Untreated GSM Can Result in Serious Complications

Medscape

a day ago

MINNEAPOLIS — Untreated genitourinary symptoms of menopause (GSM) can result in serious complications aside from vaginal symptoms, including urinary tract infections (UTIs) that increase the risk for sepsis and, in rare cases, vulvovaginal obliteration, according to a poster presented at American College of Obstetricians and Gynecologists (ACOG) 2025 Annual Meeting.
'By identifying the risks associated with untreated GSM, this research underscores the need for early diagnosis and sustained, lifelong management to prevent serious and potentially life-threatening complications,' wrote Ruben Fernandez Ibanez, a final-year medical student at the University of Alcala in Alcalá de Henares, Spain, and his colleagues.
The poster presented a narrative picture of data synthesized from three studies related to the complications of untreated GSM in more than 800 women over a period of more than 15 years. The poster addresses three categories of complications that may be related to untreated GSM: False abnormal Pap smears, recurrent UTIs and severe infections, and vulvovaginal obliteration.
With what the poster currently reports, 'it is difficult to make any definitive statement' without more information about the extent to which untreated GSM contributed to each of the conditions they review, Monica Christmas, MD, an associate professor of obstetrics and gynecology and director of the Menopause Program at the University of Chicago Medicine, Chicago, told Medscape Medical News . That said, the poster does raise awareness about the potential undertreatment of GSM in older women.
'Recurrent UTIs in the nursing home population can contribute to higher morbidity and mortality. A number of risk-reducing interventions should be in place, one of which can be local low-dose vaginal estrogen therapy,' Christmas said.
The poster noted that the absence of hormone therapy was associated with a higher incidence of recurrent UTIs.
'These infections did progress to systemic complications in some cases, with severe sepsis and usually secondary pneumonia,' the authors wrote about the observational finding. 'In contrast, the very few patients receiving hormone therapy rarely experienced such outcomes, suggesting that estrogen therapy plays a protective role not only in epithelial restoration but also in reducing infection risk and preventing renal sequelae, sepsis, and mortality.'
Providers often do not necessarily think about treating GSM in people who are not sexually active, but treating 'atrophy isn't just for sexual activity,' she said. 'Even for people who aren't sexually active, they don't want dry, itchy vaginas either.'
The poster also reported that more than 500 patients older than 40 years initially had an abnormal Pap, and after receiving local vaginal estrogen therapy, more than 90% of them saw full cytological resolution within 4-6 months.
'These findings confirm that estrogen deficiency-induced cellular atrophy mimics dysplasia, often resulting in false diagnoses,' the authors reported. 'Importantly, more than 80% of these cases were retrospectively linked to early, otherwise under-recognized GSM.'
Christmas noted an important caveat to that conclusion, however, because the poster provides very little information about those Pap smears, including what was abnormal about them.
'In older people with vaginal atrophy, you often can't get enough cervical cells, and it will come back insufficient,' Christmas said. A 2-week treatment of vaginal estrogen therapy would bring back enough cervical cells to be assessed.
Further, 'to truly be able to say the local estrogen therapy definitively improved outcome, you'd need a control group,' Christmas said. 'In most cases of ASCUS [atypical squamous cells of undetermined significance] Pap results, they revert to normal without intervention.'
The authors highlighted that appropriate recognition and treatment of GSM could potentially reduce unnecessary patient anxiety and additional interventions.
Last, the authors noted 12 cases of vulvovaginal obliteration with partial or complete labial fusion in patients aged 62-92 years.
'Total obliteration led to complications, including urinary retention, urocolpos, bilateral megaloureters, bilateral hydronephrosis, and renal insufficiency,' the authors reported. 'Immediate interlabial fusion release procedures provided relief, but long-term success was only achieved when hormone therapy was combined with gradual and continuous dilator use.'
Christmas noted, however, that the poster did not address some potential confounders that could be present in a nursing home population such as incontinence and immobility. 'Based on the data shared here, it is not clear that vaginal estrogen therapy improved urologic complications in their population,' she said.
It's possible, for example, that the patients had lichen sclerosis, which is prevalent in older populations and treated with high-potency steroids. In those with poor hygiene, lichen planus could be present, or patients could have one of these conditions along with untreated GSM.
Although the relationship of all the cases listed in this poster to GSM could not be clarified with the data provided, the results still point to the fact that GSM can lead to serious effects if it goes undiagnosed and untreated.
'The genitourinary symptoms associated with menopause are common and can have a significant impact on quality of life and function and rarely improve without intervention,' Christmas said. 'Symptoms often go unrecognized and untreated, which is a travesty as local, low-dose vaginal estrogen therapy is widely recognized as a safe and highly effective treatment option with minimal side effects or risks.'
No external funding or author disclosures were noted for the study. Christmas had no disclosures.