Recently, Ruan et al  published results of a study that aimed at investigating the genitourinary syndrome of menopause (GSM) in a large cohort of peri- and postmenopausal Chinese women. They analyzed the dependency on age and menopausal status and possible differences between non-hysterectomized and hysterectomized women. For this they assessed over 2 years, through validated questionnaires, all eligible women who attended the ‘Menopause Clinic’ coming from 31 Chinese provinces. Investigators used simple and unconditional logistic regression analysis, adjusting by all co-variates. A total of 4,063 women with a mean age of 50.5 years participated, of which 2,107 were perimenopausal and 1,956 were postmenopausal. Almost all of the symptoms of the GSM were more frequent and severe in postmenopausal females. The GSM was more frequent in hysterectomized women compared to non-hysterectomized ones. Independent of menopausal status, low sexual interest (92.78%), urinary incontinence (91.65%) and vaginal dryness (91.60%) were the top three symptoms of the GSM. Most severe were low sexual interest (21.01%), vaginal pain (20.10%) and decreased sexual pleasure (17.13%). The prevalence and severity of the GSM were not related to age but were related to menopausal status and increased with the time since menopause onset. The authors emphasize that within 2 years, more than 4,000 women with the GSM traveled from all over China to our specialized clinic, indicating the great importance of the GSM, and conclude that hysterectomy can increase the risk of the GSM, and that the GSM symptoms increase from perimenopause to post menopause and with an increase of time since menopause, pointing to the dependency on the loss of ovarian function.
In 2014, the term genitourinary syndrome of menopause (GSM) was introduced by the International Society for the Study of Women’s Sexual Health and the North American Menopause Society ; comprising genital, sexual and urinary symptoms . The most common presenting symptoms are vulvovaginal dryness, burning or irritation, sexual pain (due to inadequate lubrication), and urinary urgency, dysuria or recurrent urinary tract infections . The GSM is a chronic condition that usually starts during the menopausal transition and progresses in prevalence and in severity as women enter the postmenopausal and with time after menopause onset. The syndrome is unlikely to improve without treatment . Prevalence of the syndrome has been reported in up 50% of women from western countries; however, this rate may vary in relation to many factors such as age, menopausal status, type of menopause, ethnicity, cultural aspects, among the most important . Despite this, it is worthy to mention that the syndrome is in fact underdiagnosed due to a lack of defining criteria and to personal embarrassment and cultural reasons. Bearing this in mind, the authors, compared the prevalence and severity of the GSM in Chinese women using a validated questionnaire in a large cohort, comparing peri- and postmenopausal women, and determining the relation of the syndrome with age and time since menopause onset. A validated electronic questionnaire was used to assess the prevalence and severity of the GSM, rating a list of symptoms (from none, mild, moderate and severe) that comprise the syndrome. According to the study, more than 80% of women presented at least one of the symptoms of GSM, finding a higher rate among postmenopausal as compared to perimenopausal women. The top three most severe symptoms for perimenopausal women were low sexual interest, vaginal pain and decreased sexual pleasure, whereas for postmenopausal women these were vaginal pain, low sexual interest and low sexual pleasure. GSM was more likely to be present in hysterectomized women as compared to non-hysterectomized ones, and prevalence and severity of the GSM was not related to age yet to the menopausal status and time since menopause onset.
It is known that estrogen receptors are abundant in the female urogenital tract, explaining why postmenopausal women, who have lower estrogen levels, present more severe symptoms of the GSM as compared to perimenopausal women. Interestingly, symptoms of GSM are more prevalent in the Chinese population as compared to vasomotor ones, situation that has been previously described by the same investigators . Finding a lower prevalence of vasomotor symptoms among Asian women has been previously described and related to dietary, and cultural reasons.
Although the authors declare the limitations to their study such as selection bias related to the fact that more women with GSM and those with more severe symptoms went to their specialized clinic, and also that results are based on baseline data of a prospective cohort study, I personally think that there is another potential limitation which is the lack of specifically defining the GSM, there is only a mention of the prevalence and severity of symptoms comprising the GSM. In this sense, there is a need of finding a consensus criterion for the definition of the syndrome based not only the screening of symptoms but also combined with physical examination findings. Despite this, I agree that this is to the best of knowledge the largest prospective cohort study regarding the GSM among mid-aged Chinese women, and that the survey provides significant insights into the prevalence, severity and differences between the various symptoms of GSM in this mid-aged population, which can help sensitize clinicians regarding the diagnosis and treatment of the GSM. Indeed, there is a need for more research regarding the GSM which definitively has a negative impact on quality of life of women going through the menopausal transition.
Peter Chedraui, MD, PhD
Instituto de Investigación e Innovación en Salud Integral
Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
- Ruan X, Zhang L, Cui Y, Gu M, Mueck AO. Genitourinary syndrome of menopause in Chinese perimenopausal and postmenopausal women. Climacteric. 2021;24(3):297-304.
- Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. 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. Climacteric. 2014;17(5):557-63.
- Alvisi S, Gava G, Orsili I, et al. Vaginal health in menopausal women. Medicina (Kaunas). 2019;55(10):615.
- 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.
- Monteleone P, Mascagni G, Giannini A, et al. Symptoms of menopause global prevalence, physiology and implications. Nat Rev Endocrinol. 2018;14(4):199–215.
- Zhang L, Ruan X, Cui Y, Gu M, Mueck AO. Menopausal symptoms among Chinese peri- and postmenopausal women: a large prospective single-center cohort study. Gynecol Endocrinol. 2021;37(2):185-189.
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