Of all the changes that come with menopause, this cluster of symptoms is the most under-discussed, the most likely to be dismissed, and the most treatable. It affects the majority of women after menopause, becomes worse over time without treatment, and yet only a small proportion of women ever receive care for it. Here is what it is and what can be done.
What Genitourinary Syndrome of Menopause Actually Is
Genitourinary syndrome of menopause (GSM) is the collective term for the changes that happen to the vulva, vagina, and lower urinary tract as oestrogen declines. The older term was 'vaginal atrophy', which never quite captured how broad the picture is, or how it also affects the bladder and urethra.
The tissues of the vagina and vulva rely on oestrogen to stay thick, elastic, well-lubricated, and populated by a healthy balance of protective bacteria (mainly lactobacilli). When oestrogen falls, these tissues become thinner, drier, less elastic, and more vulnerable to irritation, infection, and pain.
The Symptoms
GSM can present with any combination of:
Vaginal dryness
Itching, burning, or irritation of the vulva
Painful sex (dyspareunia)
Reduced sexual arousal, sensation, or difficulty with orgasm
Light bleeding after sex from tissue fragility
Urinary urgency and frequency
Recurrent urinary tract infections
Discomfort or burning with urination
Not every woman experiences all of these, and the presentation can be dominated by urinary symptoms without much vaginal dryness, or vice versa.
Why It Gets Missed
There are several reasons GSM is under-diagnosed. It is rarely asked about in routine appointments. Many women assume symptoms are a normal part of ageing to be lived with. Others feel embarrassed to raise them. And unlike hot flushes, GSM does not improve with time. It progresses without treatment, which means it often becomes worse in the postmenopausal years, at exactly the point when women stop seeking hormonal care.
What Actually Works
Local Vaginal Oestrogen
This is the first-line, most effective treatment for GSM and one of the safest hormonal treatments available. It comes as low-dose creams, pessaries, tablets, or a vaginal ring. Because the oestrogen acts locally on the tissues and is minimally absorbed into the bloodstream, it does not carry the same considerations as systemic MHT. Systemic hormone levels remain postmenopausal, and current guidelines support its use for the long term when symptoms need it.
It is also considered safe for many women with a history of breast cancer, in consultation with an oncology team. This is a conversation worth having rather than assuming it is off the table.
Vaginal Moisturisers and Lubricants
Hyaluronic acid-based vaginal moisturisers used regularly (a few times a week) can help alongside or instead of local oestrogen. Water-based lubricants are useful during sex. These are non-hormonal and available without prescription.
DHEA and Ospemifene
Vaginal DHEA (prasterone) and oral ospemifene are additional options with good evidence, useful for women who cannot or prefer not to use vaginal oestrogen.
Pelvic Floor Physiotherapy
For women with pain, muscle guarding, or difficulty with penetration, pelvic floor physiotherapy is often part of proper GSM care and is under-referred.
A Note on Vaginal Laser Treatments
Vaginal laser therapies are marketed heavily for GSM. The evidence to date is limited, results are inconsistent, and cost is high. Regulatory bodies including the FDA have raised concerns about safety and effectiveness claims. Local vaginal oestrogen remains the first-line treatment for good reason.
On Advocating for Yourself
If your GP has never asked about vaginal or urinary symptoms, you may need to raise them yourself. If you are told to just use lubricant, or that these changes are simply age, ask directly about local vaginal oestrogen. GSM is common. It is treatable. And there is no version of ageing well that requires living with pain during sex or repeated UTIs when treatment exists.