The British Menopause Society (BMS) has recently released an updated consensus statement on Urogenital atrophy [1]. The statement highlights the prevalence of this distressing condition amongst the postmenopausal population and draws attention to the fact that symptoms often present many years after the menopause and consequently are not always recognized as estrogen-deficient in origin, either by women or their practitioners. The statement also reviews the prevalence and patho-etiology of urogenital atrophy, including the impact this has on the bladder, urethra, uterosacral ligaments and other supporting structures. This often results in a variety of urinary symptoms, in particular symptoms of ‘pseudo-cystitis’ and recurrent urinary tract infections. The key to successful management of these conditions is recognizing the role estrogen has in maintaining the integrity of these structures, and a course of vaginal estrogens will often lead to a dramatic improvement in symptoms. The impact that urogenital atrophy or vulvovaginal atrophy (VVA) can have on sexual function and a woman’s sense of sexual well-being is well established [2]. Equally, we also know that, in general, health professionals are very poor at enquiring about symptoms of urogenital atrophy [3], and this statement highlights the importance of specifically enquiring about symptoms of urogenital atrophy and sexual function as part of the routine consultation. The relationship between urogenital atrophy and sexual dysfunction is explored in more detail in the recent IMS White Paper [4]. It is well established that vaginal estrogens are the principal treatment for VVA, but this statement reminds us that being on systemic HRT is not in itself a guarantee that symptoms will improve and sometimes topical estrogens are required as well. It is quite safe to use standard vaginal and systemic estrogens together as the overall systemic absorption of vaginally administered estradiol and estriol is low. As well as a review of the current data on vaginal estrogens, the statement also has helpful sections on vaginal moisturizers and lubricants and reviews recent evidence for ospemifene, vaginal laser therapy and DHEA. The statement concludes with helpful practice points for clinicians and a comprehensive list of 44 references.

Comment

This is part of a series of consensus statements produced by the BMS and available on their website, www.thebms.org.uk, and published in their journal, Post Reproductive Health. This statement replaces the previous one from 2013. The Consensus statement is written and laid out in a very practical style, with useful tips aimed at the Society’s predominantly clinical membership over a third of whom work in Primary Care (GPs or Practice nurses). The Statement highlights that confusion around nomenclature continues to be a barrier to understanding of the problem. The terms urogenital atrophy and VVA are often used synonymously and are descriptive of the underlying process, the latter term being the one preferred by the IMS. The term Genitourinary Syndrome of the menopause (GSM) is also increasingly being used in some parts of the world, although the term reflects a set of symptoms rather than the underlying changes that are occurring.

The statement offers practical guidance on the differences between moisturizers and lubricants and reminds us that not all of the available products are the same. Finally, the emerging role of laser therapy for urogenital atrophy /VVA is highlighted. Since our Climacteric editorial 12 months [5] ago, a number of randomized trials have reported and others are in progress confirming the potential of this new modality for some groups of women. However, caution remains advised until longer-term evidence of safety and prolonged efficacy is established.

Tim Hillard

Consultant Obstetrician & Gynaecologist, Poole Hospital, Dorset, UK 

References

1. Pitkin J. BMS Consensus Statement. Post Reproductive Health 2018;24:133-8
   https://www.ncbi.nlm.nih.gov/pubmed/30244644
2. Nappi RE, Kingsberg S, Maamari R, Simon J. The CLOSER (CLarifying Vaginal Atrophy's Impact On SEx and Relationships) survey: implications of vaginal discomfort in postmenopausal women and in male partners. J Sex Med 2013;10:2232–41
   https://www.ncbi.nlm.nih.gov/pubmed/23809691
3. Nappi RE, Palacios S, Panay N, Particco M, Krychman ML. Vulvar and vaginal atrophy in four European countries: evidence from the European REVIVE Survey. Climacteric 2016;19:188–97
   https://www.ncbi.nlm.nih.gov/pubmed/26581580
4. Simon JA, Davis SR, Althof SE, et al. Sexual well-being after menopause: An International Menopause Society White Paper. Climacteric 2018;21:415-27
   https://www.ncbi.nlm.nih.gov/pubmed/29987939
5. Hillard TC. Turning the spotlight on lasers. Climacteric 2017;20:397-9
   https://www.ncbi.nlm.nih.gov/pubmed/28862053