What is Genitourinary Syndrome of Menopause?

Genitourinary syndrome of menopause (GSM) has replaced the term vulvovaginal atrophy (the vulva or vagina loses moisture, elasticity, and thickness) in medical communities. It can be used to describe a wide range of symptoms or changes that happen when estrogen declines during menopause. These hormonal changes can physically alter the function of vaginal, vulvar, bladder, and urethral tissues.

GSM affects up to 84% of postmenopausal women, although these numbers vary widely based on reported symptoms; many women are hesitant to bring these issues to their healthcare provider, believing symptoms are a normal part of aging. Only around 40-54% of postmenopausal women report bothersome GSM symptoms. Of these:

• 75% of women have experienced vaginal dryness,
• 40% have experienced pain during penetrative sex (dyspareunia), and
• 30-40% have experienced urinary urgency and frequency.
• Less than 50% of patients are actively treating symptoms.

Why is This Happening?

Although GSM mainly affects older individuals who are postmenopausal, it may also impact the quality of life of those who:

• Are lactating or chest feeding,
• Are experiencing hypothalamic amenorrhea (the brain has temporarily shut down the reproductive system, stopping periods),
• Are taking antiestrogen medications for uterine fibroids, endometriosis, and breast cancer,
• Have had a bilateral oophorectomy with or without total hysterectomy (this removes the ovaries, signaling menopause immediately),
• Have primary ovarian insufficiency (the ovaries stop working before the average menopausal age),
• Have had chemotherapy or radiation for cancer.

GSM may cause vaginal dryness, vaginal irritation, dyspareunia, abnormal discharge, urinary urgency or frequency, painful urination, urinary incontinence, and urinary tract infections (UTIs). This happens because of how the vagina’s microbiome responds to estrogen – or, in this case, its absence.

Normal estrogen levels help produce collagen and support healthy blood flow in the genital area, which in turn supports elasticity, thickness, and moisture in vulvovaginal tissues. This process, in combination with other vaginal microbes, helps maintain the vagina’s pH levels (normally acidic).

The extreme and sudden reduction in estrogen causes pH to become more basic, and the natural systems in place begin to malfunction. This leads to reduced collagen and blood flow, then the loss of tissue mass, moisture, and elasticity in the vulvovaginal area. This also increases the chance of vaginal infections and UTIs.

What Helps with Discomfort?

There are several treatment options available for GSM, depending on a person’s needs.

Nonhormonal options

• Vaginal lubricants to help with dryness and pain during sex. This is more of a short-term relief option.
• Moisturizers applied weekly to help with vaginal dryness and irritation for longer-term relief.
• Patients may be told to have sex more frequently, which may help maintain vaginal tissue elasticity and blood flow.
• Pelvic floor physical therapy can help with dyspareunia due to spasms or tightness in the vaginal or pelvic floor muscles.
• Dilators can help with physical changes, such as narrowing of the vaginal opening.
• Laser or radiotherapy are experimental options that can improve collagen production in the vagina, therefore improving lubrication and thickness.

Local estrogen and DHEA options

Local estrogen therapy comes in vaginal creams, suppositories (tablets or capsules inserted in the vagina), and vaginal rings. These can all help relieve vaginal dryness and irritation associated with vaginal atrophy. Local estrogen therapies also tend to be low-dose, which is safer for some populations.

Dehydroepiandrosterone (DHEA) is a naturally occurring hormone that replaces estrogen as the primary sex hormone after menopause. Local DHEA therapy is normally provided as a vaginal suppository that is known to help with dyspareunia and is a good option in situations where estrogen therapy may not be as effective.

Hormone replacement therapy (HRT)

HRT is known as systemic hormonal therapy because it treats a wider range of menopausal symptoms, such as hot flashes and night sweats, as well as some GSM symptoms (in combination with local therapy). HRT can help normalize vaginal pH, promote blood flow to the vulvovaginal area, and increase lubrication. This may be a good option for those who do not want to use vaginal therapies or prefer an oral medication.

Key Takeaways

• GSM mainly affects postmenopausal women but can affect others in various circumstances.
  • Younger women may experience GSM with hysterectomy, cancer, chest feeding, and other hormonal conditions.
• Many women do not ask their healthcare providers about their symptoms, assuming it is a normal part of aging, and healthcare providers may not know they need to ask about GSM, leading to over half of postmenopausal women not getting treatment.
• GSM is caused by a sudden drop in estrogen levels, which changes the natural process of the genitourinary system.
  • This can cause bothersome symptoms like vaginal dryness, painful sex, UTIs, and a reduced quality of life.
• There are many treatment options available for those experiencing GSM.
• If you believe you are experiencing GSM, it may be beneficial to speak with a healthcare provider.

Resources:

Carlson K, Nguyen H. Genitourinary Syndrome of Menopause. [Updated 2024 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559297/

Genitourinary syndrome of Menopause. the Menopause Society. (2025, May). https://menopause.org/wp-content/uploads/for-women/MenoNote-GSM.pdf

Kaufman, M. R., Ackerman, A. L., Amin, K. A., Coffey, M., Faubion, S. S., Hardart, A., Goldstein, I., Ippolito, G. M., Northington, G. M., Powell, C. R., Rubin, R. S., Westney, O. L., Wilson, T. S., & Lee, U. J. (2025). The AUA/Sufu/AUGS Guideline on genitourinary syndrome of Menopause. Journal of Urology, 214(3), 242–250. https://doi.org/10.1097/ju.0000000000004589

Simon, J. A., Nappi, R. E., Chedraui, P., Clark, A. L., Gompel, A., Nasreen, S. Z., Palacios, S., & Wolfman, W. (2026). Genitourinary Syndrome of menopause (GSM): Recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024). Sexual Medicine Reviews, 14(1). https://doi.org/10.1093/sxmrev/qeaf055

Wasnik, V. B., Acharya, N., & Mohammad, S. (2023). Genitourinary Syndrome of menopause: A narrative review focusing on its effects on the sexual health and quality of life of women. Cureus, 15(11). https://doi.org/10.7759/cureus.48143