Table 1. Summary of the findings of the studies included in the review.
NAMS: North American Menopausal Society; ISSWSH: International Society for the Study of Women's Sexual Health; GSM: genitourinary syndrome of menopause; UI: urinary incontinence; VMI: vaginal maturation index; VHI: vaginal health index; ET: estrogen therapy; QoL: quality of life; HCP: healthcare provider; VA: vaginal atrophy
| Author | Year | Findings |
| Portman and Gass [1] | 2014 | This review article states that vulvovaginal atrophy, by consensus of NAMS and ISSWSH, is now termed genitourinary syndrome of menopause, which incorporates signs and symptoms associated with the hypoestrogenic state including genital, sexual, and urinary symptoms |
| Nappi et al. [2] | 2019 | This study states that GSM is an early predictor for poor general health. The same is true for vasomotor symptoms. Healthcare practitioners should be proactive in diagnosing and managing GSM for the overall well-being of postmenopausal women |
| Moral et al. [3] | 2018 | This study found that the prevalence of GSM in Spanish women is about 70%, with the most prominent clinical features being vaginal dryness, UI, and dyspareunia. It has a low to moderate impact on the quality of life of the women affected |
| Gandhi et al. [4] | 2016 | According to this study, GSM is a prevalent condition in postmenopausal women, which is often undetected. Early diagnosis and custom-made prescriptions positively affect the quality of life of women and also prevent it from worsening |
| Cook et al. [5] | 2017 | This study concluded that breast cancer survivors who are on aromatase inhibitor therapy often experience GSM symptoms and sexual dysfunction, which negatively affects their quality of life. GSM assessment should be integrated into the care for breast cancer survivors |
| Peters [6] | 2021 | According to this study, diagnosis of GSM includes patient history and external genitalia examination. The findings on external genitalia examination include pale introitus, loss of vaginal rugae and elasticity, and increase in pH. Various treatment options include vaginal lubricants, moisturizers, and hormonal therapy |
| Ojha et al. [7] | 2022 | A study conducted in a tertiary care center in Nepal shows that 78.4% of postmenopausal women visiting the hospital were diagnosed with GSM. It negatively affected the quality of life of these women, mainly their sexual health |
| Sarmento et al. [8] | 2021 | According to this study, vaginal assessment for GSM is done using VMI, vaginal pH, and VHI |
| Angelou et al. [9] | 2020 | This study states that local ET is considered the gold standard for GSM. Other first-line therapies include moisturizers, lubricants, and lifestyle changes. Selective estrogen receptor modulators and laser therapy are further evolving as an option for the management of GSM |
| Briggs [10] | 2020 | According to this study, sexual health is affected by loss of lubrication, shrinkage of introitus, and loss of elasticity in GSM. Vaginal symptoms and urinary symptoms also affect the quality of life of women. Assessment is done by vaginal pH and vaginal smear to look for vaginal maturation index |
| North American Menopause Society [11] | 2007 | According to NAMS, low-dose topical ET is recommended for vaginal atrophy and is given as long as the symptoms persist. Progesterone is not recommended in low-dose ET. In non-hormonal cancer patients as well as patients with no history of cancer, low-dose estrogen therapy is preferred. In hormone-dependent cancers, oncologists should be consulted |
| Mac Bride et al. [12] | 2010 | According to this study, the clinical findings of GSM include pale and dry vaginal mucosa and petechiae, loss of elasticity and rugae within the vagina. An increase in vaginal pH is suggestive of GSM. The prevalence of GSM is increased in patients undergoing breast cancer treatments; however, low-dose estrogen therapy use in these patients is disputed |
| Davila et al. [13] | 2003 | This study found that the physical signs of GSM weakly correlated with the appearance of symptoms. Even though urogenital atrophy occurs in most postmenopausal women, many of them do not develop symptoms. Hence symptoms should not be the only key factor in deciding whether local ET therapy should be started or not |
| Palma et al. [14] | 2016 | In this study, around 935 females of an average age of 59 underwent routine gynecological examinations. Among these, 79% were diagnosed with GSM. Physical signs included mucous membrane dryness and paleness, loss of vaginal rugae, and petechiae. Only 30% of these women were previously diagnosed with GSM with many of them on local ET |
| Kim et al. [15] | 2015 | This study points out that vaginal atrophy and atrophic vaginitis were all insufficient terms to describe GSM as they do not encompass all symptoms of GSM including sexual dysfunction, urinary symptoms, and vaginal symptoms. It is important to educate women regarding this and manage the symptoms accordingly |
| Nappi and Kokot-Kierep [16] | 2012 | In this study, an online survey was conducted to estimate the understanding of vaginal atrophy in women. Around 41% of these participants suffered from vaginal symptoms; 63% of women did not know about vaginal atrophy and 46% of the participants did not know about local ET. This study concluded that postmenopausal women had a poor understanding of vaginal atrophy |
| Levine et al. [17] | 2008 | This study was done to find the association between vaginal atrophy and sexual dysfunction among postmenopausal women who are sexually active. It concluded that the likelihood of vaginal atrophy was 3.84 times greater in women with sexual dysfunction |
| Robinson and Cardozo [18] | 2003 | According to this study, estrogen has physiological effects on the lower urinary tract. Hence it can be used in irritative lower urinary tract symptoms as well as to reverse the effects of urogenital atrophy due to hypoestrogenic states |
| Felippe et al. [19] | 2017 | This study was performed to find the relationship between UI and women's sexual health. It concluded that women with UI have a higher prevalence of sexual dysfunction |
| Thornton et al. [20] | 2015 | This study suggests that sexual function decreases with age, which negatively affects QoL. HCPs should therefore be forthcoming in asking menopausal and postmenopausal women about sexual dysfunction and listen to their concerns about the same |
| Nappi et al. [21] | 2013 | This study involved a survey to study the effect of VA on sexual health and relationships. It concluded that VA has negatively affected the physical and emotional well-being of women and their partners |
| Kinsberg et al. [22] | 2013 | This study conducted on postmenopausal women concluded that around 38% of participants experienced GSM symptoms; 56% of participants had discussed this with their HCP and 44% of them were on some sort of treatment. Initiatives to improve HCP and patient communication are the key to early diagnosis and management |
| Henry-Okafor et al. [23] | 2021 | According to this review article, the reason for GSM being underdiagnosed is women not wanting to discuss this with their HCP. Thus HCPs should be forthcoming in screening postmenopausal women coming to them as well as prescribing therapy suitable for their individual needs |
| Palacios [24] | 2019 | According to the study, objective methods of diagnosing GSM include VMI and vaginal pH. These along with clinical history should guide the treatment of GSM |
| Palacios et al. [25] | 2015 | The authors recommend symptomatic relief as the main aim of treatment. This includes lubricants and moisturizers, systemic and topical ET, and newer modalities like SERM and laser |
| Brown and Bachman [26] | 2005 | According to the authors, even with newer modalities like SERM and laser therapy, low-dose topical ET remains the mainstay of treatment of GSM with minimal systemic absorption |
| Nachtigall [27] | 1994 | This study was done to compare the use of vaginal moisturizers with topical estrogen therapy. It concluded that vaginal moisturizer is as effective as local ET for increasing vaginal moisture and decreasing the symptoms |
| Nappi et al. [28] | 2022 | This study states that hyaluronic acid is a valid and safe prophylactic option in hormonal cancer patients as well as those unwilling to use ET |
| Sinha and Ewies [29] | 2013 | According to this study, lubricants provide no long-term effect on the GSM manifestations; however, it is safe and efficient to use to prevent dyspareunia during sexual intercourse |
| Sarmento et al. [30] | 2021 | This study states that in breast cancer survivors, the use of ET is disputed and hence nonhormonal options such as moisturizers and lubricants are to be used |
| The NAMS 2020 GSM Position Statement Editorial Panel [31] | 2020 | According to this study, individual patient preference, safety, and other comorbidities should direct the use of various treatment therapies for GSM |
| Suckling et al. [32] | 2006 | As per this study, estrogen therapy can be either systemic in the form of tablets and injections or topical in the form of pessaries, rings, and creams |
| Sturdee and Panay [33] | 2010 | According to this study, local estrogen is safe and efficient and thus preferred. However, if the patient is unwilling to use hormonal therapy, moisturizers and lubricants are used |
| Parish and Gillespie [34] | 2017 | According to this article, oral estrogen is used for vasomotor symptoms due to menopause as well as to improve VMI. However, it can increase the risk of stroke and thromboembolism and risk and benefit should be evaluated before prescribing |
| Kagan et al. [35] | 2019 | According to the authors, even though many treatment options are available for GSM, most patients are dissatisfied with the response. Hence better communication between HCPs can help ensure better management |
| Labrie et al. [36] | 2008 | According to this study, intravaginal application of DHEA helps in alleviating the symptoms of GSM and can be used safely in breast cancer patients |
| The North American Menopause Society [37] | 2013 | According to this study, symptomatic management of GSM can positively impact the QoL of women. Depending on symptom severity as well as the patient's need, various management modalities can be used |
| Benini et al. [38] | 2022 | According to the authors, laser therapy is emerging as an effective and safe option for the management of GSM. However, the long-term effects of laser therapy have not been studied |