Alternative treatments and patient communication for genitourinary syndrome of menopause

At the American Urological Association 2025 Annual Meeting in Las Vegas, Nevada, the “Genitourinary Syndrome of Menopause: AUA/SUFU [Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction]/[American Urogynecologic Society] Guideline” was released. One of the topics covered in the guideline is the use of vaginal estrogen for patients with genitourinary syndrome of menopause (GSM). Vaginal DHEA and oral ospemifene are presented as other hormonal options with conditional recommendations. In a recent interview with Urology Times^®, Karyn S. Eilber, MD, was asked what patient characteristics or circumstances might lead her to consider these alternatives over first-line vaginal estrogen.

“In my experience, and probably most others, vaginal estrogen alone is probably the most effective. However, there are some women who are just allergic or don't tolerate any of the ones that are commercially available. Those are [patients for whom] you might even consider compounded hormones. But also, DHEA is good for women who maybe want to have a little testosterone. Maybe they have some labial effects or something else that they want some local testosterone for, but allergies, intolerance of vaginal estrogen, and then some women just don't want to put anything in the vaginal area. They find it too messy or too cumbersome. That’s when oral therapy like ospemifene can be useful,” said Eilber, chair of the Cedars-Sinai Medical Group department of surgery and professor of urology, an associate professor of obstetrics & gynecology at Cedars-Sinai Medical Center in Los Angeles, California, and member of the plusOne Wellness Collective.

Eilber was also asked about communicating safety information about to patients who may have concerns about hormone-related therapies due to past concerns or anxieties.

“This is probably one of the most difficult things to overcome, because the packaging on vaginal estrogen does imply that it carries the same risks as if you were taking a systemic hormone therapy. But a good example that I often will tell my patients is if you have a steroid pill, you will have all the systemic effects of steroid pill. But if I have a little spot of rash and I just use steroid cream, it's only going to work in that area, and that resonates with most people; they understand the difference between systemic estrogen and just vaginal estrogen,” Eilber said.