Genitourinary syndrome of menopause is a chronic and progressive condition affecting the vulva, vagina, and lower urinary tract that impacts millions of women worldwide, yet many suffer in silence without knowing that safe and effective treatments exist.
Understanding Genitourinary Syndrome of Menopause
Genitourinary syndrome of menopause, commonly known as GSM, is a term that replaced older names like vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. This newer name was first introduced in 2014 by a consensus of the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. The change in terminology was important because the old names did not cover the full spectrum of symptoms that women experience, nor did they clearly indicate that these symptoms are related to decreased estrogen levels during menopause.[2][5]
GSM is a condition characterized by a broad spectrum of signs and symptoms affecting the vulva, vagina, and lower urinary tract. The condition is chronic and progressive, meaning it does not go away on its own and tends to worsen over time without treatment.[1] Unlike other menopause symptoms such as hot flashes or mood swings, which often improve naturally over time, GSM symptoms typically persist and require active management.[13]
Women with GSM experience a collection of vaginal, sexual, and urinary symptoms. These include vaginal dryness, burning, and irritation, as well as painful sexual intercourse, decreased lubrication during sexual activity, and bleeding after sex. On the sexual health side, women may notice decreased arousal, loss of libido, and inability to achieve orgasm. The urinary symptoms are equally troubling and include painful urination, urinary urgency, urinary incontinence of both stress and urge types, and recurrent urinary infections. Some women also develop a urethral caruncle, which is a red vascular growth on the urethra.[1][5]
How Common Is GSM: Epidemiology
Genitourinary syndrome of menopause is extremely common among postmenopausal women, yet it remains underdiagnosed and undertreated despite its high prevalence. Studies report that between 50 and 70 percent of postmenopausal women have symptomatic GSM to at least some degree.[2][8] Some research suggests the numbers may be even higher, with recent studies indicating that up to 77 percent of women experience one or more symptoms of GSM, and when physically examined, GSM is clinically evident in 90 percent of women.[15] Another source reports that up to 84 percent of postmenopausal women experience at least one symptom of this condition.[6]
The vast majority of women suffering from GSM are of older age, particularly those who have gone through menopause. However, the condition is not limited to postmenopausal women. About 15 percent of premenopausal women also experience GSM-like symptoms due to a hypoestrogenic state, which means they have reduced levels of estrogen in their body even though they have not yet reached menopause.[2] Women can enter this low-estrogen state for various reasons beyond natural menopause, including after childbirth, while breastfeeding, during cancer treatment, or even with long-term use of oral contraception.[7][13]
Despite the high prevalence of this condition, data from a US survey published in 2017 showed that 50 percent of women experiencing GSM had never used any therapy to address their symptoms.[15] This undertreatment reflects several barriers including limited public knowledge of GSM symptoms and treatments, patient and provider hesitancy in discussing the topic, and concerns regarding use of hormone therapies.[15] Many women are embarrassed to discuss their symptoms with their doctor and may resign themselves to living with these uncomfortable conditions.[4]
What Causes Genitourinary Syndrome of Menopause
The primary cause of GSM is estrogen decline, which occurs during perimenopause, menopause, and postmenopause. Estrogen is a type of hormone that promotes and maintains female traits in the body and is also referred to as a female sex hormone.[1] When a woman’s body produces less estrogen, profound physiological and anatomical alterations occur in the genitourinary system.[8]
Estrogen plays a critical role in maintaining the health of vaginal and urinary tissues. It supports collagen production, which keeps tissues elastic and resilient. It ensures adequate blood flow, which delivers oxygen and nutrients to vaginal and urethral tissues. Estrogen also promotes glycogen production, which provides fuel for beneficial vaginal bacteria and supports a balanced vaginal microbiome.[14] When estrogen levels drop during menopause, these hormonal shifts cause the vaginal and urinary tissues to become thinner, drier, and more fragile.[7][13]
Without sufficient estrogen, the lining of the vagina becomes thinner and less stretchy. The vaginal canal can also narrow and shorten. Lower estrogen levels reduce the amount of normal vaginal fluids and change the acid balance in the vagina. All of these factors make vaginal tissue more delicate and more likely to become irritated.[4] The reduced estrogen affects every organ system in the body, but especially the genitourinary tract, where there are loads of estrogen receptors. The pronounced lack of estrogen can lead to a range of genital and urinary problems.[13]
While natural menopause is the most common cause, the body can produce less estrogen during other events as well. Women who are breastfeeding, receiving treatment for cancer, or have had their ovaries removed can experience vaginal atrophy due to lack of estrogen.[4] Women who experience dips in estrogen after giving birth, during cancer treatment, or with long-term use of oral contraception are also at risk.[7][13]
Risk Factors for Developing GSM
Women in menopause are the most likely to experience GSM because their body naturally produces less estrogen. However, other factors beyond natural aging can decrease estrogen levels and lead to the condition. Decreased ovarian functioning due to chemotherapy or radiation therapy is one significant risk factor. Medications that contain antiestrogen properties, including tamoxifen, medroxyprogesterone, and nafarelin, can also contribute to GSM development.[17]
Additional risk factors include having an oophorectomy, which is the surgical removal of both ovaries; certain immune disorders; taking some birth control pills; and smoking cigarettes. Women who have penetrative sexual activity less often, with or without a partner, may also have a higher chance of experiencing GSM.[17] Studies suggest that other risk factors include the absence of vaginal childbirth, missing periods, alcohol abuse, decreased frequency of sexual activity or sexual abstinence including having few orgasms, lack of exercise, premature ovarian failure, pelvic irradiation, and having other chronic diseases, mostly urogynecological conditions like interstitial cystitis.[14]
Women who have a history of breast cancer or a history of blood clots in the legs or lungs require special consideration when discussing treatment options, as healthcare providers may need to consult with an oncologist or vascular specialist before prescribing certain therapies.[1] However, it is important to note that in most cases, these specialists are comfortable with certain treatment options because the systemic absorption into the blood stream is so low.[1]
Recognizing the Symptoms of GSM
The symptoms of genitourinary syndrome of menopause fall into three main categories: vaginal symptoms, sexual symptoms, and urinary symptoms. Understanding these symptoms is essential because they can have a great impact on the quality of life of affected women, especially those who are sexually active.[2]
Vaginal symptoms are often the first to appear and include vaginal dryness, which is the most common GSM symptom affecting more than 90 percent of women with this condition. Women also experience vaginal irritation, burning, and itching. Physical changes become evident as well, including thinning or graying of pubic hair and vaginal pelvic pain or pressure.[1][14]
Sexual symptoms can be particularly distressing and include painful sexual intercourse, a condition known as dyspareunia. This discomfort affects as many as 80 percent of women with GSM. Women also notice decreased lubrication during sexual activity, bleeding after sexual activity, decreased arousal, loss of libido, and inability to achieve orgasm.[1][14] For many women, vaginal dryness not only makes intercourse painful but also leads to distressing urinary symptoms.[4]
Urinary symptoms include painful urination, urinary urgency (a sudden, intense need to urinate more often), and urinary incontinence involving both stress and urge types. Women with GSM have an increased risk of recurrent urinary tract infections. Some women develop a urethral caruncle, which appears as a red vascular growth on the urethra.[1][4] These symptoms often get worse if left untreated and can impact not only sexual health and bladder function but also overall well-being, including increasing susceptibility to infections.[14]
In more severe cases, GSM can impact basic activities such as sitting, walking, and working, not just sex and bladder control.[13] These symptoms can vary in severity among different women, but the common thread is that they often worsen without proper treatment. Women should make an appointment with their doctor if they have any unexplained vaginal spotting or bleeding, unusual discharge, burning, or soreness, and especially if they experience painful intercourse that is not resolved by using vaginal moisturizers or water-based lubricants.[4]
Preventing Genitourinary Syndrome of Menopause
While GSM is largely driven by hormonal changes that occur naturally with aging and menopause, certain lifestyle modifications and preventive measures may help reduce the risk or delay the onset of symptoms. However, it is important to understand that prevention strategies are limited because the primary cause is the natural decline in estrogen production that accompanies menopause.
One of the lifestyle changes that can help is maintaining sexual activity. Regular sexual activity, with or without a partner, can help maintain vaginal health by promoting blood flow to the area and helping to preserve tissue elasticity. Studies have identified decreased frequency of sexual activity or sexual abstinence as risk factors for GSM, suggesting that maintaining regular sexual activity may offer some protective benefit.[14]
Smoking cessation is another important preventive measure. Cigarette smoking has been identified as a risk factor for developing GSM, likely because smoking can affect circulation and hormone levels.[14] Women who smoke should consider quitting to potentially reduce their risk of developing severe GSM symptoms.
Avoiding vulvovaginal irritants is also recommended as part of preventive care. This includes being careful about the use of personal hygiene products in the vulvovaginal area, as these can sometimes cause irritation or disrupt the natural balance of the vaginal environment.[1] Maintaining regular exercise and avoiding excessive alcohol consumption may also play a role, as both alcohol abuse and lack of exercise have been identified as risk factors for GSM.[14]
Early detection and treatment are crucial aspects of managing GSM effectively. The Menopause Society recommends GSM education and screening for all perimenopausal and postmenopausal women.[15] Women should be made aware of these problems and should not feel embarrassed about discussing symptoms with their healthcare providers. Regular communication with a doctor can lead to earlier intervention and better outcomes.
How GSM Changes Normal Body Function: Pathophysiology
Understanding how GSM changes normal bodily functions requires looking at what happens at the tissue level when estrogen levels decline. The genitourinary system undergoes profound physiological and anatomical alterations during menopause due to the loss of endogenous sex steroids.[8]
In a healthy premenopausal woman, the vaginal lining consists of thick, moist tissue with good blood flow. Estrogen maintains the thickness and elasticity of vaginal and urethral tissues, promotes adequate blood circulation to these areas, and supports the production of natural lubrication. When estrogen levels drop, the tissue that lines the wall of the vagina becomes thin, dry, and inflamed. With vaginal atrophy, this tissue becomes dry and thin with less blood flow to the area.[17]
Without estrogen, several specific changes occur in the vaginal environment. The vaginal epithelium, which is the lining of the vagina, becomes thinner and loses its layered structure. The vaginal wall loses its normal folds called rugae, and the tissue becomes less elastic and more fragile. Blood flow to the area decreases, which means less oxygen and nutrients reach the tissues. Natural lubrication decreases significantly, leading to dryness and discomfort.[1]
The vaginal canal itself can undergo structural changes, becoming narrower and shorter. In some cases, introital stenosis occurs, which is a narrowing of the vaginal opening. Physical signs include labial atrophy, decreased moisture, loss of vaginal rugae, vaginal pallor (paleness), decreased elasticity, and thinning or graying of pubic hair.[8]
Changes also occur in the chemical environment of the vagina. The vaginal pH increases to levels higher than 5, becoming more alkaline than the normal acidic environment. This change in pH affects the vaginal microflora, the community of beneficial bacteria that normally inhabit the vagina. The reduction in glycogen production means there is less fuel available for beneficial bacteria like lactobacilli. This disruption in the vaginal microbiome increases susceptibility to infections, particularly urinary tract infections.[14]
In the urinary system, similar changes occur. The urethra, bladder trigone, and surrounding tissues all have estrogen receptors and are affected by estrogen decline. The urethral tissue becomes thinner and more vulnerable to irritation. Changes can occur in the urethral opening, including urethral prolapse or caruncle formation and meatal stenosis (narrowing of the urethral opening). The bladder trigone, an important region at the base of the bladder, can experience ischemia, meaning reduced blood flow. These changes contribute to urinary symptoms including urgency, frequency, incontinence, and increased susceptibility to urinary tract infections.[8]
The cellular changes in vaginal tissue include an increase in parabasal cells and a decrease in superficial cells on wet mount examination or maturation index. These cellular changes are sometimes used as supportive findings to confirm the diagnosis of GSM during physical examination.[5] All these changes together create an environment where the tissues are more vulnerable to trauma, slower to heal, more prone to infection, and less comfortable during daily activities and sexual activity.
