Genitourinary Syndrome of Menopause
Up to 84% of postmenopausal women experience symptoms affecting their vaginal, sexual, and urinary health, yet many suffer in silence, unaware that safe and effective treatments exist for this chronic condition.
Table of contents
- What is Genitourinary Syndrome of Menopause?
- Other Names for This Condition
- Signs and Symptoms
- What Causes GSM
- Who Is Affected
- How GSM Is Diagnosed
- Treatment Options
- Is Treatment Safe?
What is Genitourinary Syndrome of Menopause?
vulvovaginal atrophy, atrophic vaginitis, urogenital atrophy, vaginal atrophy
Genitourinary syndrome of menopause, or GSM, is a term that describes a collection of changes affecting the vagina, vulva, and lower urinary tract. The term was first introduced in 2014 to replace older names like vulvovaginal atrophy or atrophic vaginitis, which didn’t fully capture the range of symptoms women experience[1][2].
GSM is a chronic and progressive condition, which means that once symptoms begin, they typically do not improve on their own and often worsen without treatment[1][6]. The condition affects multiple body systems at once, including the genital organs, sexual function, and urinary system[5].
Other Names for This Condition
Before 2014, this condition was known by several different names. Healthcare providers may still use terms like vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy to describe the same collection of symptoms[2][4]. The newer term “genitourinary syndrome of menopause” was chosen because it better describes the full range of symptoms that affect not just the vagina but also the urinary system[5].
Signs and Symptoms
GSM causes a wide variety of symptoms that can be grouped into three main categories: vaginal symptoms, sexual symptoms, and urinary symptoms[1][5].
Vaginal symptoms are among the most common and bothersome. These include vaginal dryness, which affects more than 90% of women with GSM, making it the most frequent symptom[14]. Women may also experience vaginal irritation, burning, or itching. The skin of the vagina may become thinner and paler, with decreased moisture and loss of the normal folds in the vaginal wall. Some women notice thinning or graying of their pubic hair, or feel vaginal or pelvic pain and pressure[1][8].
Sexual symptoms can significantly affect quality of life and intimate relationships. Painful sexual intercourse, called dyspareunia, affects as many as 80% of women with GSM[14]. During sexual activity, women may notice decreased lubrication and reduced arousal. Some experience bleeding after intercourse, loss of libido, or difficulty reaching orgasm[1][7].
Urinary symptoms can also be troubling. Women with GSM may experience painful urination, often described as a burning sensation when urine touches the thin vaginal tissue. Urinary urgency—a sudden, intense need to urinate—and increased frequency of urination are common. Some women develop urinary incontinence, which can be either stress incontinence (leaking with coughing or sneezing) or urge incontinence (sudden leaking). Recurrent urinary tract infections become more likely, and some women develop a red vascular growth on the urethra called a urethral caruncle[1][7].
In severe cases, GSM can impact not just sexual activity and bladder control, but also basic daily activities such as sitting, walking, and working[7].
What Causes GSM
GSM is primarily caused by declining levels of estrogen, a hormone that promotes and maintains female traits in the body[1][7]. Estrogen plays several important roles in maintaining the health of vaginal and urinary tract tissues.
When estrogen levels are adequate, the hormone supports collagen production, which keeps tissues elastic and resilient. It ensures proper blood flow to deliver oxygen and nutrients to vaginal and urethral tissues. Estrogen also helps with glycogen production, which provides fuel for beneficial vaginal bacteria and supports a balanced vaginal environment[14].
When estrogen levels drop during menopause, these protective effects diminish. The vaginal and urinary tissues become thinner, drier, and more fragile. The vaginal canal can narrow and shorten. The amount of normal vaginal fluids decreases, and the acid balance in the vagina changes. All of these factors make the vaginal tissue more delicate and more likely to become irritated[4][7].
The decline in estrogen also affects the urinary tract. Changes occur in the bacterial environment, which increases susceptibility to urinary tract infections. The tissues of the bladder and urethra also become thinner and less elastic[14].
Who Is Affected
Recent studies report that up to 84% of postmenopausal women experience one or more symptoms of GSM. When physically examined, GSM is clinically evident in 90% of women[6]. Other estimates suggest that 50 to 70% of postmenopausal women have symptomatic GSM to at least some degree[2][8].
The majority of women experience GSM symptoms during menopause, although for some women, symptoms can start earlier or even years after menopause[6]. While GSM mainly affects postmenopausal women, it is also seen in premenopausal women. About 15% of premenopausal women experience GSM-like symptoms due to low estrogen levels[2][14].
Several factors can put women at increased risk of developing GSM beyond natural menopause. Women who experience dips in estrogen after giving birth or while breastfeeding may develop GSM symptoms. Cancer treatments, including chemotherapy, pelvic radiation, and certain medications, can reduce estrogen levels and lead to GSM. Women who have had their ovaries removed surgically are also at risk. Even long-term use of some types of oral contraception can lead to GSM in some women[7][13].
Other risk factors include having few or no vaginal childbirths, missing periods, alcohol abuse, cigarette smoking, lack of exercise, decreased frequency of sexual activity or sexual abstinence, and having other chronic diseases, particularly conditions affecting the urinary and gynecological systems[14].
Despite how common GSM is, many women don’t seek treatment. Women may be embarrassed to discuss their symptoms with their doctor and may resign themselves to living with these symptoms. As a result, GSM remains extremely underdiagnosed despite its high prevalence[4][8].
How GSM Is Diagnosed
Diagnosis of GSM typically involves several steps. Your doctor will ask about your symptoms and medical history. A physical examination is usually performed, during which the doctor visually examines your external genitalia, vagina, and cervix. During a pelvic exam, the doctor may feel your pelvic organs to assess their condition[4].
If you have urinary symptoms, your doctor may order a urine test to check for infection or other problems. This involves collecting and testing your urine[4].
Your doctor may also perform an acid balance test, which involves taking a sample of vaginal fluids or placing a paper indicator strip in your vagina to test its acid level. In GSM, the vaginal pH is typically greater than 5, which is higher (less acidic) than normal[4][5].
Physical examination may reveal specific signs of GSM, including decreased moisture, loss of the normal folds in the vaginal wall, vaginal pallor (paleness), decreased elasticity, thinning or graying pubic hair, and signs affecting the urethra such as a urethral caruncle[5][8].
Treatment Options
The primary goal of treating GSM is to relieve symptoms and improve quality of life. Treatment approaches can be divided into non-hormonal therapies and hormonal therapies[2].
Non-Hormonal Treatments
Non-hormonal therapies are often recommended as first-line treatments. These include lifestyle changes and over-the-counter products[1][12].
Lifestyle changes can help manage symptoms. Maintaining sexual activity is beneficial, as it helps preserve vaginal health. Stopping smoking is recommended, as smoking can worsen symptoms. Avoiding vulvovaginal irritants, including perfumed personal hygiene products in the vulvovaginal area, can reduce irritation[1].
Vaginal moisturizers are products that can help restore moisture to the vaginal area. They are typically applied every few days and their effects generally last longer than lubricants. Examples of over-the-counter vaginal moisturizers include Replens, Refresh, Good Clean Love, and Luvena[1][12].
Water-based lubricants are applied just before sexual activity and can reduce discomfort during intercourse. Examples include Astroglide, K-Y Jelly, and Sliquid. It’s important to choose products that don’t contain glycerin or warming properties, as women who are sensitive to these substances may experience irritation. If you use condoms, avoid petroleum jelly or other petroleum-based products for lubrication, as petroleum can break down latex condoms on contact[12].
Some doctors may recommend mucosal lidocaine for symptom relief[1].
Hormonal Treatments
If non-hormonal therapies don’t provide sufficient relief, hormonal therapy is considered. Vaginal estrogen therapy is generally regarded as the “gold standard” treatment for GSM[1][2].
Vaginal estrogen is the most effective treatment for GSM. It works by improving the quality of the vaginal skin and tissues in and around the vagina. It thickens the skin of the vaginal canal and increases natural lubrication. It also restores the normal acid balance (pH) of the vagina. Studies have shown that vaginal estrogen reduces the risk of urinary tract infections[1].
Vaginal estrogen comes in several forms, including cream, tablet, or ring. The advantage of vaginal estrogen is that it is effective at lower doses and limits overall exposure to estrogen because very little is absorbed into the bloodstream[1][12].
When using vaginal estrogen cream or tablets, it is advised to wait 12 hours after insertion before having sex, although the risk to your partner is not thought to be of concern[1].
Alternative Treatments
Some newer therapeutic approaches are being studied, including energy-based devices like laser treatment. However, laser treatment has yet to show consistent promise in the treatment of GSM. For patients experiencing vaginal atrophy, sexual dysfunction, and pain with intercourse, laser therapy may offer short-term improvement, but the benefits may not last for more than a few months. In a recent study published in the Journal of the American Medical Association, there was no significant improvement in vaginal symptoms one year after laser treatment when compared with placebo. Potential adverse events associated with laser use include vaginal pain, vaginal bleeding, and urinary tract infection[1].
Other alternative options being studied include selective estrogen receptor modulators and other agents, but further research is required to investigate their use in day-to-day clinical practice[2][8].
Is Treatment Safe?
Overall, vaginal estrogen therapy is considered safe. Local vaginal hormonal therapy is associated with minimal to no side effects or risks when used as prescribed, because very little is absorbed into the bloodstream[1].
Before prescribing vaginal estrogen, your doctor will ask about your medical history, particularly if you have a history of breast cancer or blood clots in the legs or lungs. If you have either of these conditions, your doctor may consult with your oncologist or vascular specialist before prescribing vaginal estrogen. In most cases, these specialists approve vaginal estrogen use because the systemic absorption (absorption into the bloodstream) is so low[1].
Studies have shown that vaginal estrogen use does not increase the risk of cardiovascular disease or cancer[1].
It’s important to make an appointment with your doctor if you experience any unexplained vaginal spotting or bleeding, unusual discharge, burning, or soreness. Also see your doctor if you experience painful intercourse that’s not resolved by using vaginal moisturizers or water-based lubricants[4].
