Management of

genitourinary in menopause
Matchima Huabkong
Division of Urology, Department of Surgery, Rajavithi Hospital
27th January 2023
Outline
• Genitourinary syndrome of menopause (GSM)
• Recurrent UTI
Genitourinary syndrome of
menopause (GSM)
Definition of GSM
• A set of symptoms associated with a decrease of estrogen, androgen,
and other sex steroidal hormone during menopause.

• Menopause: natural, spontaneous or interventional amenorrhea > 12

months

• Replacing of term “ atrophic vaginitis”

Pathophysiology
• Estrogen:
• Stimulated the maturation of the vaginal epithelium and its production of glycogen
• >>glycogen breakdown to glucose
• >>>glucose is metabolized by vaginal lactobacilli
• >>>>produce hydrogen peroxide to control the growth of vaginal pathogen

• Vaginal shorten and narrow due to loss of elasticity and rugae

• Atrophy of urethral epithelium, decreased amount of collagen

• Anterior wall prolapse

Sign and symptom of GSM
• Gynecological • Urinary
• Dryness
• Burning
• Urgency
• Irritation • Dysuria
• Lack of lubrication • Frequency
• Discomfort/ pain
• Impaired function
• Nocturia
• Dyspareunia • Incontinence
• Post-coital bleeding • Prominence of urethral meatus
• Decrease arousal, orgasm, desire
• Recurrent UTI
• Female sexual dysfunction(FSD)
• Hypoactive sexual desire disorder(HSDD)
• Skin change
 Management of GSM
• Non-hormonal treatment
• Life style modification
• Vulvar hygiene , skin care, local steroid ointment
• Pelvic floor Kegel exercise
• Bioadhesive vaginal moisturizing gel
• Cranberry products
• Protein intake
• Vaginal vitamin E
• (Laser and radiofrequency??)
Management of GSM
• Hormone replacement therapy
• Estrogen
• Selective estrogen receptor modulators(SERMs)
• Progesterone
• Testosterone
Estrogen therapy
• Local vs systemic
• Vaginal tablet
• Lowest dose as possible
• Prevent rUTI
• Subjectively improve stress urinary incontinence
• Adjunct to anticholinergic for OAB management
• Women using estrogen only had statistically significantly lower risk of
diabetes and fracture than women taking placebo.
• Women using estrogen plus progestin had statistically significantly lower risk
of colorectal cancer, diabetes, and fracture than women taking placebo.
• Risk:— statistically significantly increased for gallbladder disease, stroke,
venous thromboembolism.
— increase urinary incontinence at 1 year follow-up
Recurrent UTI
Definition of recurrent UTI(rUTI)
• 2 or more UTIs in 6 months or 3 or more UTIs in a year

• Typical symptoms of UTI: dysuria, frequency, urgency, and/or

incontinence

• Confirmation of UTI:
• Urine dipstick test positive for nitrite
• Microscopic evaluation of urine
• Result of mid stream urine culture
Pathophysiology of rUTI
• Antibiotics resistance strain
• Host defense mechanism: skin and epithelial barrier, lost of vaginal
lactobacilli, catheter
Clinical presentation esp. in elderly
• Localized genitourinary symptoms
• Confusion
• Delirium
• Increase lethargy
• Blunted fever response
• New-onset incontinence
• Anorexia
Ddx from asymptomatic bacteriuria
• Can be difficult!!
• Essential to ensure appropriate use of antimicrobial
Management of rUTI
• Antimicrobial
• Complicated UTIs: combination antimicrobial therapy with amoxicillin plus an
aminoglycoside, or a second-generation cephalosporin plus an aminoglycoside

• Complicated UTIs with systemic symptoms: empirical intravenous treatment with a third-
generation cephalosporin

• Continuous low-dose prophylaxis for 3-6 months to prevent recurrent UTIs:

nitrofurantoin, fosfomycin, cephalexin, cefaclor

• Special caution of using quinolone or fluoroquinolone in the elderly due to higher risk of
tendon injury
Management of rUTI
• Non-antimicrobial
• Estrogen: topical
• Cranberry products: capsule
• Oral lactobacilllus
• Probiotics
• NSAIDS
• OM-89 E.Colin bacterial lysate vaccine
• D-mannose
• Vitamins(C, D)
• Immunotherapy
• Xyloglucan-based medical device
Thank you