Genitourinary Atrophy

Genitourinary atrophy is another consequence of estrogen loss. The tissues of the vagina, vulva, urethra, and trigone of the bladder all have large numbers of estrogen receptors, and all 3 undergo atrophy during menopause. Estrogen loss accounts for most of the postmenopausal anatomic, cytologic, bacteriologic, and physiologic urogenital changes (Table 7). Such changes may even occur during the perimenopause, well before menses ceases. Although this is the least discussed consequence of estrogen loss, virtually every woman will experience such atrophy. The resulting potential for urinary and sexual dysfunction creates significant changes in a woman's quality of life.

Table 7

The atrophic vulva loses much of its collagen, adipose tissue, and water-retaining ability. Vaginal shortening and narrowing occur as the vaginal walls become thin, lose elasticity, and grow pale in color. The vagina produces fewer secretions and loses much of its ability to lubricate in response to sexual stimulation. The urethra is easily irritated, often resulting in dysuria, urgency, and frequency. All of these changes enhance the likelihood of trauma, infection, and pain. All tend to decrease comfort during and interest in coitus. Estrogen replacement is the only treatment that significantly improves all of these problems. In addition, important data have documented that the frequency of urinary tract infections in postmenopausal women may be decreased by estrogen use, and as many as 50% of women with genuine urinary stress incontinence show improvement with estrogen.(50)

Sexuality in menopausal women is a topic that is all too infrequently discussed in the healthcare office. It is surrounded by myths, taboos, and personal beliefs. It is a fallacy that women lose interest in sexual activity after menopause. A whole host of factors can contribute to sexual dysfunction (Table 8), some physical and some psychological. But what is apparent is that women are concerned about their ability and desire to engage in sexual activity. Half of menopausal women list sexual dysfunction as 1 of their top 3 complaints.(51) Other studies have shown that among older women the most common reason for not being sexually active is the lack of an available partner.(51,52) In addition, a woman's premenopausal sexual activity is predictive of her postmenopausal sexuality.(53)

Table 8

In fact, in a survey of 1001 women conducted by Yankelovich Partners, Inc., 4 out of 5 women said their sex lives had either improved or remained the same since menopause.(54) The women in the survey were aged 50 to 65, and about 900 respondents had already passed through menopause. About half the women were taking HRT. When asked to compare their sex lives before and after menopause, 82% of women taking HRT said their sex lives had remained the same or improved, compared to 69% of those not taking HRT.

Nurses can play an important role in helping menopausal women voice their concerns about sexuality. Sensitive interviewing that establishes sexuality as a normal healthy part of life can elicit more information.(55) It can lead to an opportunity to discuss measures that can improve sexual dysfunction. For example, estrogen, in the form of either an oral supplement or a vaginal cream, can attenuate much of the physical discomfort that women experience. Any method of delivery is effective, but direct, vaginal application is the most rapid in onset of action.