Are Hormonal Treatments and Vaginal Moisturizers useful for Genitourinary Syndrome of Menopause?

Recent systematic review published in the Annals of Internal Medicine offers insights into the effectiveness and safety of treatments for genitourinary syndrome of menopause (GSM). Hormones such as vaginal estrogen, vaginal dehydroepiandrosterone (DHEA), and oral ospemifene, as well as vaginal moisturizers, are commonly used to alleviate symptoms of GSM, including vaginal dryness and painful intercourse. The review, led by Elisheva Danan, MD, MPH, and her colleagues, encompassed 46 randomized controlled trials, with most treatments lasting for 12 weeks or less. However, the safety of long-term use of these therapies remains unclear, particularly regarding the potential risk of uterine cancer with extended use of vaginal estrogen or ospemifene. The findings from the review indicate that hormonal treatments are associated with reduced pain during intercourse and decreased vaginal dryness, while moisturizers are linked to reduced dryness. Vaginal estrogen showed mixed effectiveness in reducing pain during intercourse compared to DHEA or ospemifene, although it outperformed placebo. The review also highlighted the scarcity of evidence on the benefits of oral DHEA, raloxifene, bazedoxifene, vaginal oxytocin, or vaginal testosterone for the treatment of GSM. Notably, the conclusions drawn from the review have low certainty due to the short duration of most studies and varying definitions of GSM symptoms. Furthermore, the review did not address the association between GSM and recurrent urinary tract infections (UTIs). According to Rachel Rubin, MD, a urologist and sexual medicine specialist, hormones are essential for addressing the root cause of GSM and reducing the risk of recurrent UTIs. Rubin emphasized the link between UTIs and GSM, indicating that the lack of hormones to the tissue due to GSM can lead to recurrent UTIs, underscoring the importance of longer-term safety data for these treatments. In an accompanying editorial, Stephanie Faubion, MD, MBA, raised concerns about the lack of diversity among the patients represented in GSM treatment trials and the exclusion of women with cardiovascular challenges or cancer. This raises questions about the safety of these treatments for women with specific health conditions, such as cardiovascular risk factors or a history of cancer. Overall, the review provides important insights into the effectiveness of various treatments for GSM but underscores the need for further research, particularly regarding long-term safety and the association between GSM and UTIs.

Key Points

1. The systematic review in the Annals of Internal Medicine evaluates the effectiveness and safety of treatments for genitourinary syndrome of menopause (GSM), including vaginal estrogen, vaginal dehydroepiandrosterone (DHEA), oral ospemifene, and vaginal moisturizers.

2. The review encompasses 46 randomized controlled trials, with most treatments lasting for 12 weeks or less. It highlights the reduced pain during intercourse and decreased vaginal dryness associated with hormonal treatments and moisturizers, but also notes the uncertainty regarding the long-term safety of these therapies, particularly the potential risk of uterine cancer with extended use of vaginal estrogen or ospemifene.

3. Vaginal estrogen, DHEA, and ospemifene show varying effectiveness in reducing pain during intercourse, with vaginal estrogen outperforming placebo, while the evidence on the benefits of oral DHEA, raloxifene, bazedoxifene, vaginal oxytocin, or vaginal testosterone for the treatment of GSM is limited.

4. The review did not address the association between GSM and recurrent urinary tract infections (UTIs), which is highlighted as crucial, emphasizing the link between UTIs and GSM due to the lack of hormones to the tissue, and the importance of longer-term safety data for these treatments.

5. An accompanying editorial raises concerns about the lack of diversity among the patients in GSM treatment trials and the exclusion of women with cardiovascular challenges or cancer, which questions the safety of these treatments for women with specific health conditions.

6. The review provides vital insights into the efficacy of various GSM treatments but underscores the need for further research, particularly regarding long-term safety and the association between GSM and UTIs.

Reference -

Elisheva R. Danan, Catherine Sowerby, Kristen E. Ullman, et al. Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause: A Systematic Review. Ann Intern Med.2024;177:1400-1414. [Epub 10 September 2024]. doi:10.7326/ANNALS-24-00610