A decrease in ovarian estrogen production during menopause results in a variety of systemic and genitourinary changes. Genital, sexual and lower urinary tract symptoms are all part of the chronic illness known as genitourinary syndrome of menopause (GSM), which is caused by estrogen insufficiency [1]. Vaginal dryness, burning, or irritation, dyspareunia, dysuria, urgency when urinating and recurrent UTI are common symptoms. In contrast to certain vasomotor symptoms, GSM can significantly impair sexual function, intimate relationships, urinary health and general quality of life. If left untreated, it may also worsen or persist [1-3]. Menopause may occur naturally or be induced surgically, chemically, or by pelvic radiation [4, 5]. It represents a psychological milestone influenced by complex neuroendocrine feedback mechanisms involving the hypothalamic- pituitary-ovarian-axis [6]. Natural menopause often occurs between the ages of 50-51 years, thought this might vary based on lifestyle, environmental and genetic factors [7, 8]. The sudden end of ovarian activity in premenopausal women after bilateral oophorectomy with or without hysterectomy is referred to as surgical menopause [4, 5 & 9]. Surgical menopause causes an abrupt and total loss of ovarian steroid production mainly estrogen, progesterone and androgens in contrast to natural menopause which happens gradually with progressive follicular depletion and hormonal transition [5, 6]. In contrast to the slow shift observed in natural menopause, this abrupt hormonal withdrawal causes menopausal symptoms to manifest more severely and quickly [1, 10]. Compared to the progressive hormonal decrease of natural menopause, the GSM symptoms trends to manifest quicker and more strongly in women undergoing surgical menopause due to the sudden and total absence of estrogen [5, 10]. Moreover the simultaneous removal of the ovaries stops the generation of androgens which makes vaginal atrophy and sexual dysfunction worse [10].

Chronic urogenital discomfort, diminished self-esteem and avoidance of sexual engagement can result from untreated genitourinary complaints [11-13]. It has been demonstrated that local estrogen therapy, selective estrogen receptor modulators and newly developed non-hormonal modalities including vaginal moisturizers and laser therapies greatly enhance symptoms and quality of life [14, 15]. Low dose vaginal estrogen therapy delivers estrogen directly to affected tissue, restoring epithelial thickness, lowering vaginal pH, restoring lactobacilli dominance and improving urinary tract mucosa integrity [16].

Heinemann et al developed the menopause Rating Scale (MRS), a validated and self-administered tool for evaluating menopausal symptoms. It consists of 11 items divided into three domains: somatic (1-4) psychological (5-8) and (9-11). Symptoms are scored from 0 (no symptoms) to 4 (very severe), allowing for both domain and overall score calculation. The MRS is a trustworthy and useful screening tool in clinical settings [17]. Improving women’s health outcomes during the perimenopausal and postmenopausal stages requires early detection and organized management [18].

Given the understanding that women with surgical menopause experience a high prevalence of genitourinary symptom that eventually have a heavy burden of physical, psychological as well as financial stress, the present study was planned to evaluate the efficacy of vaginal estrogen on genitourinary symptom in surgical menopause women with a history of uterine, cervical, or ovarian pathologies by using the MRS tool.

The present prospective interventional study was done in department of Obstetrics and Gynaecology, King George’s Medical University (KGMU), Lucknow, Uttar Pradesh, India . Over a period of 18 months from September 2024 to March 2026 after receiving ethical clearance from the institutional committee (ref no: 965/Ethics/2025 dated 17/09/2024; ref code: XXVIII-PGTSC-IIA/P50) Study Population Women from aged 20-65 years who had undergone surgical menopause at least 3 months and reported symptoms of GSM were enrolled for this study. GSM symptoms refer at baseline included vaginal burning or irritation, vaginal dryness, urinary urgency, dyspareunia, and recurrent urinary tract infection. A total of 75 women who underwent surgical menopause were enrolled in this study after taken the written consent. All the women enrolled according inclusion exclusion criteria: Inclusion Criteria: • Women aged 20–65 years, • ≥3 months post-surgical menopause, • Presence of GSM symptoms such as vaginal dryness, irritation, burning, dyspareunia, urinary urgency, dysuria, recurrent UTI • Patients giving written informed consent will be taken. Exclusion Criteria: • Women on estrogen therapy, • Women with active malignancy • Women with history of estrogen dependent malignancy without oncology clearance, • Unexplained vaginal bleeding, • Women having hepatic dysfunction, thromboembolic disorders or known to hypersensitivity to estrogen. • Patients who do not want to participate in this study Sample Size: The sample size was calculated based on a previous study that reported the basis of expected prevalence of surgical menopause (5.1%, prevalence (Sheryl A Kingsberg et al 2020], 95% level of confidence and Error rate, usually set at 0.05 level is 4. Total 75 patients will be included in each group of the study by the formula n=Z2 P(1-P)/d2, Where, n = sample size, Z = Z statistic for a level of confidence, for the level of confidence of 95%, which is conventional, Z value is 1.96..P = expected prevalence or proportion (in proportion of one; if 5.1%, P = 0.051), d = precision (in proportion of one; if 5%, d = 0.05). Methodology- All surgical menopausal patients were recruited who were admitted in or visiting OPD in Department of Obstetrics and Gynaecology, KGMU, Lucknow as per the inclusion criteria Informed consent was obtained from all recruited women. Detailed history was obtained from the patient about the demographic profile, diagnosis , surgical history and treatment. History was taken to assess genitourinary symptoms of menopause namely vaginal dryness, irritation, burning, dyspareunia, urinary urgency, dysuria, recurrent UTI. An assessment of genitourinary symptoms was performed at baseline through MRS score. The 11 components of this scale include hot flushes, heart discomfort, sleep problems, depressive mood, irritability, anxiety, physical and mental exhaustion, sexual problems, bladder problems, dryness of vagina and joint and muscular discomfort. Participants received low-dose vaginal estrogen in the form of estriol 1mg inserted intravaginally twice-weekly for 12 weeks. Post 3 months therapy, assessments of genitourinary symptoms was recorded through MRS score. Menopausal Rating Scale (MRS) Tool The Menopausal Rating Scale (MRS) is a standardized and validated tool used to assess the severity of menopausal symptoms and their impact on quality of life. It helps to measure the severity of menopausal symptoms, evaluate the impact of menopause on health-related quality of life, monitor treatment effects (e.g., hormone therapy, lifestyle interventions), The Menopausal Rating Scale consists of 11 items, grouped into three subscales: a) Somatic (Physical) (1-4) - Hot flushes, heart discomfort, sleep problems, joint and muscle discomfort b) Psychological (5-8) - Depressive mood, irritability, anxiety, physical and mental exhaustion c) Urogenital (9-11) -Sexual problems, bladder problems, vaginal dryness. Each of the 11 symptoms is rated on a 5-point Likert scale. Sum of all 11 items score from range from 0-44. Higher score is indicates more severe menopausal symptoms. Score 0- 4 (no or few symptoms) is used to score each item. Total score of 5-8 (mild), 9-15 (moderate), and ≥16 severe symptoms [18]. STATISTICAL ANALYSIS: Data were analyzed by using IBM-SPSS version 23.0. Continuous variables were presented as mean ± standard deviation and for categorical variable were presented as percentage (%).the paired students t-test was used to compare mean MRS scores across pathological subgroups. Chi–square test were used to compare the categorical variables and Wilcoxon signed-rank test was used to compare severity of before and after treatment. The p-value <0.05 was considered statistically significant.

The study comprised 75 post-menopausal women who underwent surgical menopause. The participants ranged in age from 20-56 years with an average of 42.65±7.61. 49.3% of women were between the ages of 35-45 years, while 34.7% were between the ages of 45-55 years. Out of all the women participants, 48.0% came from rural area and 52.0% from urban areas. Middle class (34.6%) was the most prevalent socioeconomic group. Prior to enrollment, 96.0% of post-menopausal women had received surgery alone, while 4.0% had received chemotherapy after surgery (Table 1).

Table 1: Demographic characteristics of post-menopausal women (N=75)

Distribution of post-menopausal women according to genitourinary symptom is shown in Table 2. The most common GSM symptom among the 75 participants was vaginal dryness, which was reported by 46 (61.3%) of the women, followed by vaginal irritation in 43 (57.3%). In 31 (41.3%) of the individuals, vaginal burning and dyspareunia were noted. Only 1 (1.3%) participants reported recurrent UTI, whereas 2 (2.7%) experienced dysuria and urine urgency.

Table 2: Distribution of Subjects according to Genitourinary Symptoms (n=75)

In Table 3, the chi-squire test(X² test) shows  no statistically significant correlation was found between any of the evaluated genitourinary symptoms and the uterine pathology reported vaginal dryness at a rate of 75.0%, ovarian pathology at 62.5% and cervical pathology at 47.4% (X²= 7.062, p=0.133),vaginal irritation (X²=3.174, p=0.529), and recurrent UTI (X²=1.701,p=0.790).

Table 3: Association of Gynaecological Pathology with Genitourinary Symptoms

Table 4 shows the distribution of individual menopausal symptoms measured by MRS among the various gynaecological pathology groups. The chi-square test shows no statistically significant correlation between any of the specific MRS symptoms and the underlying gynaecolgical pathology. Among the somatic symptoms, 52(69.3%) subjects reported hot flushes, while 48(64.0%) reported sleep issues. The most common physiological symptom, which affected 60 (80.0%) women, was anxiety. In the urogenital domain, 54(72.0%) women reported sexual issues, 11(14.7%) experienced bladder symptoms and 71(94.7%) reported vaginal dryness. Although it did not achieve statistical significance, sleep issues showed the highest variation between pathological groups (X²=8.947, P= 0.062). hot flashes (X²=1.942,P=0.746), heart discomfort (X²=4.529.p=0.339), depression X²=1.128, p=0.529), ²sexual problems (X²=1.128, p=0.890), vaginal dryness (X²=0.825,P=0.935 ) and bladder symptoms (X²=1.733,p=0.785).

Table 4: Distribution of Baseline Genitourinary symptoms according to Menopausal Rating Scale (MRS) in different Gynaecological Pathologies

By comparing MRS score before and after three months of estrogen treatment,  the impact of vaginal estrogen therapy was evaluated by paired students t-test. Every MRS domain showed a statistically significant decline. The mean somatic score dropped by 1.25±1.55 (t=6.995, p<0.001) from 2.87±1.77 before therapy to 1.61±1.40 after therapy. The mean psychological score dropped by 0.67±0.86 (t =6.717, p <0.001) from 2.23±1.31 to 1.56±1.18.

The urogenital domain showed the highest improvement with the mean score falling from 4.45±1.65 to 1.64± 1.18, or a mean reduction of 2.81± 2.00 (t=12.195, p<0.001). Additionally, the mean total MRS score dropped by 4.73±3.31 (t=12.400, p<0.001) from 9.55±3.61 before therapy to 4.81±3.24 after therapy.

Table 5: Comparisons of Baseline MRS Scores with before and after therapy

After estrogen treatment, there was notable reduction in the overall intensity of menopausal symptoms. Menopausal symptoms were significantly reduced overall with estrogen therapy after three month of treatment there was a statistically significant improvement in all three domain scores and the overall MRS score.  Before treatment, 2(2.7%) women had no or few symptom, 25 (33.3%) had mild symptoms, 39(52.0%) had moderate and 38(12.0%) have severe symptoms. After three month of estrogen therapy the percentage of women with no or few symptoms increase to 38 (50.7%), while in mild severity remained 25(33.3%) in mild severity, and the percentage of women with moderate symptoms decreases 12(16.0%). Wilcoxon signed-rank test (Z) revealed that the change in the MRS severity distribution was statistically significant (Z=6.991, p<0.001).

Table 6: Change in severity of Menopausal Rating Scale (MRS) after therapy

Genitourinary syndrome of menopause (GSM) is a chronic consequence of estrogen deficiency which affects the vulvovaginal lower urinary tract and can substantially impair sexual function, and quality of life. The current prospective study evaluated menopausal symptom burden and GSM symptoms in women undergoing surgical menopause as well as the effectiveness of low dose vaginal estriol therapy during a three month period. This prospective interventional study was carried out on a total of 75 women (age range 20 to 56 years; mean age 42.65±7.61 years).The majority of women (84.0%) were aged between 35 and 55 years, with the most common age group being 35-45 years (49.3%). This age profile is notably younger than that reported in most studies evaluating vaginal estrogen therapy for genitourinary symptoms [19, 20]. Vaginal dryness (61.3%) and vaginal irritation (57.3%) were the most frequent presenting complaints. Recurrent UTIs (1.3%) urgency (2.7%) and dysuria (2.7%) were among the less common urinary symptoms. This pattern aligns with the pathophysiology of menopausal genitourinary syndrome, where a lack of estrogen causes the vaginal epithelium to shrink, lubrication to decrease and sensitivity to discomfort and irritation to increase [21, 12 & 17]. According to an observational analysis of a randomized trial on GSM treatment, vulvovaginal discomfort varied in quantity and intensity and vaginal symptoms were important to the overall GSM burden. The results show that vulvovaginal and sexual symptoms are common [22]. The GSM symptoms were not found to be significantly correlate with gynaecological pathology in the study, suggesting that clinically measured symptoms had no bearing on the underlying diagnosis. Sleep issue came to close significance (X2= 8.947, p= 0.062), indicating that hormonal effect of surgical menopause may have a stronger impact on symptom expression than particular diseases. After surgical menopause, sleep problems are more common. In comparison to women who underwent natural menopause, those who underwent surgical menopause reported far worse sleep quantity and were more than twice as likely to suffer from insomnia, according to a study of 526 postmenopausal women. .this implies that sudden hormonal shift could be factor in these symptoms [23, 24]. But the interpretation is explanatory because in this study the association was not statistically significant, may be it’s due to small sample size. The baseline assessment using the Menopausal Rating Scale (MRS) found that vaginal dryness was the most prevalent urogenital symptom (94.7%), followed by hot flushes (69.3%) in the somatic domain and anxiety (80.0%) in the psychological domain. The high prevalence of anxiety reflects both psychological effects of abrupt estrogen withdrawal and psychological impact cancer and surgical treatment. Page et al (2023) found that psychological symptoms confound the effect of menopause on executive functioning [25], supporting the need for comprehensive assessment including psychological wellbeing. A notable finding was found after following three month of low-dose vaginal estriol therapy, significant improvement were observed in this study. After three month of treatment MRS score decreased in somatic domain, psychological domain and as well as in urogenital domain (p< 0.001). The greatest improvement was observed in urogenital domain. The mean urogenital score dropped from 4.45±1.65 at baseline to 1.64±1.18, which showed a mean reduction of 2.81± 2.00 points (P<0.001). The study findings aligns with the established efficacy of vaginal estrogen in restoring urogenital heath through mechanisms including restoration of epithelial thickness, enhancement of cell proliferation, lowering of vaginal pH and restoration of lactobacilli dominance [26,27]. Study by Gueldini de Moraes et al (2024), the Vaginal Health Index score, Vaginal Maturation, visual analog scale for Volvo vaginal Atrophy (VVA) symptoms (dyspareunia, dryness, and burning), and MRS for urogenital symptoms were used for assessments at baseline and after four months, after thr four month of treatment, the pH of the vagina dramatically dropped along with MRS score for VVA symptoms showed a notable improvement in overall symptom specially in urogenital symptom [28]. But a study done by Jongjakapun et al., in a randomized double- blinded, placebo controlled study, tested the combination of lactobacilli and vaginal estriol in postmenopausal women with lower urinary tract symptoms. When compared to placebo, after one month treatment did not significantly reduce urinary symptoms, although being well tolerated. Variations in treatment duration, estrogen formulation and dosage, baseline symptom characteristics and outcome assessments can all contribute to study variance their trial concentrated on lower urinary tract symptoms with shorter treatment duration [29]. While our study used the MRS score to evaluate a more comprehensive menopausal symptom profile over a three months period. The categorical analysis shows the change in overall symptom severity, after three months treatment, the proportion with no few symptoms increased to 50.0%, while moderate symptoms declined to 16.0% and no participant remained in the severe category. The change in severity was statistically significant (p<0.001).The magnitude of improvement observed in our study is consistent with previous studies evaluating vaginal estrogen therapy [19, 30 & 31]. In the study done by Oliveira et al. (2023) vaginal estriol was associated with significant improvement in GSM symptoms and Vaginal Health Index after treatment [30]. The baseline scores are comparable to the study done by Fernandes et al. (2014) and Tanmahasamut et al. (2020), who evaluating vaginal estrogen therapy and reported significant improvement after treatment [31,32]. A systemic review by Biehl et al. (2019) concluded that vaginal estrogen products have few adverse effects and are recommended as first line therapy for women with moderate to severe genitourinary symptoms [27]. There is no major adverse effect found in our study.we found safe and effective. Vaginal estrogen is still cost-effective, according to Jafarzade et al. (2025), who observed no discernible differences in the effectiveness of CO2 laser therapy and estrogen, despite the laser being 23–24 times more expensive. [33]. In a study, Gueldini de Moraes et al (2024), also suggested that estrogen therapy is safe and effective, particularly for the women, who cannot prefers not to use estrogen therapy [28]. While the trial's findings are notable, there are limitations to consider: it was a single-arm study with only 75 patients and lacked a placebo group, making it difficult to eliminate the influence of spontaneous symptom changes and other factors. Additionally, the follow-up period of three months does not provide insight into long-term safety or the sustainability of benefits, particularly given that research suggests some GSM abnormalities may recur after discontinuing vaginal estrogen, indicating a potential need for ongoing treatment. Large multicentric randomized controlled trial with comparison group needed.

Genitourinary syndrome of menopausal women, including those with a history of gynaecological malignancy, can be safely and effectively treated with vaginal estrogen therapy. Significant improvements were observed in every MRS domain after 3 months of treatment, with urogenital symptom showing a 63.1% decrease. The proportion of women with moderate to severe symptoms decreased from 64.0% to 16.0%. Treatment response was comparable across different clinical groupings and there were no significant side effects. Thus, vaginal estrogen as the first line treatment for GSM in surgically menopausal women.

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