(124) GENITOURINARY SYNDROME OF LACTATION (GSL): A NEW PERSPECTIVE ON POSTPARTUM AND LACTATION-RELATED GENITOURINARY SYMPTOMS
Authors: Perelmuter S , Burns R , Shearer K , Grant R , Sogoor A , Jun S , Alexis Meurer J , Rubin R 
Published: June 2024

Abstract

Introduction
Genitourinary syndrome of menopause (GSM) is a well-documented and researched condition characterized by a range of genitourinary symptoms in peri- and postmenopausal women. Similar to GSM, postpartum and lactating women experience significantly reduced estrogen and androgen levels. However, there is limited research on the occurrence and impact of similar symptoms during the postpartum and breastfeeding period, as well as possible treatment options.

Objective
The aim of this project was to review the available literature for genitourinary health in the postpartum breastfeeding population and summarize the key findings and potential treatment options.

Methods
We performed a comprehensive literature review utilizing several databases and the following keywords individually or in combination “physiology of postpartum” or “physiology of lactogenesis” or “vulvovaginal health” or “vaginal atrophy” or “vaginal dryness” or “dyspareunia” or “urinary incontinence” or “lactation” or “breastfeeding” or “vaginal estrogen.” Full text review of 75 articles was performed, and ultimately 50 articles were included in this review.

Results
During lactation, high levels of prolactin inhibit estrogen and androgen secretion via negative feedback mechanisms (1). These hormonal changes lead to an increased prevalence (of up to 50% higher) of vulvovaginal atrophy in lactating and breastfeeding women compared to non-breastfeeding women (2,3). The shift in hormones also contributes to increased rates (~30% higher) of dyspareunia (4–7), likely due to a lack of vaginal lubrication (up to 46%) among breastfeeding women (8). Decreased sexual desire is also common and reported to be experienced by up to 46% of postpartum women (8). Despite these highly prevalent and potentially devastating symptoms, there is a lack of consistent screening at postpartum visits and no treatment guidelines available to healthcare providers. Similar to GSM, vaginal lubricants can be used by breastfeeding women with vaginal dryness. However, for lactating women with refractory vaginal dryness or significant vulvovaginal changes, vaginal estrogen or DHEA therapy may be considered. Studies have shown minimal or no transfer of estrogen to breast milk even at high concentrations, and no reduction in breast milk supply (9–11), likely because vaginal estrogen is not a systemic dose. Studies on vaginal estrogen therapy in postpartum women are limited, but one randomized placebo-controlled trial showed excellent compliance and a subjective improvement in women utilizing vaginal estrogen (12).

Conclusions
Postpartum breastfeeding women experience similar physiology and symptoms to the postmenopausal phase, as seen in GSM. We propose the introduction of a novel term to describe the genitourinary changes seen in breastfeeding individuals: Genitourinary Syndrome of Lactation (GSL). The creation and diagnostic use of a syndrome, such as GSL, will equip healthcare providers with an all-encompassing term to bring awareness to the symptoms experienced by postpartum breastfeeding individuals. This awareness can lead to improved screening and treatment guidelines for the high numbers of breastfeeding individuals suffering from these genitourinary changes.

Disclosure
No.