Genitourinary Syndrome of Menopause (GSM): Symptoms, Causes and Treatment

What is genitourinary syndrome of menopause?

In 2014, the International Society for the Study of Women's Sexual Health and The North American Menopause Society (now The Menopause Society) introduced the term genitourinary syndrome of menopause to replace "vulvovaginal atrophy" (Portman 2014). The new name reflects that low estrogen affects the vulva, vagina, urethra and bladder together, and that the symptoms are sexual and urinary as well as vaginal. It was also meant to be a term women would be more comfortable using with their clinicians.

GSM affects an estimated 27% to 84% of postmenopausal women (NAMS 2020). In a survey of more than 3,000 postmenopausal US women with symptoms, only about half had ever discussed them with a health care provider, and few connected them to menopause (Kingsberg 2013).

What are the symptoms of GSM?

Vaginal and vulvar symptoms

• dryness, which was the most common symptom (55%) in the survey above
• burning, itching or irritation
• discomfort with tight clothing, exercise or sitting
• changes in discharge, or light spotting after sex

Sexual symptoms

• pain with sex, reported by 44% of women in the same survey
• less lubrication with arousal
• less sensation, or difficulty with orgasm
• bleeding or soreness after sex

Urinary symptoms

• needing to urinate urgently or often, including at night
• burning with urination without an infection
• repeat urinary tract infections
• leaking urine

The impact is broader than many people assume: in the REVIVE survey, 59% said symptoms affected their enjoyment of sex, and about a quarter said they affected sleep or general enjoyment of life (Kingsberg 2013).

By the numbers

How common and disruptive GSM is

27–84%of postmenopausal women are estimated to have GSMSource: NAMS 2020

55%of surveyed women with symptoms reported dryness, the most common oneSource: Kingsberg 2013

44%of surveyed women with symptoms reported pain with sexSource: Kingsberg 2013

59%said symptoms affected their enjoyment of sexSource: Kingsberg 2013

What causes GSM?

The tissues of the vulva, vagina, urethra and bladder base are rich in estrogen receptors. Estrogen keeps the vaginal lining thick and folded, supports blood flow and natural lubrication, and promotes lactobacilli, the bacteria that keep the vagina acidic and resistant to infection. When estrogen falls, the lining thins and becomes paler and more fragile, elasticity and lubrication drop, and the pH rises. The urethra and bladder lining thin too, which is why urinary symptoms are part of the picture.

Natural menopause is the most common cause, and symptoms can begin in perimenopause. Other causes of low estrogen can trigger GSM at any age:

• removal of both ovaries (surgical menopause), which causes a sudden drop
• breast cancer treatments, especially aromatase inhibitors
• chemotherapy or pelvic radiation
• medicines that suppress ovarian hormones, such as GnRH agonists
• breastfeeding, which temporarily lowers estrogen

Smoking and having less sexual activity may make symptoms worse, while regular sexual activity or vaginal stimulation helps maintain blood flow and elasticity.

How is GSM diagnosed?

GSM is a clinical diagnosis. A clinician asks about your symptoms and how they affect your life, and examines the vulva and vagina for thinning, paleness, loss of folds, redness or tiny tears. A vaginal pH test can support the diagnosis. Blood hormone tests aren't needed.

Just as important is ruling out look-alikes:

ACOG's patient guide to vulvovaginal health explains everyday care and common conditions.

How is GSM treated?

The Menopause Society recommends choosing treatment by severity and preference. Non-hormonal products give enough relief for most women with mild symptoms, and low-dose vaginal estrogen, vaginal DHEA, systemic estrogen and ospemifene are effective for moderate to severe GSM (NAMS 2020).

Non-hormonal first steps

• Vaginal moisturizers used every two to three days for everyday dryness
• Lubricants every time you have sex; silicone-based ones last longest
• Gentle care: plain water or a mild, fragrance-free cleanser on the vulva only, no douching, breathable underwear
• Pelvic floor physical therapy for pain, muscle tightness or bladder symptoms

Our guide to vaginal moisturizers vs lubricants covers how to choose products.

Low-dose vaginal estrogen

Available as a cream, tablet or soft insert, or a three-month ring. A systematic review found all commercially available vaginal estrogens improved dryness, painful sex, urinary urgency and frequency, and incontinence, and reduced UTIs, with blood estradiol staying in the postmenopausal range for low-dose products (Rahn 2014). In a classic randomized trial, vaginal estriol cream sharply cut repeat UTIs in postmenopausal women compared with placebo (Raz 1993). Compounded estriol is another option some clinicians use; see estriol cream for vaginal atrophy.

Vaginal DHEA and ospemifene

Prasterone (Intrarosa) is a nightly vaginal DHEA insert, and ospemifene (Osphena) is a daily pill that acts like estrogen on vaginal tissue. Both are FDA-approved for moderate to severe painful sex due to menopause, and ospemifene is also approved for dryness.

Systemic hormone therapy

If you also have hot flashes, night sweats or menopause-related sleep problems, whole-body hormone therapy can treat those and often improves GSM too, though some women still need a vaginal product. See local vs systemic HRT.

Vaginal laser and energy devices

The Menopause Society found too few placebo-controlled trials to recommend laser or other energy-based treatments for GSM, and these devices aren't FDA-approved for this use.

Is vaginal estrogen safe?

Low-dose vaginal estrogen keeps blood levels low. In the Women's Health Initiative Observational Study of more than 45,000 postmenopausal women not taking systemic hormones, vaginal estrogen users did not have higher rates of breast cancer, endometrial cancer, stroke or blood clots than non-users (Crandall 2018). A progestogen generally isn't needed with low-dose vaginal therapy, though trials of endometrial safety haven't lasted beyond about a year, so any bleeding after menopause should be checked.

When to see a clinician

• symptoms that don't improve after a few weeks of moisturizers and lubricants
• pain with sex, or avoiding sex because of discomfort
• repeat UTIs, or urinary urgency or leaking
• any bleeding after menopause
• itching, white patches, sores or skin changes on the vulva

It helps to say it plainly: "I've had dryness and pain with sex since my periods changed, and I'd like to talk about treatment." If pain with sex is your main concern, our guide to painful sex after menopause goes deeper.

Where Amie fits

For many women, GSM arrives alongside hot flashes, night sweats and poor sleep. Amie offers Amie HRT+, a single compounded cream with estradiol and progesterone, strength chosen by the clinician, for those whole-body menopause symptoms. It is not FDA-approved and is not a vaginal treatment; women with ongoing vaginal or urinary symptoms may still need a local product. A licensed clinician reviews your symptoms and health history, including any cancer, blood clots, stroke, heart or liver disease and unexplained bleeding, to decide whether it's appropriate. Your own gynecologist and FDA-approved vaginal treatments are equally good starting points.