Genitourinary syndrome (vulvovaginal atrophy)

Vaginal dryness, painful intercourse and reduced lubrication are the most common and distressing symptoms of a condition known as genitourinary syndrome (also known as atrophic vaginitis, vulvovaginal atrophy or urogenital atrophy). Declining oestrogen levels are the main reason for this condition, most commonly associated with menopause, however hypoestrogen can also affect premenopausal women.

Genitourinary syndrome is inflammatory condition which results in changes to the tissue of the vagina and distal urinary tract. Tissue becomes dry, thin and crumbly with poor blood flow and reduced ability for lubrication, impacting quality of life for those who are sexually active. This condition can be distressing and result in pain during intercourse.

Other reasons associated with vaginal dryness include fluctuations in the female hormonal cycle, vaginal fungal infections (candidiasis), insufficient intake of essential fatty acids, anxiety and the autoimmune condition - Sjogren’s syndrome.

Vaginal fluid

Vaginal fluid is composed of vaginal transudate, secretions from glands within the vaginal area, epithelial cells, residual urine, mucous from cervix and endometrial fluids, and metabolites by the vaginal microbiota - which contribute significantly. These metabolites function in the maintenance of health and homeostasis of the vagina. They offer a chemical barrier to protect against pathogens and influence pH. Short-chain fatty acids are one of the predominate metabolites along with protein, salts and carbohydrates. Age, hormonal changes, menstrual cycle, condom use, recent sexual activity, illness and infection contribute to changes in the microbiota of the vagina.

Characteristics of genitourinary syndrome

Vaginal dryness is the main characteristic of genitourinary syndrome. This is due to reduced secretory function of the epithelium (the surface cells of the vagina), decreased vaginal blood flow, thinning of the mucosal lining, changes in the microbiome and inflammation. Other symptoms which may accompany the dryness can include itchiness and pain during intercourse (dyspareunia). These symptoms can increase with age and as menopause advances.

What happens to the vagina when oestrogen is low?

Low oestrogen (hypoestrogen) can result in a thinning of the vaginal wall tissue. It may lose its elasticity and the ability to produce mucus. This also means a reduction of nutrients needed for healthy lactobacilli (good bacteria) which reside in the vagina– reducing their numbers. The pH of the vagina increases. Over-growth of other microbes (bacterial, fungal) can lead to urinary tract infections.

Risk factors of low Oestrogen

• Hormonal contraception
• Child birth (postpartum) – when hormonal and breastfeeding
• Peri- and post-menopausal females and medically induced menopause
• Inflammatory conditions
• Metabolic disorders
• Anticholinergic or chemotherapeutic medications

What can help genitourinary syndrome?

A diagnosis from a medical practitioner/doctor can establish causes of vaginal dryness. The gold standard medical treatment is usually hormonal therapy using oestrogen medication and topical lubricants. However, there are some natural therapies available which can also help. Obtain advice from doctor and naturopath before supplementation.

Symptom relief is often the first line of treatment with the use of lubricants. Supporting declining oestrogen, supporting the microbiome, increasing essential fatty acids and reducing anxiety can all be employed to reduce symptoms.

Personal lubricants

Herbs, vitamins and nutrients can be applied topically as suppositories, ointments or creams to help with lubrication, inflammation, irritation and healing. The following ingredients are often found in individually or together in products.

• Calendula
• Kiwifruit vine extract
• Aloe vera
• Vitamin E
• Royal jelly
• Coconut oil
• Hyaluronic acid

Vaginal Health

Probiotics and Prebiotics

Lactobacillus species is the most prevalent of the vaginal microbiome which produce fatty acids (fatty acids help with the over-all health of the vagina). Good quality probiotics will often contain prebiotics in their formula. Prebiotics are found in non-digestible food ingredients such as root vegetables, beans, bananas, garlic, onion and asparagus. Fructooligosaccharides (FOS), galactooligosaccharides (GOS) and inulin are prebiotics which stimulate the growth and activity of bacteria.

Taken orally, probiotics and prebiotics can support vaginal health.

Essential fatty acids

Fats do have a role to play in the health of the body. In fact, essential fatty acids are just that – essential. They must come from what we eat as the human body cannot make them. Essential fatty acids (EFAs) - linoleic acid (omega-6) and alpha-linolenic acid (omega-3) are both needed but often the omega-3 fatty acids are insufficiently consumed. Essential fatty acids help with lubricating the body and combating dryness, reducing inflammation and may help with menopausal symptoms. Foods to include -  oily fish (salmon, herring and sardines), fish oil supplements, microalgae, flaxseeds (and oil), chia seeds and walnuts.

Vitamin D

Vitamin D has been shown to improve dryness and dyspareunia, and decrease pH. Normal vaginal pH level is between 3.8 and 4.5 which is slightly acidic and this helps to create a barrier against yeast and bacterial.

Phytoestrogens from nature

Phytoestrogens in the form of food, or from herbal supplements, can help with declining oestrogen level. Phytoestrogens have a similar chemical structure to human oestrogen, and are able to bind to the same receptors. Including them in the diet may help with symptoms of menopause and low oestrogen.

• Isoflavones from soy, chickpeas, mung beans and alfalfa. 
• Coumestans from sprouted legumes (mung beans and soy), alfalfa sprouts.
• Lignans from linseeds, grains and vegetables.

Providing phytoestrogens, fibre, minerals and vitamins.

Herbal supplements for menopause symptoms

There are many herbal supplements which can help with symptoms of menopause and low-oestrogen such as Black cohosh, Red clover, Asparagus racemosus (Shatavari) and Dong quai.  Discuss with your healthcare provider what may work for you.  

References

1. https://www.sciencedirect.com/topics/medicine-and-dentistry/vaginal-dryness
2. Factors associated with developing vaginal dryness symptoms in women transitioning through menopause: a longitudinal study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6136974/
3. Vaginal dryness: individualised patient profiles, risks and mitigating measures https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459457/
4. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data https://pubmed.ncbi.nlm.nih.gov/32399320/
5. Female Sexual Function at Midlife and Beyond https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6226268/
6. Current treatment options for postmenopausal vaginal atrophy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6074805/
7. Vaginal Atrophy https://www.ncbi.nlm.nih.gov/books/NBK559297/
8. Comparison between vaginal royal jelly and vaginal estrogen effects on quality of life and vaginal atrophy in postmenopausal women: a clinical trial study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217810/
9. Hyaluronic Acid in Postmenopause Vaginal Atrophy: A Systematic Review https://pubmed.ncbi.nlm.nih.gov/33293236/
10. The Role of Fatty Acid Metabolites in Vaginal Health and Disease: Application to Candidiasis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8282898/
11. The Effect of Omega 3 Fatty Acids on Atrophic Vaginitis in Breast Cancer Survivors https://kb.osu.edu/handle/1811/51959
12. https://pubchem.ncbi.nlm.nih.gov/compound/isoflavone
13. https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/isoflavones
14. https://www.sciencedirect.com/topics/chemistry/coumestans