Understanding GSM: Addressing Hormonal and Musculoskeletal Factors for Symptom Relief
We’re still celebrating Women’s History Month here at The Pelvic Model! With this, let’s talk more about women’s health, more specifically: Menopause.
Menopause marks a significant transition in the lives of individuals with uteruses, one that is often met with mixed feelings. While the relief of no longer experiencing monthly menstruation is welcomed by many, it also brings about challenges such as hot flashes and heightened anxiety for some. Moreover, there's a noticeable absence of formal education or preparation regarding what to expect during menopause or perimenopause. Most individuals are left navigating this pivotal life stage with minimal guidance, and they turn to their peers and personal networks to decipher the new symptoms they’re experiencing.
Well, let The Pelvic Model help you navigate one thing those in menopause may experience: Genitourinary Syndrome of Menopause (GSM).
When it comes to the pelvis, menopause can bring about symptoms such as increased susceptibility to UTIs, burning sensation during urination, painful intercourse, and more. These symptoms arise due to a depletion of sex hormones. The primary sources of sex hormones—estrogen, progesterone, and testosterone—are mainly the adrenal glands and the ovaries. As individuals reach the age of 35, the adrenal glands begin to produce fewer sex hormones, and with menopause, the ovaries cease hormone secretion altogether. This presents a challenging situation for individuals assigned female at birth, as they are expected to live many more decades with sex hormones that progressively decline.
The repercussions of these depleted hormones manifest as genitourinary syndrome of menopause (GSM), wherein individuals with vulvas experience discomfort in the entrance of the vagina (known as the vestibule), frequent urination and/or urge urination, painful intercourse (also referred to as dyspareunia), pain during urination, vaginal dryness, recurrent UTIs, and so forth.
Hormonal changes can potentially contribute to vestibulodynia (pain at the entrance of the vagina), as previously mentioned in The Pelvic Model's brief overview of vulvodynia. As we understand, individuals in menopause experience decreased levels of sex hormones, which can exacerbate uncomfortable symptoms in the genital area. In this blog, we explore the concept of menopause, the role of hormones in genitourinary syndrome of menopause, and further details on this condition.
What is Menopause?
The North American Menopause Society (NAMS) defines menopause as “The final menstrual period, which can be confirmed after 12 consecutive months without a period. This time marks the permanent end of menstruation and fertility. It is a normal, natural event associated with reduced functioning of the ovaries, resulting in lower levels of ovarian hormones (primarily estrogen).”
However, in regards to pelvic health, burgeoning research is urging professionals to look further than estrogen in treating the genitourinary system. Multiple studies have broken down the role of androgens in genitourinary health in females, and testosterone plays more of a role than once thought. These crucial hormones play a role in what we now call genitourinary syndrome of menopause.
What is Genitourinary Syndrome of Menopause (GSM)?
GSM used to be called vulvovaginal atrophy (VVA). But in 2014, the name was updated. This change was backed by the American College of Obstetricians and Gynecologists, and lots of others agreed with it too. The reason for the change was to cover both genital and urinary symptoms that happen when the ovaries stop working regularly during menopause. The old term, VVA, didn't really capture all the effects on the genital and urinary areas.
Symptoms of GSM are associated with decreased hormone levels and may involve the labia majora/minora, vestibule, clitoris, vagina, urethra, and bladder. Symptoms can include irritation in the vestibule (opening of the vagina), pain with urination, urinary frequency and/or urgency, recurrent UTIs, vaginal dryness, labial resorption, loss of vaginal rugae, protrusion of the urethral meatus and urethral sensitivity, and dyspareunia.
Hormones and the Genitourinary system:
Many people believe that estrogen is the primary driver in female hormones; however, when addressing GSM and vestibular health, it is important to consider the role of androgens.
Vagina: In the vagina there are both androgen and estrogen receptors. Both are crucial in mucin production, neurotransmitter content, and nerve density in the vagina.
Bladder/urethra/prostate: In regards to the bladder neck, estrogen and progesterone are important for adequate blood flow to decrease incidence of urinary incontinence.
Clitoris/vulva/labia: The clitoris has been known to be androgen-dependent. However, estrogen plays a crucial role in this structure. When not sexually stimulated, estrogen is crucial for clitoral volume, and it is negatively correlated to vascular resistance.
Given this, it's no surprise that individuals experiencing menopause start to feel symptoms of GSM.
What does physical therapy have to do with this then?
Many individuals turn to us before realizing they may be experiencing GSM. This is because increased tension in the pelvic floor muscles can mimic UTI symptoms as well as vaginismus. Initially, we conduct an assessment to identify which muscles are involved in your symptoms. Additionally, we perform further tests to determine if hormones are possibly contributing to your symptoms. If they are, we refer you to a physician for further testing.
As mentioned, symptoms of GSM can overlap with those of increased pelvic floor tension. Furthermore, experiencing GSM can lead to muscle guarding because it can be painful thus worsening symptoms. Therefore, addressing both the hormonal and musculoskeletal aspects is crucial.
Following the initial assessment, we assist you in assembling an interdisciplinary team, including a physician to address hormonal concerns. Together, we develop a plan to alleviate your symptoms. Depending on our findings, treatment may involve techniques such as pelvic floor relaxation, breathing exercises, stretching, and improving control of your pelvic floor, core, and pelvic girdle muscles. This approach aims to eliminate the pelvic floor as a contributing factor to your symptoms while addressing hormonal issues through your curated interdisciplinary team.
We understand that this information may raise further questions, and we are always available to provide assistance. Please feel free to contact us at (323) 403-0234, and we will gladly discuss your concerns.
Menopause. UCLA Obstetrics and Gynecology. http://obgyn.ucla.edu/menopause. Accessed August 13, 2019.
Simon JA, Goldstein I, Kim NN, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM). Menopause. 2018;25(7):837-847. doi:10.1097/gme.0000000000001138.
Traish AM, Vignozzi L, Simon JA, Goldstein I, Kim NN. Role of Androgens in Female Genitourinary Tissue Structure and Function: Implications in the Genitourinary Syndrome of Menopause. Sexual Medicine Reviews. 2018;6(4):558-571. doi:10.1016/j.sxmr.2018.03.005.
Labrie F. Intracrinology and menopause. Menopause. 2019;26(2):220-224. doi:10.1097/gme.0000000000001177.
