Guideline No. 422b: Menopause and Genitourinary Health

Objective: Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population: Perimenopausal and postmenopausal women. Benefits, Harms, and Costs: Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence: Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002-2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience: physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS: 1. The effects of estrogen deficiency on urogenital tissues include signs and symptoms of vulvovaginal atrophy, urinary urgency, dysuria, and recurrent urinary tract infection (high). 2. Genitourinary syndrome of menopause is common and impairs quality of life, sexual function, and partner relationships (high). 3. Without treatment, this syndrome will evolve chronically in most women and progress to functional and structural urogenital tissue changes that can be difficult to reverse even with treatment (high). RECOMMENDATIONS: 1. Women entering menopause should be educated about the progressive impact of estrogen deficiency on urogenital health and the many options available for symptom relief (strong, high). 2. Menopausal women should be comprehensively screened for genitourinary syndrome of menopause symptoms on an ongoing basis, as symptoms can present insidiously and become bothersome long after the menopausal transition (strong, high). 3. First-line management options for genitourinary syndrome of menopause may include vaginal lubricants and/or vaginal moisturizers, particularly if patient concerns are limited to vaginal dryness or dyspareunia (strong, high). 4. Second-line therapy for genitourinary syndrome of menopause is vaginal estrogen, administered either as a cream, tablet, or sustained-release ring (strong, high). Clinically significant systemic hormone absorption does not occur with low-dose therapy, so concomitant progestogen therapy is not needed (strong, high). 5. Other second-line pharmacotherapy for atrophic vaginal symptoms includes the oral selective estrogen receptor modulator, ospemifene, and vaginal dehydroepiandrosterone ovules (strong, high). 6. Long-term use of intravaginal laser therapy to manage genitourinary syndrome of menopause or stress urinary incontinence remains experimental and should be conducted only within the protocols of well-executed clinical trials designed to establish its safety and efficacy (strong, very low).