What is in a name? A decade after changing from VVA to GSM have we come any closer to ending the ‘silent suffering’ of postmenopausal women with genitourinary symptoms?

World Menopause Day in 2011 recognized the significance of vulvovaginal atrophy (VVA) with a theme of ‘ending the silent suffering’ of postmenopausal women. To coincide with this, the International Menopause Society (IMS) published recommendations for the management of postmenopausal VVA [1]. The aim was to highlight VVA as a major cause of distress in midlife women and beyond, and its significant impact on sexual health and quality of life [2].

VVA was an old problem newly recognized [3] according to many surveys of women’s perspectives on this chronic medical condition associated with menopause [4]. Symptoms of VVA were common, largely underreported by women and undertreated by clinicians worldwide because of several biopsychosocial determinants which perceived symptoms of VVA as an inevitable part of aging not worthy of treatment [4–6].

In May 2013, a consensus conference was held in Chicago (Illinois, USA) promoted by boards of the North American Menopause Society (NAMS) and the International Society for the Study of Women’s Sexual Health (ISSWSH), respectively [7]. Interdisciplinary experts agreed that the term genitourinary syndrome of menopause (GSM) was ‘a medically more accurate, all-encompassing, and publicly acceptable term than VVA’ [7]. It is fair to say that the new nomenclature has provided significant advances in assessing the signs and symptoms of GSM as well as in developing novel therapeutic interventions [8]. Postmenopausal women have benefited from a detailed recognition of the constellation of genital, sexual and urinary symptoms, and health-care providers (HCPs) have had access to supporting tools to objectively document clinical signs of urogenital atrophy and to manage appropriate treatments [9]. The relative contribution of menopausal estrogen deficiency associated with androgen decline has been characterized along with other aging-related phenomena [10], emphasizing the importance of discussing and treating genitourinary symptoms and addressing sexual well-being in midlife women [11].

However, it has become evident that we are in need of more research because the terms VVA and GSM are not interchangeable. Indeed, VVA is clearly the anatomical substrate of genitourinary and sexual dysfunctions, but GSM is a large basket encompassing signs and symptoms related also to clinical conditions with other etiologies [12,13]. In addition, the development of a core outcome set for GSM guiding clinical practice is mandatory to fulfill the goal of treating postmenopausal women effectively [14]. At present, therapeutic strategies approved by regulatory authorities describe treating moderate–severe VVA according to established diagnostic criteria, which do not completely reflect the new definition of GSM and do not consider different phenotypes of postmenopausal women [15]. Also, the so-called anti-aging techniques such as laser therapy and other thermal energy or non-invasive devices still await further high-quality research before they can be fully recognized in terms of both efficacy and safety [16]. Recently, the NAMS published an updated position statement with a GSM therapeutic algorithm based on the severity of symptoms, the effectiveness and safety of treatments for the individual patient, and patient preference [17]. The NAMS and the ISSWSH considered also specific patient populations such as women with or at high risk for breast cancer [18]. Many other scientific societies and expert groups revised the topic adapting clinical recommendations to a variety of cultural backgrounds and to the availability of treatment options for their communities [19].

We believe that treatment goals should include restoration of urogenital physiology and alleviation of symptoms, acknowledging that adherence is essential to achieve these benefits [1,17]. There are still barriers to treatment. These include poor awareness of the chronic nature of GSM, the need for treatment and fears over the use of hormones amongst women [20]. Many women cite a lack of knowledge, a lack of educational materials and a lack of time and confidence. The same can be said for many HCPs [21]. Many women and some HCPs do not appreciate that time is required for many treatments to demonstrate significant improvement in symptoms, let alone restoration of urogenital tissues to their premenopausal state [22]. It is also important to note that the indication to treat with labeled products only women with moderate and severe GSM may result in hampered efficacy. A recent clinical study reported that those patients receiving treatment complained of more severe symptoms than those untreated, suggesting a delayed request by women or a late intervention by HCPs [23]. Interestingly, women on systemic menopausal hormone treatment had fewer and milder symptoms and presented with better vaginal and vulvar health than women on other treatments [23]. Collectively, these data support the notion of ‘no woman left behind’ at menopause, and not being a suitable candidate for systemic hormone should not convert into poor urogenital care.

That notwithstanding, it is time to reconsider the best way to achieve the goal of ending the ‘silent suffering’ which is still not fulfilled 10 years after the new definition of VVA. Education on individual and lifestyle risk factors and implementation of women’s ability to care for urogenital health, including pelvic floor training and vulvovaginal hygiene, are the first-line measures. After that, the chronic nature of such an endocrine and aging-related clinical condition indicates that non-hormone therapies available without a prescription should be standard practice in women at midlife to minimize discomfort over time, especially in those with well-known contraindications to hormone therapies. Lubricants and moisturizers are safe and target tissue structure and the occurrence of symptoms at an early stage, being suitable as a preventive strategy for GSM. Lastly, research should guide the most appropriate choice of hormonal treatments depending on clusters of bothersome symptoms, accurate mapping of clinical signs and evaluation of the impact on daily living and partner relationship at different post-reproductive stages. In general, products are mutually exclusive in the clinical investigation setting but HCPs may consider a combination of strategies addressing more than one target in a real-life setting to maximize efficacy, bearing in mind that safety is always a priority. A multidisciplinary management and even a couple-centered approach should be recommended in the most difficult cases.

In conclusion, we welcome this special issue entirely dedicated to GSM. It is a comprehensive update of the most recent research data to characterize this distressing multifaceted condition in postmenopausal women considering also special populations (breast cancer survivors, HIV patients) and offering clues for further investigations. Moreover, it critically revises the full range of treatment options providing clear points for practice. We hope this special issue will serve the scope of developing precision GSM care to improve urogenital health and sexual longevity for millions of women around the world.

Let us see if by the next decade the ‘silent suffering’ will come to an end!

Potential conflict of interest

No potential conflict of interest was reported by the authors.

Source of funding

REN declares fees for lectures, membership of advisory boards, and consultancy from Abbott, Astellas, Bayer HealthCare, Endoceutics, Exeltis, Fidia, Gedeon Richter, Merck & Co., Novo Nordisk, Organon & Co., Shionogi Limited, Theramex and Viatris. These companies have no involvement in the present editorial.

RB declares fees for lectures, membership of advisory boards and consultancy from Besins, Theramex, Mayne Health and Abbott.