Menu
The Elephant in the Room is Cancer. Tea is the Relief Conversation Provides.
Menu
The Elephant in the Room is Cancer. Tea is the Relief Conversation Provides.
Genito-What?
Genitourinary Syndrome of Menopause Part I: The Sneaky but Significant Side Effect You’ve Never Heard Of
Disclaimer: This information is not a substitute for medical care. Always inform your healthcare team of any concerning symptoms you are experiencing, and consult with your provider before starting new treatments, therapies, or health routines.
Quick question for all my vulva and vagina-owning peeps out there: Has your cancer care team ever asked about bothersome genital symptoms like dryness, irritation, itching, or pain?
Even though genital symptoms like these can occur with several different cancer treatments and are common in AYAs, healthcare professionals don’t do a great job of regularly assessing vulvovaginal health at follow-up appointments (1). Lots of young survivors begin to develop these issues in survivorship without realizing that it could be a side effect of their treatments! The good news is that there are effective management options to help relieve symptoms and prevent them from worsening over time.
This is the first of a three-part series on genitourinary syndrome of menopause, affectionally known in the medical world as GSM. Today, we’re going to dig into what GSM is, how it can develop in AYAs, and why it’s a condition that’s important to recognize and manage. In forthcoming articles, parts II and III will explore the safety and effectiveness of available treatments and interventions. Let’s get started, shall we?
GENITO-WHAT?
Genitourinary syndrome of menopause sounds intimidating, but it’s basically just a fancy way of lumping together a bunch of genital, sexual, and urinary symptoms that can develop over time in response to low estrogen levels (2). The term might be confusing because, um, menopause? Isn’t that something that only happens when you’re, like, 50?
MENOPAUSE . . . AS AN AYA?
Here’s the thing. Menopause is simply the term that refers to a person’s last menstrual period. Postmenopausal is the term used to describe the physiological state of individuals who’ve experienced menopause—that is, had their last period—and thus, whose ovaries have stopped producing estrogen. Because the symptoms of GSM develop in response to prolonged low levels of estrogen in the body (called a hypoestrogenic state), anything that impacts the production of estrogen in the ovaries can lead to the development of GSM.
For most people, menopause occurs naturally somewhere between their mid-40’s and mid-50’s as their ovaries slow, and eventually stop making estrogen over time (this is called natural menopause). However, there are many different reasons other than aging that can impact ovarian function, and some of these are cancer treatments (2,3,4). In these cases, a menopausal state is induced; that is, caused by a medical treatment or surgery. So (surprise!), you can definitely be postmenopausal as an AYA (5). Augh.
WHAT CANCER TREATMENTS CAN PUT ME AT RISK FOR GSM?
As I mentioned, many treatments for cancer can affect a person’s estrogen levels. Some of these treatments may halt estrogen production only temporarily. For example, the ovaries often stop making estrogen in response to certain types of chemotherapies but may resume regular function again after chemo. This is why some people don’t get their period during treatment, but it might return once treatment is complete. (PSA: Whether or not you’re getting your period doesn’t necessarily correlate with whether or not you can get pregnant, so be sure to use birth control when needed!) If you stop getting your period during chemo, you might experience some genital symptoms like vaginal dryness. However, once treatment ends and your ovaries begin making estrogen again, these symptoms can resolve.
Estrogen levels are also impacted by endocrine therapies that some people receive for hormone-sensitive cancers. A group of medications called gonadotropin releasing hormone (GnRH) agonists intentionally shut down ovarian function with the purpose of reducing a person’s estrogen levels to prevent cancer growth or recurrence. Examples include the medications leuprolide (Lupron) and goserelin (Zoladex), among others. These meds are also sometimes given to people who are receiving gonadotoxic chemo treatments to help protect the ovaries (3).
For young people with hormone-receptor positive breast cancers, a GnRH agonist might be paired with an aromatase inhibitor (AI). Although most estrogen is made in the ovaries, a little also gets made in other body tissues. AIs are oral medications that stop this process, with the goal of further depleting estrogen levels. Tamoxifen, another type of endocrine therapy, works by disrupting the effects of estrogen in the body and can also cause genitourinary symptoms. These anti-estrogen therapies are typically only temporary, and discontinuing them allows ovarian function and estrogen levels to return to normal. However, many people are on these treatments for years as maintenance therapy and can develop bothersome GSM symptoms over that timeframe.
There are also cancer treatments that can lead to more permanent estrogen loss. For example, a person’s ovarian function doesn’t always return after chemo, especially with high doses or if you are on the more mature (ahem) end of the AYA age spectrum when you begin treatment. Pelvic radiation therapy and total body irradiation can also damage ovarian tissue. The dosage and duration of pelvic radiation influence whether ovarian dysfunction is temporary or permanent. Of course, removing a person’s ovaries through surgery (oophorectomy) results in permanent loss of ovarian estrogen production. Lastly, treatments can also indirectly impact estrogen levels by damaging the pituitary gland with brain radiation or surgery. This can disrupt the hormone communication pathway from your brain to your ovaries and result in the loss of ovarian function.
This is all to say that lots of treatments can lead to less estrogen in your body, and less estrogen in your body over time can lead to GSM.
WHY DOES LOW ESTROGEN CAUSE VULVOVAGINAL SYMPTOMS?
There are a ton of estrogen receptors in the vagina and on the vulva (the outer or external genitals) that rely on estrogen to stay happy. Estrogen is responsible for keeping vulvovaginal tissues moist, thick, and resilient to injury. Without it, tissue thinning and a loss of flexibility and stretching occur as the elastin and collagen properties of vulvovaginal tissues are altered (1). Reduced blood flow to the area can slow natural vaginal secretions, causing dryness and irritation. As the tissues become more fragile and less elastic, they are more prone to tearing. Estrogen receptors have also been found on sensory neurons in the vagina, and estrogen loss might contribute to an increased sensitivity to pain (2).
Additionally, estrogen is essential to maintaining a healthy vaginal flora (the mix of bacteria and other microorganisms) that protects against infection. It does this by creating a glycogen-rich vaginal lining that supports the growth of Lactobacilli, the dominant bacteria species found in a healthy vaginal environment. These Lactobacilli produce lactic acid, keeping the vaginal pH low and preventing unwanted microbes from proliferating and causing infection. Estrogen loss reduces the food source for Lactobacilli, and the number of these bacteria diminishes. Fewer Lactobacilli means less lactic acid, increasing the pH level and making the vaginal environment more friendly to types of microbes that can cause problems.
Together, all these changes related to a loss of estrogen can eventually manifest in the bothersome genital symptoms of GSM (2,3,4): vulvovaginal dryness and decreased lubrication, itching, irritation, burning, soreness or chafing, vaginal discharge, painful sex or bleeding or spotting after sex, changes in sexual arousal and orgasm, and increased infections.
GSM IN REAL LIFE
Genitourinary syndrome of menopause is no joke. It’s a chronic condition that can negatively affect a person’s quality of life (1,4). If you are experiencing any of these symptoms related to estrogen loss, you know first-hand how annoying and frustrating they can be!
Studies exploring (cis) women’s experiences with vulvovaginal symptoms have identified notable negative consequences in multiple areas of their lives (2,6) (Unfortunately, research looking at the experiences of trans and gender non-conforming peeps is lacking). Sexual intimacy and romantic relationships can be negatively affected. Your confidence levels and how you feel about your body might change. GSM symptoms can even be a barrier to beginning a new relationship for some people (7), who may worry about a new partner’s reaction to some of the sexual challenges that can accompany genital changes.
Beyond sexual implications, these symptoms can also impact a person’s regular daily activities (2,3,4,6). Vulvovaginal soreness and discomfort can occur during exercising or playing sports, running, walking, or from long periods of sitting. You might notice sensitivity while wiping with toilet tissue or discomfort with certain underwear or tighter clothing. Symptoms can even impact sleeping (6).
HOW CAN GSM BE MANAGED?
Some people never develop noticeable symptoms or concerns in response to longterm estrogen loss, and many have mild but manageable symptoms. For others, however, symptoms can become significant and distressing as time goes on. The thing about GSM is that unlike some of the other side effects of estrogen loss that tend to resolve over time (like hot flashes), genital changes can actually progress and worsen without intervention (1). This makes it important to identify the issue early, so that it can be appropriately managed (1).
For how common and how distressing these symptoms can be, it’s hard to believe that so many clinicians never bring it up! This means that you might have to be the one to ask your care team for help. If you are experiencing genital symptoms, you should always have a physical exam. Lots of other things besides estrogen loss can lead to vulvovaginal symptoms (2,3,4) and understanding the correct cause of your concern is critical to getting the right treatment.
For vulvovaginal symptoms related to GSM, there are lots of options. In the next issue we’ll explore the (surprisingly fascinating) world of personal lubes and vaginal moisturizers, and after that we’ll focus on topical hormonal treatments, other prescription options, and newer technologies like vaginal laser therapies. Stay tuned!
* * *
IF MY SYMPTOMS AREN’T RELATED TO GSM, WHAT ELSE COULD THEY BE?
Low estrogen definitely isn’t the only cause of vulvovaginal symptoms like itching, dryness, irritation, vaginal discharge, or pain with sex. Any time you are experiencing genital concerns, it’s important to see a clinician who can help you determine a cause and find a solution to your symptoms.
Vulvovaginal symptoms can also be related to (2,3,4):
* * *
WAIT, WHAT’S UP WITH THE “URINARY” PART OF “GENITOURINARY SYNDROME OF MENOPAUSE”?
OK, yes, great question! Actually, let’s start with a fun fact: The lower urinary tract (the bladder and the urethra, or the tube that carries pee from the bladder to the outside of the body) develops from the same types of tissue as the genital tract, so both are highly sensitive to estrogen (2). This means that these structures are also affected by estrogen loss.
Estrogen plays a role in the ability of the bladder to stretch, impacting volume capacity and contractility. Estrogen also impacts the thickness and elasticity of the urethral lining and the ability of the urethral sphincter muscles to contract to hold in urine, as well as the strength of the pelvic floor muscles. Without estrogen, the bladder walls and urethral lining can thin and stiffen, becoming more easily irritated. The urethra itself can shorten, and the pelvic floor muscles can weaken. Together, these changes can lead to symptoms like increased urinary frequency and urgency, pain or burning with urination, urinary leakage (incontinence), and frequent urinary tract infections (UTIs) (2,3,4).
Talk with your care team about any urinary concerns you are having and the best way to manage them.
* * *
BIBLIOGRAPHY/REFERENCES
Elephants and Tea is a trademark of the Steven G. Cancer Foundation, a registered 501(c)(3) nonprofit under federal tax guidelines.
Join the Conversation!
Leave a comment below. Remember to keep it positive!