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Summary

Mercer et al. [1] performed a prospective cohort study to evaluate the impact and feasibility of pelvic floor muscle training (PFMT) in postmenopausal women affected by the genitourinary syndrome of menopause (GSM). GSM is characterized by genito-urinary symptoms and signs secondary to sex hormone deprivation after the menopause. For this, 32 non-obese postmenopausal women (68.0 ± 6.6 years) underwent for 12-weeks a PFMT program and home pelvic floor muscle exercises. Genital atrophy, sexual function, urine leakage episodes and the impact on quality of life were evaluated with standardized scores and questionnaires before and after the intervention. The data were analyzed using one-way analysis of variance. 91% of the women completed the program and 76% of them reported a clear improvement of symptoms. Results were statistically significant for all evaluated parameters. None of the participants reported an increase of the severity of symptoms. Interestingly, in 31% of women, vaginal discharges increased after the intervention.  In women treated with hormonal therapy (HT) this latter effect was not observed. The positive effect was related to vulvo-vaginal blood flow improvement and increase in PFM coordination and normalization of PFM tone.

Commentary

During the postmenopausal period there is a progressive alteration in the composition of the female pelvic floor [2]. Sex hormone deprivation and aging lead to a progressive decrease in collagen, skeletal muscle mass and strength [2]. These changes contribute in the development of lower urinary tract symptoms, urinary incontinence (UI) and pelvic organ prolapse [2]. The effect of estrogen deprivation on urogenital epithelium can result in a complex of symptoms involving the vulva, clitoris, introitus, vagina, urethra, and bladder, more generally known as the GSM [2,3]. In addition to the somatic effects, GSM is often associated to an adverse psychological impact and substantial reduction of patients’ quality of life [3]. The gold standard in conservative treatment of GSM are systemic and local hormone therapy (HT), vaginal dehydroepiandrosterone and oral selective estrogen receptor modulators [3]. Although it is known that HT is a safe and useful option for selected populations [4], many postmenopausal women still refuse its use. Moreover, those therapies present several contraindications [3]. In these women GSM is often underdiagnosed and undertreated [5]. Non-pharmacological therapies include non-hormonal local preparations, acupuncture, laser therapies and PFMT. Lubricants, moisturizers and hyaluronic acid-based preparations may be useful to relieve symptoms of GSM [3]. Even if there is some evidence that laser therapies can restore the vaginal epithelium to that of the premenopausal state, these studies lack randomization [3].

PFMT could be a valid option: cheap, harmless and safe. In the study of Mercer [1], the PFMT program significantly reduced the signs and symptoms of vaginal atrophy and IU, improving vaginal discharges, sexual function and quality of life. PFMT is defined as an exercise program aimed to increase muscle strength, endurance, power, flexibility, and relaxation of the PFM [6]. Moreover, authors hypothesize that the increase of vascularization secondary to muscular mass development can explain the improvement of vaginal and vulvar epithelium tropism and the increase of vaginal secretion. Consistent with the literature, PFMT programs are effective in reducing symptoms of stress and urgency UI [7]. However, it is important to note that PFMT was less effective in women who were simultaneously on HT [1]. These data are supported by a randomized control study propose by Ignácio Antônio et al. [8], that showed that PFMT does not provide a significant improvement in women simultaneously treated with HT. This data is difficult to justify, and further studies are needed to explain this apparent discrepancy. Due to the lack of contraindication, PFMT is supported as a valid treatment of GSM in women with past or present history of breast cancer [5]. As the authors conclude, PFMT alone or associated with other therapies can be an effective option for GSM in women who are not candidates for pharmacological therapies.

Francesca Massimello, MD
Paolo Mannella, MD, PhD

Department of Clinical and Experimental Medicine
University of Pisa

References

  1. Mercier J, Morin M, Zaki D, Reichetzer B, Lemieux MC, Khalifé S, Dumoulin C. Pelvic floor muscle training as a treatment for genitourinary syndrome of menopause: A single-arm feasibility study. Maturitas. 2019;125:57-62.
    https://pubmed.ncbi.nlm.nih.gov/31133219/
  2. Dumoulin C, Pazzoto Cacciari L, Mercier J. Keeping the pelvic floor healthy. Climacteric. 2019;22(3):257-262.
    https://pubmed.ncbi.nlm.nih.gov/30653374/
  3. Kagan R, Kellogg-Spadt S, Parish SJ. Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs Aging. 2019;36(10):897-908.
    https://pubmed.ncbi.nlm.nih.gov/31452067/
  4. Palacios S, Stevenson JC, Schaudig K, Lukasiewicz M, Graziottin A. Hormone therapy for first-line management of menopausal symptoms: Practical recommendations. Womens Health (Lond). 2019;15:1745506519864009.
    https://pubmed.ncbi.nlm.nih.gov/31378196/
  5. Faubion SS, Larkin LC, Stuenkel CA, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women’s Sexual Health. Menopause. 2018;25(6):596-608.
    https://pubmed.ncbi.nlm.nih.gov/29762200/
  6. Bo K, Frawley HC, Haylen BT, Abramov Y, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Int Urogynecol J. 2017;28(2):191-213.
    https://pubmed.ncbi.nlm.nih.gov/27921161/
  7. Radzimińska A, Strączyńska A, Weber-Rajek M, Styczyńska H, Strojek K, Piekorz Z. The impact of pelvic floor muscle training on the quality of life of women with urinary incontinence: a systematic literature review. Clin Interv Aging. 2018;13:957-965.
    https://pubmed.ncbi.nlm.nih.gov/29844662/
  8. Ignácio Antônio F, Herbert RD, Bø K, et al. Pelvic floor muscle training increases pelvic floor muscle strength more in post-menopausal women who are not using hormone therapy than in women who are using hormone therapy: a randomised trial. J Physiother. 2018;64(3):166-171.
    https://pubmed.ncbi.nlm.nih.gov/29914808/
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