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The “Genitourinary Syndrome of Menopause”: A Leap Forward?

Vieira-Baptista, Pedro MD1; Marchitelli, Claudia MD2; Haefner, Hope K. MD3

Journal of Lower Genital Tract Disease: October 2015 - Volume 19 - Issue 4 - p 362–363
doi: 10.1097/LGT.0000000000000127
Commentary
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Comment on the new “Genitourinary Syndrome of Menopause,” namely, its implication in terms of vulvar pathology.

1Serviço de Ginecologia e Obstetrícia, Centro Hospitalar de São João, Porto, Portugal; 2Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; and 3University of Michigan Health System, Ann Arbor, Michigan

Reprint requests to: Pedro Vieira Baptista, MD, Rua José Pinto Miranda, 14, 2500–287 Caldas da Rainha, Portugal. E-mail: pedrovieirabaptista@gmail.com

No grants or funding were received for the elaboration of this article.

No conflicts of interest to declare.

In 2012, the board of directors of the International Society for the Study of Women's Sexual Health and the board of trustees of the North American Menopause Society felt there was a need to review the current terminology associated with genitourinary tract symptoms in relation to menopause. They cosponsored a terminology consensus conference that occurred in May 2013 in Chicago, Illinois.

The primary goal was to “improve and ease” conversations between menopausal patients and their health-care providers. A panel of 20 experts decided that a new terminology for “vulvovaginal atrophy” was needed; it should be called “genitourinary syndrome of menopause” (GSM).1–4 The recommendation of the consensus conference was that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, publicly acceptable, and less embarrassing term than vulvovaginal atrophy. The new terminology, genitourinary syndrome of menopause (GSM), was endorsed by the boards of International Society for the Study of Women's Sexual Health and North American Menopause Society in 2014.

Concerns about the new GSM terminology exist. Their incentives for this new designation were as follows: 1) atrophic “vaginitis” implies infection or inflammation which may not be present, 2) urinary signs and symptoms are overlooked, 3) “atrophy” has “negative connotations,” and 4) the vulva and vagina are not generally accepted terms by women and the media. Although most people agree on the first 2 points, the other points have raised disagreement. “Atrophy” was considered as having a negative connotation, and a Merriam-Webster Dictionary was used to prove it: “a decrease in size or wasting away of a body part or tissue; wasting away or progressive decline, as from disuse.” The authors concluded that, as the condition is not directly related to disuse, it is not applicable. However, is it not related at times to a decline in hormones, which can affect sexual activity? It was considered that “atrophy” has a “negative connotation for midlife women,” but for some women, the same will be true with GSM. Some women may prefer to hear that they have an “atrophy” rather than a syndrome of “menopause.”1–4

Another concern is that with this terminology, many diagnoses of vulvovaginal disease in the menopause will fit into GSM. The impact that this new designation might have in clinical practice is of concern to many vulvologists. More than just a new name, the authors created a new “syndrome.” Rather than a few signs, it includes also symptoms such as pruritus, itching, pain, and dysuria. If we consider a patient presenting, for example, with pruritus, labia minora resorption, pallor, and fissures, it fits perfectly into GSM. However, there is a good likelihood she will have lichen sclerosus, a major cause of sexual dysfunction,5 but will be treated, most likely, only with estrogens6 or an estrogen agonist/antagonist.7 Similarly, patients seeking help for genitourinary symptoms, such as dysuria and urinary frequency/urgency, will find they are also part of the new syndrome. However, urologic evaluation is not recommended, and an alternative diagnosis may be missed. It should be emphasized that GSM is a diagnosis by exclusion. Although these symptoms are often related to a lack of estrogen, they are not always attributable to it.

Finally, although it is difficult to include every potential professional organization related to specific disorders, some major societies involved with diseases of the vulva, vagina, and bladder were not part of the panel and, thus, were not present to express their opinions and concerns.

Rather than a leap forward, this new designation might turn out to be a step backward. Patients seeking help on the Internet will eventually come across GSM, and they will find a perfectly good explanation for their symptoms, potentially delaying an alternative diagnosis. We need to work on educating the public with anatomically correct words from an early age, answering their questions about their anatomy without embarrassment, humiliation, and disapproval. As clinicians, we should be fighting to stop the taboos and barriers to anatomical terminology.8 We should teach women to know their own anatomy and physiology, rather than averting it and disguising it with a term that can fit almost all genital signs and symptoms. Great emphasis is put in the fact that the words vulva and vagina are not very well accepted. There is no reason to be offended by these 2 words in the first place. Women represent almost 50% of the population; thus, approximately half of the world have vulvas and vaginas.

Independent of the terminology, vulvovaginal signs and symptoms of menopause are very common.9 They are a major cause of sexual dysfunction. Every effort to improve their identification and adequate treatment should be undertaken. Despite the ambitious intention of the authors that this new designation and the concept of this new syndrome will be widely used, it should not be taken lightly, and others should be encouraged to express their opinions.

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REFERENCES

1. Portman DJ, Gass ML. Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and The North American Menopause Society. J Sex Med 2014; 11: 2865–72.
2. Portman DJ, Gass ML. Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Vulvovaginal Atrophy Terminology Consensus Conference Panel. Maturitas 2014; 79: 349–54.
3. Portman DJ, Gass ML. Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society. Vulvovaginal Atrophy Terminology Consensus Conference Panel. Climacteric 2014; 17: 557–63.
4. Portman DJ, Gass ML. Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Vulvovaginal Atrophy Terminology Consensus Conference Panel. Menopause 2014; 21: 1063–8.
5. Haefner HK, Aldrich NZ, Dalton VK, et al. The impact of vulvar lichen sclerosus on sexual dysfunction. J Women’s Heal 2014; 23: 765–70.
6. Rahn DD, Carberry C, Sanses TV, et al. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol 2014; 124: 1147–56.
7. Portman D, Palacios S, Nappi RE, et al. Ospemifene, a non-oestrogen selective oestrogen receptor modulator for the treatment of vaginal dryness associated with postmenopausal vulvar and vaginal atrophy: a randomised, placebo-controlled, phase III trial. Maturitas 2014; 78: 91–8.
8. Buni C. The Case for Teaching Kids ‘Vagina,’ ‘Penis,’ and ‘Vulva’. The Atlantic. Washington: Atlantic Monthly Group; 2013. Available at: http://www.theatlantic.com/health/archive/2013/04/the-case-for-teaching-kids-vagina-penis-and-vulva/274969/. Accessed May 1, 2015.
9. Kingston A. Vulval disease in the postmenopausal patient: a guide to current management. Menopause Int 2010; 16: 117–20.
Keywords:

genitourinary syndrome of menopause; vulvovaginal atrophy; menopause

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