distress during the premenstrual phase; however, there is an essential need to formulate standardized tools for definite diagnosis. Selective serotonin re-uptake inhibitors (SSRIs) and combined oral contraceptive pills (COCPs) are approved medications for PMDD, while flibanserin and bremelanotide are effective in treating FSD. However, the potential effects of these treatment modalities on the two comorbid conditions render them inconclusive. Awareness of PMDD and FSD among clinicians and society can allow the implementation of targeted interventions to alleviate the suffering of women and enhance their quality of life.

Prospective, multicenter, uncontrolled study on the effectiveness and safety of a hyaluronic acid water-based vaginal lubricant in alleviating vaginal dryness and dyspareunia

BACKGROUND

Vaginal dryness (VD) represents a significant concern affecting women across diverse life stages, encompassing both pre- and postmenopausal women at any age. Dyspareunia, defined by genital pain that can be experienced before, during, or after intercourse, is often associated with vaginal dryness.

AIM

This study aimed to evaluate the effectiveness and safety of a water-based vaginal lubricant with hyaluronic acid to reduce sexual discomfort associated with vaginal dryness.

METHODS

A prospective, multicenter, uncontrolled clinical investigation was conducted over a three-month period in women aged 18 years or older experiencing pain or difficulty during sexual intercourse for whom the use of a vaginal lubricant was recommended.

RESULTS

Significant improvements were observed in the FSFI scores, indicating enhanced sexual function (p < .001). Vaginal dryness symptoms, including irritation, dryness, itching, and dyspareunia, significantly decreased after product use (p < .001).

CLINICAL IMPLICATIONS

This study contributes to the limited scientific knowledge on the application of lubricants in the context of symptoms associated with VD.

STRENGTHS & LIMITATIONS

In addition to the short study period, inherent limitations of the study design, and lack of placebo control, it is pertinent to acknowledge that some of the pros used in this study were not based on validated questionnaires. However, as far as we know, this study is the only one that analyzes well-being and sexual pleasure as results using a lubricant formulated with hyaluronic acid.

CONCLUSION

This tested vaginal lubricant with hyaluronic acid has demonstrated efficacy in improving vaginal dryness and female sexual function, particularly in reducing pain and improving lubrication during sexual intercourse, and showed a favorable safety profile, with minimal and transient adverse events.

Geriatric Genital Dermatology

As women age, hormonal changes set the stage for a variety of vulvovaginal pathologies. Health care providers in long-term care facilities should be able to recognize and treat these conditions, especially because residents may be unable to communicate their discomfort. The objective of this article is to highlight the major vulvovaginal conditions affecting older women and provide up-to-date information on treatment for providers in long-term care facilities.

The Persistency Index: a novel screening tool for identifying myofascial pelvic floor dysfunction in patients seeking care for lower urinary tract symptoms

BACKGROUND

Patients with myofascial pelvic floor dysfunction often present with lower urinary tract symptoms, such as urinary frequency, urgency, and bladder pressure. Often confused with other lower urinary tract disorders, this constellation of symptoms, recently termed myofascial urinary frequency syndrome, is distinct from other lower urinary tract symptoms and optimally responds to pelvic floor physical therapy. A detailed pelvic floor myofascial examination performed by a skilled provider is currently the only method to identify myofascial urinary frequency syndrome. Despite a high influence on quality of life, low awareness of this condition combined with no objective diagnostic testing leads to the frequent misdiagnosis or underdiagnosis of myofascial urinary frequency syndrome.

OBJECTIVE

This study aimed to develop a screening measure to identify patients with myofascial urinary frequency syndrome (bothersome lower urinary tract symptoms secondary to myofascial pelvic floor dysfunction) from patient-reported symptoms.

STUDY DESIGN

A population of patients with isolated myofascial urinary frequency syndrome was identified by provider diagnosis from a tertiary urology practice and verified by standardized pelvic floor myofascial examination and perineal surface pelvic floor electromyography. Least Angle Shrinkage and Selection Operator was used to identify candidate features from the Overactive Bladder Questionnaire, Female Genitourinary Pain Index, and Pelvic Floor Distress Index predictive of myofascial urinary frequency syndrome in a pooled population also containing subjects with overactive bladder (n=42), interstitial cystitis/bladder pain syndrome (n=51), and asymptomatic controls (n=54) (derivation cohort). A simple, summated score of the most discriminatory questions using the original scaling of the Pelvic Floor Distress Index 5 (0-4) and Genitourinary Pain Index 5 (0-5) and modified scaling of Female Genitourinary Pain Index 2b (0-3) had an area under the curve of 0.75. As myofascial urinary frequency syndrome was more prevalent in younger subjects, the inclusion of an age penalty (3 points added if under the age of 50 years) improved the area under the curve to 0.8. This score was defined as the Persistency Index (possible score of 0-15). The Youden Index was used to identify the optimal cut point Persistency Index score for maximizing sensitivity and specificity.

RESULTS

Using a development cohort of 215 subjects, the severity (Pelvic Floor Distress Index 5) and persistent nature (Female Genitourinary Pain Index 5) of the sensation of incomplete bladder emptying and dyspareunia (Female Genitourinary Pain Index 2b) were the most discriminatory characteristics of the myofascial urinary frequency syndrome group, which were combined with age to create the Persistency Index. The Persistency Index performed well in a validation cohort of 719 patients with various lower urinary tract symptoms, including overactive bladder (n=285), interstitial cystitis/bladder pain syndrome (n=53), myofascial urinary frequency syndrome (n=111), controls (n=209), and unknown diagnoses (n=61), exhibiting an area under the curve of 0.74. A Persistency Index score ≥7 accurately identified patients with myofascial urinary frequency syndrome from an unselected population of individuals with lower urinary tract symptoms with 80% sensitivity and 61% specificity. A combination of the Persistency Index with the previously defined Bladder Pain Composite Index and Urge Incontinence Composite Index separated a population of women seeking care for lower urinary tract symptoms into groups consistent with overactive bladder, interstitial cystitis/bladder pain syndrome, and myofascial urinary frequency syndrome phenotypes with an overall diagnostic accuracy of 82%.

CONCLUSION

Our study recommends a novel screening method for patients presenting with lower urinary tract symptoms to identify patients with myofascial urinary frequency syndrome. As telemedicine becomes more common, this index provides a way of screening for myofascial urinary frequency syndrome and initiating pelvic floor physical therapy even before a confirmatory pelvic examination.

A study of the objective benefits and safety of Er-YAG laser in the treatment of genitourinary syndrome of menopause

The aim of this study is to evaluate changes in vaginal pH and epithelium maturation after erbium-doped yttrium aluminum garnet (Er-YAG) laser treatment, and to assess its safety and efficacy on the symptoms of genitourinary syndrome of menopause (GSM). This was a retrospective study conducted between November 2019 and April 2022 and included 32 women diagnosed with GSM who had not benefitted from lubrication treatment and could not or would not use estrogen. Patients received three sessions of Er- YAG laser. All patient data before and after treatment were obtained from computer records. Vaginal maturation index (VMI), maturation value (MV) and vaginal pH values of the patients before and after laser treatment were compared. We also evaluated post-procedural complications and symptoms. Mean age was 59.72 ± 5.66 years. After laser therapy, there was a significant decrease in vaginal pH (p < 0.001) and the proportion of parabasal cells in VMI (p < 0.001), while there was a significant increase in MV (p < 0.001) and the proportion of superficial cells in VMI (p < 0.001). In 84.4% of the patients, GSM-related symptoms regressed completely or decreased to a tolerable level. Patients in which symptoms disappeared completely had significantly lower mean age (p = 0.002) and duration of menopause (p = 0.009). The laser procedure resulted in complications including mucosal injury in 5 (15.6%) patients (all recovered spontaneously) and vaginal burning sensation in 2 (6.3%) patients. Vaginal Er-YAG laser treatment may be a safe and effective alternative treatment method in a population of women with GSM who do not want to or cannot use estrogen therapy.

Current challenges in the pharmacological management of genitourinary syndrome of menopause

INTRODUCTION

Genitourinary syndrome of menopause is caused by climacteric estrogens drop and leads to bothersome and progressive genital and urinary symptoms. Considering the high frequency in the population and the impact on quality of life, it is crucial to find a safe and effective treatment. Pharmacological therapies aim to modulate the hormonal system and reverse tissue changes due to hypoestrogenism and consequently the symptoms.

AREAS COVERED

We analyzed the scientific evidence concerning the main pharmacological treatments, which include systemic and topical estrogens, prasterone and ospemifene. This literature review focused on recent safety and efficacy findings in an attempt to identify the best treatment choice for each individual patient.

EXPERT OPINION

There are encouraging data regarding the efficacy of all currently available pharmacological options and concerning their short and long-term safety. There are still doubts regarding best treatment choice for oncological high-risk population, in particular for breast cancer survivors, and some issues relative to patients' poor compliance and treatment adherence. For these reasons further studies need to be conducted with a patient-tailored focus.

A Randomized, Placebo-Controlled Trial Evaluating the Single and Combined Efficacy of Radiofrequency and Hybrid Fractional Laser for Nonsurgical Aesthetic Genital Procedures in Post-Menopausal Women

BACKGROUND

The efficacy of interventions that provide long-term relief of genitourinary symptoms of menopause has not been determined.

OBJECTIVES

The authors sought to evaluate radiofrequency and hybrid fractional laser (HFL) treatments for menopausal vulvovaginal symptoms.

METHODS

Thirty-one postmenopausal women completed all treatments and at least 1 follow-up. Outcomes included the Vulvovaginal Symptom Questionnaire (VSQ), Vaginal Laxity Questionnaire (VLQ), Urogenital Distress Short Form, Incontinence Impact Questionnaire (IIQ), Female Sexual Function Index (FSFI), laxity measurements via a vaginal biometric analyzer probe, and gene expression studies.

RESULTS

Mean VSQ score decreased 2.93 (P = 0.0162), 4.07 (P = 0.0035), and 4.78 (P = 0.0089) among placebo, dual, and HFL groups 3 months posttreatment and decreased to 3.3 (P = 0.0215) for dual patients at 6 months. FSFI scores increased in the desire domain for placebo and dual groups and in arousal, lubrication, orgasm, satisfaction, and pain domains for the HFL group 3 and 6 months posttreatment. An increase of 1.14 in VLQ score (P = 0.0294) was noted 3 months and 2.2 (P = 0.002) 6 months following dual treatment. There was also a mean decrease of 15.3 (P = 0.0069) in IIQ score for HFL patients at 3 months. Dual, HFL, and RF treatments resulted in statistically significant decreases in collagen I, elastin, and lysyl oxidase expression.

CONCLUSIONS

Several self-reported improvements were noted, particularly among HFL, dual, and placebo groups 3 and 6 months posttreatment. Objective biopsy analysis illustrated decreased gene expression, suggesting that treatments did not stimulate new extracellular matrix production.

LEVEL OF EVIDENCE: 2