Treatment of Genitourinary Syndrome of Menopause

[Dr. Yahir Santiago-Lastra]
Their comprehensive treatment plan for genitourinary syndrome of menopause is going to include number one, vaginal estrogen supplementation. And it can be really hard because some women will say, "Oh, I tried vaginal estrogen and it didn't work." And what happens is that sometimes they're not applying it properly because just dabbing it in the front of the vagina is not going to be effective. So it's sometimes transitioning them to a different mode of estrogen delivery, like an estrogen ring for example. And then also explaining to them that this medication has to be tried for at least six months for it to achieve a full effect.

So when I tell them that it can be a disappointing thing to say because who wants to wait six more months for a treatment option to work? What we'll typically say then is that, "Look, this is what I think is going to be the investment that's going to keep you from getting these infections in the long-term. But in the short-term, this is what we can do." And we'll order them a standing urine culture so that whenever they have these symptoms, they can submit a urine sample and we'll treat them based on the sensitivities. For some women that are reliable, I'll also give self-start antibiotics if I can trust them to submit a urine sample before. And then for the levator myalgia, I really try to partner with them with a pelvic floor therapist so that they get pelvic floor physical therapy. And sometimes pelvic floor therapy can be really difficult for these women because of the pain.

And what I'll recommend then are also some locally delivered vaginal treatments like vaginal diazepam and baclofen. We have a really good relationship with a compounding pharmacy that will also make us some estrogen supplementation vaginally, because some commercially available estrogen products like Premarin for example, or like Vagifem, are going to be made in these moieties that can have certain components like polyethylene glycol and other sort of emollients that make them slippery. That can actually be very irritating to atrophic vaginal tissue. So in the beginning it may be really hard for them to apply. So sometimes I'll partner with a compounding pharmacy who will make me these ovules in almond oil, or even emu oil, there's one that offers it in emu oil, but those are a little better tolerated. The other way that a compounding pharmacy can be really helpful is that a lot of these treatments can be expensive. So we'll partner with them so that they can offer lower cost options to patients who maybe can't afford the vaginal estrogen that's covered by their insurance.

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[Dr. Jose Silva]
And for those patients that have the symptoms and always have a positive urine culture, do you treat the positive urine culture always? Or do you start suppression therapy until you figure it out? Or do you try to get rid of it? How that period of time until everything's settle down, do you give them antibiotics?

[Dr. Yahir Santiago-Lastra]
It's on a case-by-case basis. But as a general rule, I will try to not put patients on long-term antibiotics. Sometimes there are exceptions to everything because medicine is an art and not everybody's going to follow the pathway that you have set out for 80, 90% of patients. But some patients, for example, will refuse to try vaginal estrogen. One common group that feels very uncomfortable with it are patients that have a breast cancer history, and patients who have recently been diagnosed with breast cancer who are on anti-estrogen treatments, because we have demonstrated efficacy and safety of vaginal estrogen supplementation in post-menopausal breast cancer survivors. But there isn't a lot of data about what we do with peri-menopausal or pre-menopausal women who have breast cancer who are on anti-estrogen treatment.

So those women, I'll often partner with their oncologist to determine whether or not they would be candidates for estrogen supplementation. Some oncologists are very much on board with that for quality of life purposes, but even so some patients are very concerned about it. So those are patients that may not want to proceed with estrogen supplementation. So for those patients, we still have to change the microbiome environment of the vagina to make it less likely that they will experience UTIs. And again, remember this assumes these women have a completely normal genitourinary tract. So it completely changes if they don't empty their bladder all the way, or if they have these other anatomical issues. But we're talking about a woman who voids completely normally, has had a completely normal urologic history who all of a sudden, with loss of estrogen or with getting older, has started developing all of these urinary symptoms associated with potentially menopause.

So for those women who do not want to do vaginal estrogen supplementation, there are other things that you can try. There's RepHresh cream that helps stabilize the vaginal pH, and that can be beneficial. But often you will have women who are having UTIs who will not use estrogen. And those women, sometimes you have to think about other suppressive therapies like methenamine, D-mannose if they get e-coli infections, and also prophylactic nightly or postcoital antibiotics, although that's not my preferred route. Sometimes I'll use these for six months at a time, reassess, see how the patients are doing and then make decisions.

[Dr. Yahir Santiago-Lastra]
So I only really prescribe opioids to my post-op patients and those patients get very few opioids. I don't think that opioids have a strong role in the management of pelvic floor disorders or pelvic pain. Occasionally, I will have patients that will ask and I typically will recommend to them if they have already been on those opioids that we collaborate with a pain management specialist, but it's extremely rare that they will prescribe them as well. We typically try to find them an alternative pain management route, either through injections. A lot of these patients will also have lower back pain issues, so sometimes ganglion blocks, pudendal nerve blocks and other things can really help. There's also neuromodulation that can be really helpful, and I partner with my pain management specialist to try dual pain stimulator and sacral neuromodulation concomitantly.

So that will be another strategy. But opioids play an extremely limited role and I honestly can't remember the last time I prescribed an opioid to a patient with pelvic pain. And then with regards to NSAIDs, I typically try not to prescribe NSAIDs because I don't want to rely on a medication that when used chronically, and this is a chronic problem, that when used chronically can cause some adverse effects. So what I'll usually prescribe them or recommend to them is pyridium for flares. And I rely heavily on the vaginally directed treatments like the vaginal diazepam or the vaginal baclofen. And I have patients who are even on this mixture of vaginal lidocaine, Gabapentin. And I've had patients come to me with even vaginal ketamine, which is really interesting and I don't tend to prescribe, but some pain management specialists will use that as well.

Another new kid on the block, as far as pelvic floor treatments for pain are concerned is cannabis. In California, obviously we have had a very strong medical marijuana treatment paradigm. I don't prescribe it, but I do have a lot of patients that I send to colleagues that specialize in medical marijuana. And sometimes vaginally delivered cannabis, or even systemic cannabis will have a relaxing effect on the pelvic pain, especially for women who have dyspareunia.