Alan Wein: Hello again. I'm Alan Wein from UroToday, and it's my great pleasure to have the opportunity to interview Melissa Kaufman, who chaired the AUA Guideline Committee on genitourinary syndrome of menopause. I think something that, it's a phrase that a lot of us repeat perhaps when we see patients, but I'm not sure that anyone has a clear understanding of what it means until after Melissa gives a talk about it.

Melissa Kaufman: So, we didn't always call this the genitourinary syndrome of menopause. This terminology has really only been around since about 2014. There was a consensus panel put together, really to improve medical accuracy and public acceptance. I remember in the days before we used to say erectile dysfunction, right? So it's to decrease the social stigma so we can have a conversation and move forward with science in the field.

So, what is it? What are we referring to when we talk about GSM? It encompasses a very broad range of both signs and symptoms, but they mainly involve dryness in the vagina, burning, irritation, dyspareunia, pain in general, impaired function, and of course, dysuria, urgency, frequency and recurrent urinary tract infections. And it involves all the tissues in the area. It involves the urethra, the bladder, the vagina, the vestibule, the clitoris, the labia. And it's associated not just with imbalances in estrogen, but also other sex steroids like testosterone.

And I want to relay, this is the genitourinary syndrome of menopause. This is intimately related to a number of the different types of conditions that we deal with every day in urology. So we're not just talking about treating GSM, we're going to also discuss talking about treating overactive bladder, recurrent urinary tract infections, and the entirety of really vaginal, pelvic and urinary health for these women.

You say, well, I don't know much about this. It can't be that common because certainly, I haven't seen it as much as you think. Well, what you seek is what you find, right? The prevalence in postmenopausal women can be up to 87%, even women on systemic estrogen, and we'll discuss a guideline statement about that. Women who are in perimenopause, but we're not just talking about these women. How about women who are breastfeeding, or young women on oral contraceptives, or those who've undergone pelvic surgeries or radiation, chemotherapy? What do we do with women who are on aromatase inhibitors or selective estrogen receptor modulators? What about those who've had other surgical interventions like oophorectomy? All these women fit into this category of having GSM in many instances, if they're symptomatic. So it is a very, very broad swath of many of the patients that you're going to encounter in urology.

And what causes this? Well, the vagina is this stratified squamous epithelium, and the predominant regulator of physiology is estrogen. Testosterone is also crucial. So in this low estrogen environment, you've lost a lot of the superficial cells in the vagina, and this potentiates issues with regards to the colonization of protective, symbiotic bacteria. It really causes a dysbiosis in the vagina. What does this end up with? Well, some very definitive changes in anatomy. You reduce the blood flow, you lose the rugal folds, you could decrease length. There's atrophy of the tissues and narrowing of the vagina, and generally, irritative symptoms related to what's occurring on the epithelium.

So, I wanted to just jump in to some of the cases that you may see in the clinic because I think it's really going to inform you about how to use these guidelines directly with patients, because these guidelines really provide extraordinarily pragmatic statements that are designed for you to rapidly implement in your practice. And these are going to be transformational. Transformational for you as a urologist treating these conditions, and certainly transformational for patient outcomes.

This is a really typical patient we all see. She's 77, she comes in, she's got recurrent urinary infections, she's got some frequency and urgency, some storage symptoms, she's got dryness. A pretty benign past history and a maternal grandmother with breast cancer at an advanced stage. So, one of our first statements is that patients with symptoms of GSM should undergo a genitourinary examination. This is found not only with the symptoms that the patient is experiencing, but also the signs that they have on actual physical exam.

And what exactly is that? What is an appropriate exam? To say no CVA tenderness is probably not an appropriate exam for this patient population. A pelvic exam really is an appropriate exam. It doesn't necessarily mean that it has to be a full pelvic exam with a speculum. You don't need to evaluate all the things that a gynecologist will evaluate, but you need to do an appropriate pelvic exam and you want to do it in a trauma-informed fashion. A lot of these patients are very, very reticent to have exams. And so in a shared decision-making process, speak to them about what's the benefit to do it. And if they're not comfortable that day, then perhaps bring them back on a day when they would be comfortable to perform the exam.

So it's a visual inspection and a gentle visual inspection. You can see we're using a Q-tip in this situation, but what do you see? You see very pale, fragile epithelium, petechiae, often erythema. The tissues are thinning and oftentimes it's very uncomfortable for the patient and they'll let you know exactly where their discomfort is during the exam. So be trauma-informed, be kind, be gentle, and do the best thing that you can in order to make a diagnosis.