Genitourinary syndrome in Paris

Intimate female surgery at Henri Mondor Hospital

Genitourinary syndrome in Paris

Plastic, Reconstructive & Aesthetic Surgery in Paris Est Créteil

Genitourinary syndrome of the menopause (GSM) is the new term for vulvovaginal atrophy (VVA). Symptoms of oestrogen deficiency in the genitourinary tract are troublesome in over 50% of women, having a negative impact on quality of life, social activity and sexual relations. GSM is a chronic and progressive syndrome that is under-diagnosed and under-treated.

Genitourinary menopause syndrome (GSM) is a relatively new term, first introduced in 2014 by a consensus of the International Society for the Study of Women’s Sexual Health and the North American Menopause Society.

GSM, formerly known as vulvovaginal atrophy, atrophic vaginitis or urogenital atrophy, is a term that describes the spectrum of changes caused by the lack of oestrogen during the menopause.

Intimate female surgery

Genitourinary syndrome in Paris

GSM-type symptoms may also be present in 15% of pre-menopausal women as a result of the hypoestrogenic state.

However, the vast majority of women suffering from GMS are older, with 50-70% of post-menopausal women being symptomatic to at least some extent. To date, GMS remains extremely under-diagnosed despite its high prevalence, mainly because of women’s reluctance to seek help due to embarrassment, or because of a tendency among many women to regard it as a normal feature of natural ageing.

However, in many cases, the reluctance of health professionals to address these problems is a major cause of the lack of awareness of this syndrome among the women affected.

Genitourinary syndrome in Paris

Pr Hersant Plastic, Aesthetic & Reconstructive Surgery

GSM is a chronic, progressive condition of the vulvovaginal and lower urinary tracts, characterised by a wide range of signs and symptoms. The common clinical manifestations of the disease are summarised in this table.

SIGNS AND SYMPTOMS OF GSM
Genital

– Vaginal dryness

– Irritation/burning/itching

– Leucorrhoea

– Thinning pubic hair

– Vaginal/pelvic pain and pressure

– Prolapse of the vaginal vault

Sexual

– Dyspareunia

– Reduced lubrication

– Post-coital bleeding

– Decreased arousal, orgasm, desire

– Loss of libido, arousal

– Dysorgasmia

Urinary

– Dysuria

– Incontinence

– Recurrent urinary tract infections

– Urethral prolapse

– Bladder trigone ischaemia

These symptoms are directly linked to the reduction in circulating oestrogen levels after the menopause. Oestrogen receptors (ER; α and β) are present in the vagina, vulva, pelvic floor musculature, endopelvic fascia, urethra and bladder trigone during reproductive life; their levels decline with the menopause and can be restored by oestrogen treatment.

As a result of oestrogen deficiency after the menopause, anatomical and histological changes occur in female genital tissue, including a reduction in collagen and hyaluronic acid content and elastin levels, thinning of the epithelium, alterations in smooth muscle cell function, increased connective tissue density and a decrease in the number of blood vessels. These changes reduce vaginal elasticity, increase vaginal pH, lead to changes in vaginal flora, reduce lubrication and increase vulnerability to physical irritation and trauma.

Because oestrogen plays such an important role in lower urinary tract function throughout the premenopausal period, oestrogen deficiency after the menopause leads to lower urinary tract symptoms such as dysuria, urgency, frequency, nocturia, urinary incontinence (UI) and recurrent urinary tract infections.

The prevalence and severity of the symptoms mentioned above vary according to the time elapsed since the menopause, most of them being more frequent and more intense five years after the menopause compared with women closer to premenopausal status (GSM symptoms occur in 84% of women six years after the menopause compared with one year after the menopause in 65%).

GSM symptoms have an impact on the quality of life of women affected. This is because they rarely resolve spontaneously and, in most cases, deteriorate if left untreated, adversely affecting patients’ confidence and intimacy with their partners. The impact on quality of life was more profound in sexually active women.

The main aim of GSM treatment is to relieve symptoms. The treatment options available, in addition to local and systemic hormone therapy, include lifestyle changes and non-hormonal treatments.

With regard to the conservative approach, a positive link between maintaining vaginal elasticity and the lubricant response to sexual arousal with sexual activity has been demonstrated.

In addition, avoiding any risk factors associated with GSM, such as smoking cessation, may be helpful, as smoking has been associated with increased oestrogen metabolism leading to vaginal atrophy. Nevertheless, the first-line treatment for GSM is the use of non-hormonal vaginal lubricants and moisturisers.

Lubricants are water-, silicone- or oil-based products that are not absorbed by the skin. They act immediately and provide temporary relief from vaginal dryness and pain during intercourse. Vaginal moisturisers are applied regularly. These are bioadhesive and can improve coital comfort and increase vaginal hydration.

Moisturisers mimic vaginal secretions and lower the pH by altering the fluid content in the vaginal epithelium. However, both of these products are primarily suitable for women with mild to moderate symptoms, and many patients will eventually require additional hormonal medication.

Other complementary therapies such as oral vitamin D, vaginal vitamin E and probiotics have been proposed as alternative modalities to GSM therapy; however, data on their efficacy are scarce and further studies and trials are needed to validate them.

Vaginal hyaluronic acid is a colourless gel containing a derivative of hyaluronic acid that releases water molecules into the tissues, thereby alleviating vaginal dryness without irritating the vaginal mucosa. The FDA currently regulates hyaluronic acid-based products as medical devices.

Only one product currently has CE marking for the genital area: DESIRIAL from the Vivacy brand. This is a cross-linked acid with the following indications:

intimate dryness

vaginal discomfort

chronic irritation

Hyaluronic acid is naturally present in the vaginal epithelium, as in the rest of the body, where it helps to hydrate tissues.

Injections of hyaluronic acid will therefore hydrate the vulvo-vaginal area, soothe irritated areas and improve the tissue quality of the genital mucosa. There are no keratocytes in the vaginal mucosa, so the product will spread very quickly over the entire vaginal wall.

Desirial is a cross-linked hyaluronic acid with a rheology adapted to the genital area: it is concentrated at 21 mg/g, elastic and viscous. It contains mannitol, which has an antioxidant action and slows down its degradation. It is made in France.

Yes, an annual gynaecological examination is recommended for all women after the start of their sexual life. A normal smear test is also recommended before any procedure in this area. You should also check that there are no local conditions such as herpes or mycosis….

Two types of anaesthetic are generally used in combination:

Topical gel anaesthesia: of the vestibule and vagina with a 2% lidocaine gel to be applied 30 minutes before the injection.

Local anaesthesia: submucosal injection of 2% lidocaine at the entrance to the vagina. This is a rapid injection, but it is an area that is relatively feared by patients; the use of nitrous oxide (inhaled gas) may be necessary in addition.

What is the procedure for injecting hyaluronic acid for vulvovaginal dryness (or atrophy or genitourinary syndrome)?

The patient is placed on a gynaecological table with stirrups for greater comfort, but this is not compulsory. A speculum can also be used if necessary.

The skin and mucous membranes must be disinfected with gynaecological betadine.

The optimal volume to inject is 1 ml. The injection is made into the vestibule, at the level of the posterior wall of the vagina over the first few centimetres.

Minor complications may occur after the injection, such as oedema, haematoma, tenderness at the injection site or pruritus. These usually resolve within a few days. Infectious complications may also occur.

No major complications have been reported.

In more persistent cases, hormone therapy using oestrogenic products is generally considered the ‘gold standard’. Hormone therapy is an option for treating moderate to severe symptoms of GSM that are not relieved by conservative methods. Hormone therapy includes oestrogen-based products that can be administered by different routes (vaginal, oral, transdermal or subcutaneous), with vaginal tablets or creams showing better results than others.

If you have a history of oestrogen-sensitive tumours, such as breast or endometrial cancer, any hormone therapy should be used with caution; the benefit/risk ratio must be individualised and coordinated with an oncologist. The risks associated with hormone therapy must be carefully assessed, and factors such as age, duration of use, dose, type of treatment, route, histological type of malignancy and prior exposure must be taken into account before prescribing such a regimen in gynaecological cancer survivors. Breast cancer is a hormone-sensitive carcinoma in many cases; therefore, systemic hormone therapy is not generally recommended for women with breast cancer.

Hormone therapy can be introduced by your gynaecologist, endocrinologist or anti-ageing doctor.

Recently, laser therapy (fractionated or erbium: YAG) and radiofrequency have emerged as alternative treatment modalities for GSM, particularly for patients with a history of breast cancer.

Several studies have shown that fractional CO 2 laser therapy can restore the vaginal epithelium to a state similar to the premenopausal state, increase the quantities of lactobacilli and other premenopausal flora, and improve the Vaginal Health Index (VHI) and symptoms of GSM, including lower urinary tract symptoms.

Histologically, thermal energy applied to the vaginal mucosa stimulates the proliferation of healthy glycogen-rich multi-layered epithelium, neocollagenesis in the lamina propria and neovascularisation.

In the field of regenerative medicine, autologous platelet-rich plasma (PRP) and hyaluronic acid (HA) have been identified as having considerable potential as tools for tissue regeneration. In a phase II study, we demonstrated in a clinical trial the value of using the combination of PRP and HA for the treatment of vaginal atrophy in patients with a history of breast cancer.

The results of this study clearly showed an improvement in the vaginal health score, with an increase in fluid volume, a decrease in pH, maintenance of epithelial integrity and an increase in hydration. An improvement in the quality of the participants’ sex life was reported after treatment with PRP-HA injections.