Expert discusses genitourinary syndrome of menopause guidelines

The recent release of the “Genitourinary Syndrome of Menopause: AUA/SUFU [Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction]/[American Urogynecologic Society] Guideline” has been met with praise by health care professionals.

Among the guideline’s recommendations is the use of local low-dose vaginal estrogen as first-line therapy for genitourinary syndrome of menopause (GSM). Given the moderate-level evidence supporting its role in reducing recurrent urinary tract infections (UTIs), in a recent interview, Urology Times® asked Karyn S. Eilber, MD, how she discusses this benefit with patients who present with both GSM symptoms and a history of UTIs.

“Most women are so happy to get this, to find out there actually is something that can help both their sexual symptoms and vaginal dryness, as well as to help prevent recurrent urinary tract infections. What is really interesting is, for many, many years, my colleagues and I have been using vaginal estrogen to prevent urinary tract infections, but this is not on the label for the vaginal estrogen, so it sometimes becomes a little tricky getting insurance coverage for it…But most of the time, women are very, very receptive, because they usually don't have just 1 isolated symptom. It is those GSM symptoms of frequency, burning with and without urination, vaginal dryness, pain with intercourse, [and patients say], ‘Oh, and I also have recurrent urinary tract infections,’ ” 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.

Although the guideline notes that physical signs may support the diagnosis of GSM, hormonal levels are not required. When asked in what specific clinical scenarios she might consider ordering hormone level testing when evaluating a patient with suspected GSM, Eilber said, “If you have a woman, say, who is 70 or 75 or even older, and she's been menopausal for a while, you know what her hormone levels are. They are very low, and especially if she's not been on hormone therapy for more than 10 years since menopause, you are not going to put her on systemic therapy because there's actually a higher risk. So you just focus on treating the GSM. You don't need to know systemic hormone levels to treat GSM, because vaginal estrogen in general is not absorbed systemically in any significant amount, and we don't adjust treatment based on hormone levels anyway.”