Genitourinary syndrome of menopause (GSM): symptoms and treatment

Genitourinary syndrome of menopause (GSM) is the medical name for the dryness, irritation, pain with sex, and urinary symptoms caused by falling estrogen in the vagina, vulva, urethra, and bladder. It is very common, can begin in perimenopause, and usually worsens without treatment. Effective options range from over-the-counter moisturizers to low-dose vaginal estrogen, which has a reassuring long-term safety record.

What GSM is and why it happens

The vagina, vulva, urethra, and base of the bladder develop from the same tissue and are rich in estrogen receptors. As estrogen declines, the vaginal lining thins, makes less moisture, and loses elasticity. Vaginal pH rises, typically above 5.0, and protective lactobacilli become less dominant. The tissue tears and bleeds more easily, and the urinary tract becomes more vulnerable to infection.

The term GSM was adopted in 2014 to replace “vulvovaginal atrophy.” The Menopause Society explains why: the old term described how tissue looks rather than how women feel, ignored urinary symptoms, and “atrophy” carries negative associations.

Natural menopause is the most common cause, but anything that lowers estrogen can trigger GSM: surgical removal of both ovaries, breastfeeding, aromatase inhibitors after breast cancer, and chemotherapy or pelvic radiation. GSM after surgical menopause tends to be more severe.

Symptoms

Women may have some or all of these:

• Genital: dryness, burning, itching or irritation, sometimes discharge
• Sexual: less lubrication, pain or discomfort with penetration, bleeding after sex
• Urinary: burning with urination, urgency, frequency, recurrent urinary tract infections

You do not need to be sexually active to have bothersome GSM. Some women notice it first as discomfort during exercise or burning when they urinate.

Other conditions cause similar symptoms, including yeast infections, lichen sclerosus and other vulvar skin diseases, contact dermatitis, and vulvodynia. That is one reason an exam matters before treatment.

How common it is

The Menopause Society’s 2020 position statement estimates that GSM symptoms affect about 27% to 84% of postmenopausal women. The 2025 AUA/SUFU/AUGS guideline cites a wider range, 13% to 87%, and notes that estimates vary with how symptoms are measured.

Symptoms build through the transition. In the Study of Women’s Health Across the Nation (SWAN), which followed 2,435 women for up to 17 years, vaginal dryness rose from 19.4% at ages 42 to 53 to 34.0% at ages 57 to 69. Advancing menopausal stage and surgical menopause were linked to new dryness.

GSM is also undertreated. In a survey of 1,858 US women with symptoms, half had never used any treatment, and almost three-quarters of those had never discussed their symptoms with a clinician, mostly because they assumed it was a natural part of aging.

How it is diagnosed

Diagnosis is based on your symptoms plus a genitourinary exam. The AUA guideline asks clinicians to take a focused medical, sexual, and psychosocial history and to look for other conditions that can coexist, such as infection, skin disease, or an active UTI. Tests like vaginal pH are used in research but are not required. A culture or biopsy is considered if findings are unusual or symptoms do not improve with treatment.

Treatment options

Treatment is chosen by severity and preference. The AUA guideline stresses shared decision-making and does not require you to step through hormonal options in a fixed order.

Option	How it is used	Best suited for	Notes
Lubricant	During sex	Friction and pain with sex	Over the counter; first-line
Vaginal moisturizer	2 to 3 times a week	Day-to-day dryness	Over the counter; first-line
Low-dose vaginal estrogen (cream, tablet or insert, ring)	Daily for about 2 weeks, then 2 to 3 times a week; ring replaced every 3 months	Moderate to severe GSM, including urinary symptoms	Strongest evidence base
Vaginal DHEA (prasterone)	Daily vaginal insert	Dryness and pain with sex	Vaginal discharge in about 6%
Ospemifene	Daily pill	Dryness and pain with sex when a vaginal product is not wanted	Hot flashes in 7.2% vs 2% with placebo
Systemic hormone therapy	Pill, patch, gel, or spray	GSM plus hot flashes	Vaginal treatment can be added if needed

Lubricants and moisturizers are graded Level A first-line therapy by The Menopause Society. Our guide to vaginal moisturizers and lubricants covers how to choose them, and vaginal dryness treatments compares every option in more detail.

Low-dose vaginal estrogen is the treatment the AUA guideline says has “the most robust evidence base.” All approved products have beaten placebo in randomized trials, and they work about equally well, so the choice comes down to preference: creams can also be applied to the vulva, tablets and inserts are fixed-dose and less messy, and the ring is changed four times a year.

Pelvic floor physical therapy and dilators help when pain has caused the pelvic floor muscles to tighten. See pelvic floor physical therapy.

What not to rely on: the AUA guideline says evidence does not support supplements for GSM, and it advises avoiding vulvovaginal irritants and harsh cleansers.

Safety of vaginal estrogen

Low-dose vaginal estrogen is absorbed only minimally. Two large US cohorts are reassuring:

• In the Women’s Health Initiative Observational Study (45,663 women, median follow-up 7.2 years), vaginal estrogen users with a uterus had no significant increase in stroke, invasive breast cancer, colorectal cancer, endometrial cancer, or blood clots compared with nonusers.
• In the Nurses’ Health Study, over 18 years of follow-up, vaginal estrogen use was not associated with higher risk of cardiovascular disease, cancer, or hip fracture.

A progestogen is not needed with low-dose vaginal estrogen, and routine endometrial monitoring is not recommended. Any bleeding after menopause still needs to be evaluated.

The boxed warning is changing. For years, low-dose vaginal estrogen carried the same boxed warning as systemic hormone therapy, covering endometrial cancer, breast cancer, cardiovascular disorders, and probable dementia. On November 10, 2025, the FDA asked manufacturers of all menopausal hormone therapies, including local vaginal products, to remove the boxed-warning language on cardiovascular disease, breast cancer, and probable dementia, and to remove the endometrial cancer language except on systemic estrogen-alone products. For vaginal products, it also asked that safety information be condensed to what is relevant to local use. Because labels are updated product by product, a package insert printed before the change may still show the old warning.

After breast cancer, the AUA guideline says vaginal estrogen may be recommended through shared decision-making that includes your oncologist. Non-hormonal options are covered in options for breast cancer survivors.

When to see a clinician

• Dryness, irritation, or pain with sex that bothers you or makes you avoid intimacy
• Any bleeding after menopause, or bleeding after sex
• Itching, white patches, sores, or skin changes on the vulva
• Two or more UTIs in six months
• Over-the-counter products that have not helped after several weeks

An OB-GYN near you can examine the tissue and rule out other causes.

How to bring it up

Many clinicians do not ask, so you may need to raise it yourself. A simple opener works: “I’ve had vaginal dryness and pain with sex for six months, and I’d like to talk about treatment, including vaginal estrogen.” Bring a short list of your symptoms, how long you have had them, any UTIs, and what you have already tried. Writing these down before the visit makes the conversation easier.