It is common for patients with vulvas who are older than 50 years of age to present to the emergency department with symptoms of urinary tract infections (UTIs). They complain of urinary frequency, urinary urgency, pelvic pain, pain with urination, vaginal dryness, and constipation. Some have scary-looking urinalyses, and others never have positive cultures. We know from the “Choosing Wisely” campaign that we should (a) not treat asymptomatic bacteriuria and (b) not run urine cultures on asymptomatic patients, but as some of these women present again and again, what’s an emergency physician to do?

The answer should never just be antibiotics.

The answer should be antibiotics if there is an infection and treatment of the underlying problem to prevent the symptoms from happening again. This is a condition called genitourinary syndrome of menopause (GSM). As if hot flashes and night sweats weren’t enough, the lack of hormones after age 50 causes these significant genital and urinary symptoms. And unlike hot flashes, they don’t magically get better or go away with time. In fact, they just keep getting worse.

But all of this is not only treatable—dare we say, it is preventable.

What Is GSM and Why Does It Matter?

In a recent study, 68 percent of postmenopausal women with recurrent UTIs treated with vaginal estrogen alone did not go on to receive additional therapy.¹

GSM is a relatively new term that was established around 2014 to replace the diagnosis of vulvovaginal atrophy/atrophic vaginitis.² Not shockingly, describing anything as atrophic is deeply concerning to patients, and just as important, the term atrophy doesn’t describe the signs and symptoms of what actually happens to the genitals and urinary tract after hormone withdrawal.

GSM is essential for an emergency physician to understand, diagnose, and treat.

GSM is a chronic and progressive condition that has the potential to pose significant morbidity and even mortality to patients. Think about the 90-year-old nursing home patient with urosepsis. The source of the urosepsis is much more likely from her GSM than her 2-mm nonobstructing stone. And you can bet we would place her on FDA-approved vaginal estrogen or dehydroepiandrosterone, with refills lasting forever.

Without circulating estrogens and androgens, there is a loss of collagen and elastin, diminished blood supply, and a loss of an acidic environment, which changes the entire ecosystem of the genital and urinary tract. Because of these changes, women develop urinary frequency, urgency, dysuria, pelvic pain, and recurrent UTIs. Additional symptoms include vaginal dryness; dyspareunia; and difficulties with desire, arousal, and orgasm.³

Approximately 50 percent of postmenopausal women experience GSM symptoms, and 10 to 15 percent of women over 60 years old have recurrent UTIs.^4,5 Among women who are experiencing GSM symptoms, less than 10 percent are prescribed therapies; this discrepancy between prevalence and treatment is due in part to lack of patient education regarding GSM and the lack of physician-initiated assessment.⁶

There Is Hope for Patients and Prescribers

A promising development is the 2019 guidance of the American Urological Association (AUA) to include vaginal estrogen as a prophylaxis for peri- and postmenopausal women with recurrent UTIs to reduce future UTI risk (moderate recommendation, evidence level: Grade B).⁷ These treatment guidelines are an important initial step toward the medical community introducing the assessment and treatment GSM in its clinical practice.

The problem is that few women with GSM are prescribed vaginal estrogen, and many who get the prescription don’t use it properly, can’t afford it, stop using it, or fear using it because of misinformation and inappropriate FDA boxed warnings.⁸ 

But the crazy thing about this is that vaginal estrogen is a local treatment. It’s completely safe for essentially all women.⁹ In fact, there are very few women over 50 for whom we wouldn’t recommend the use of local vaginal estrogen. For hormone-sensitive cancers (breast and some endometrial), we always pick up the phone and talk about it with the patient’s oncologist, and after a collegial discussion, most of these women are encouraged to use it. 

Figure 1: Pharmacological Treatments for GSM