ISSWSH: Both Androgens and Estrogens Play a Role in Treating GSM

The International Society for the Study of Women’s Sexual Health (ISSWSH) has released a new expert consensus document regarding the role androgen therapy in the treatment of genitourinary syndrome of menopause (GSM), naming vaginal dehydroepiandrosterone as an effective option for the management of dyspareunia in menopause.

Dyspareunia is a characteristic symptom of GSM, which is experienced by more than half of middle-aged and older women. The disorder can be especially burdensome with respect to sexual functioning, body image, emotional wellbeing, and intimate relationships.

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“GSM is a real disorder with significant health and relationship consequences,” said lead author and ISSWSH President James A. Simon, MD, CCD, NCMP, IF, FACOG, obstetrician-gynecologist at IntimMedicine Specialists in Washington, DC, and clinical professor at the George Washington University. “It needs proper diagnosis and treatment. Too few women with GSM are being diagnosed and treated.”

If left untreated, GSM can lead to reduced sexual activity and satisfaction, as well as serious adverse consequences in relationships. Untreated GSM also predisposes women to urinary tract infections.

In addition, a careful examination to confirm GSM could give way to diagnosing other underlying disorders with serious consequences. According to Dr Simon, the skin disorder lichen sclerosus can masquerade as GSM, and lichen sclerosus is associated with a higher risk for skin cancer if left untreated.

With these factors in mind, Dr Simon and an international consensus panel of 13 other experts sought to examine the history and roles of androgen and estrogen therapies in the treatment of GSM, as tissues in the genitourinary system are both androgen- and estrogen-dependent.

In their document, the panel noted that although the treatment of GSM has historically involved both androgen- and estrogen-based therapies, estrogen-based therapies subsequently became the predominant form of treatment. This is likely because estrogen-based therapies were available long before regimens with actions like both estrogens and androgens, said Dr Simon.

Despite this rise in estrogen-based therapies, it is important to note that androgen-based therapies can also play a key role in the treatment of GSM, and treatment regimens with both androgens and estrogens can optimize treatment outcomes in some patients.

“Certain tissues of the vagina, vestibule, and vulvar skin may be particularly sensitive to the beneficial effects of androgens,” Dr Simon explained.

Research continues as to whether other treatments, such as vaginal testosterone, may also benefit women with GSM. According to the panel, some studies have suggested that systemic testosterone may be associated with improved vaginal epithelial health and blood flow, among other benefits. However, more studies are still needed regarding its efficacy in this patient population.

In addition, researchers have begun to investigate whether androgen- and estrogen-based treatments can benefit other women with menopause, but without GSM.

“We are assessing whether menopausal patients without GSM, but with abnormal sexual function—specifically low or no sexual desire—can benefit from improved sexual function by using a low-dose estrogen and androgen vaginal treatment,” Dr Simon said.

James A. Simon, MD, CCD, NCMP, IF, FACOG, is an obstetrician-gynecologist at IntimMedicine Specialists in Washington, DC and a clinical professor at the George Washington University. He is also the president of the International Society for the Study of Women’s Sexual Health, and a past president of the North American Menopause Society.

—Christina Vogt

Reference:

Simon JA, Goldstein I, Kim NN, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review. Menopause. 2018;25(7):837-847. doi:10.1097/GME.0000000000001138