Genitourinary syndrome of menopause

Common symptoms and how to find relief

You're in your 40s or 50s. Lately, intimacy with your partner has become uncomfortable or even painful. You might also notice more frequent trips to the bathroom or a persistent feeling of vaginal dryness. These changes aren't just "part of getting older." They're signs of a treatable medical condition.

Genitourinary syndrome of menopause (GSM) describes a range of physical changes that happen when estrogen levels drop during perimenopause and after menopause. While estimates vary, about 75% of postmenopausal women have symptoms, yet more than half never seek treatment.

Brytanie N. Marshall, MD, a Geisinger physician, helps patients understand that GSM is both common and highly treatable. You don't have to live with these symptoms.

What is genitourinary syndrome of menopause?

The condition used to be called vulvovaginal atrophy, but the newer term GSM better captures the full range of symptoms that can affect your genital and urinary health.

GSM happens when declining estrogen levels cause physical changes in your vagina, vulva and urinary tract. Menopause brings a dramatic 95% reduction in estrogen production, which affects the tissues in your genital and urinary systems.

Unlike hot flashes that often improve over time, GSM is progressive and irreversible without treatment

“If you don’t get treatment, your symptoms will only get worse,” says Dr. Marshall. “That's why recognizing the symptoms early and getting treatment matters.”

When your ovaries were working at top capacity, your vagina was constantly growing an abundance of new, protective cells and shedding old cells. The shed cells feed helpful bacteria. Flourishing good bacteria create a more acidic environment — something between the pH of vinegar and beer. In addition to possibly staining your dark underwear, the acidity fights bad bacteria.

That changes when you’re approaching or in menopause or you’ve lost ovarian function. When estrogen plummets, vaginal cell growth slows to a crawl and supports fewer good bacteria. Your vagina gets less acidic, closer to the pH of milk. This lets bad bacteria flourish and increases your chances of vaginal and urinary infections.

Without that constant cell turnover, your vagina is also more easily irritated by friction or — especially troubling — sex.

Common symptoms of vaginal atrophy and GSM

GSM symptoms fall into 3 main categories. According to recent research, you might have just a few symptoms or several.

Vaginal and vulvar symptoms: 75% of women have vaginal dryness. You may also have itching, burning, irritation, a feeling of tightness or soreness and discomfort with sitting or exercising. The vaginal tissue might feel more fragile.
Sexual symptoms: 40% of women report pain during intercourse (dyspareunia). Decreased lubrication during sexual activity is often the first sign of GSM. You might also notice pain on penetration, light bleeding after sex or find that sexual activity is simply less comfortable than it used to be.
Urinary symptoms: Between 30% and 40% of women feel an urgent need to pee, or pee more often. You may develop recurrent urinary tract infections (UTIs) and some women feel burning when they urinate.

Common myths about GSM in women

There are many myths about GSM.

It’s just aging and nothing can help. Not true. Evidence-based GSM treatment works for most people.
It’s only vaginal dryness. GSM also includes urinary urgency, frequency and recurrent infections.
Symptoms go away on their own. They usually don’t. Gentle, consistent care helps tissues heal and stay healthy.
Hormonal options aren’t safe. Low-dose local therapies have minimal systemic absorption for most people.

“Your gynecologist can help you find treatment that will protect you from pain and infection as you age,” says Dr. Marshall. “The value of treating this condition is a key part of living a long, fulfilling life.”

How GSM affects your quality of life

“The impact of genitourinary symptoms extends beyond physical discomfort,” explains Dr. Marshall. “These changes can affect your relationships, self-esteem and daily activities.”

Sexual intimacy may become a source of anxiety rather than pleasure. Many women worry about the long-term effects on their partnerships. The condition can also disrupt sleep and make everyday activities like sitting, walking or wearing certain clothing uncomfortable.

How GSM is diagnosed

A careful conversation and a gentle pelvic exam are usually enough to diagnose genitourinary syndrome of menopause. The goals are to confirm GSM, rule out other causes and find factors that shape your treatment plan.

“Your healthcare provider may test you for infection and perform a pelvic exam to make an accurate diagnosis,” Dr. Marshall explains. “Most important, they will ask you about your symptoms and past history, and your honest answers will be key to finding relief.”

Treatments for GSM

Several effective treatments can help manage GSM symptoms. Your path to relief often starts simple and progresses as needed.

Non-hormonal options: Over-the-counter vaginal moisturizers used 2 to 3 times weekly and lubricants used during sexual activity are often tried first. These can provide relief for mild symptoms without a prescription. Avoid moisturizers with a warming, tingling or heating sensation. They can make you more irritated.

Vaginal estrogen therapy: For moderate to severe symptoms, low-dose vaginal estrogen is considered the gold standard for treatment. It comes in creams, tablets or rings and works directly where you need it most. This treatment for genitourinary syndrome of menopause largely stays out of your bloodstream, so it’s useful even for those who are concerned about using hormones.

Other prescription options: Your doctor might recommend vaginal DHEA inserts or oral ospemifene, both of which have been shown to improve dryness and pain. These options work well for women who prefer alternatives to estrogen or need additional relief.

“Don't wait for symptoms to become severe,” advises Dr. Marshall. “Early treatment can prevent progression and improve your quality of life more quickly. Remember, healthcare providers are trained to discuss these concerns. What might feel embarrassing to you is routine for them — and we want to help you feel better.”