Genitourinary syndrome of menopause (GSM) is a progressive condition that shows up as various symptoms that affect the vulva, vagina, and urinary tract (bladder and urethra) during and after
menopause.
GSM is caused by a drop in estrogen levels, a hormone produced by the ovaries that keeps the vagina and bladder tissue thick, lubricated, and elastic.
When estrogen drops during menopause, the tissues lining the vagina become thin (called vaginal atrophy), causing symptoms like dryness, burning, itching, pain, and urinary tract infections (UTIs).
GSM often starts five to six years after a woman's last period, but it sometimes begins in the years leading up to menopause (
perimenopause).
This condition can be uncomfortable and frustrating, but the symptoms are manageable with over-the-counter remedies and prescription medicines.
The loss of estrogen during menopause can cause vaginal, urinary, and sexual symptoms.
Vaginal symptoms include:
- Dryness
- Burning
- Itching inside and around the vagina
- Irritation
- Pain and pressure
Urinary symptoms include:
- Loss of sex drive
- Painful sex
- Spotting or bleeding during or after sex
- Inability to reach orgasm
The drop in estrogen during menopause causes GSM.
When estrogen levels are low, the body produces less collagen and other substances that keep tissues inside the vagina lubricated and stretchy.
As a result, the vagina gets thinner, drier, and less elastic.
Because the tissue is more fragile, it gets irritated and tears easily. The loss of estrogen also changes the pH in the vagina and alters the balance of helpful bacteria that protect against UTIs.
Naturally occurring menopause isn't the only reason someone might have a drop in estrogen levels. Other life events or treatments can lower estrogen levels and cause these symptoms, such as:
- Ovary removal surgery
- Cancer treatments such as chemotherapy, aromatase inhibitors, or radiation to the ovaries or pelvis
- Medications that lower estrogen levels, such as methotrexate and some birth control pills
- Breastfeeding
- Autoimmune disease
Smoking can cause early menopause or make GSM worse.
To diagnose GSM, doctors ask about symptoms like vaginal dryness, pain during sex, and UTIs.
A physical exam may show some or all of the following signs in the vulva and vagina.
- Dryness
- Redness
- Swelling
- Thinning
- Narrowing or shortening
- Cuts or tears
Lab tests like
urinalysis (urine test) or tissue culture usually aren't needed to diagnose GSM.
But these tests can be helpful for ruling out other conditions, such as UTIs or sexually transmitted infections (STIs).
Over-the-counter vaginal lubricants and moisturizers and prescription hormone therapy are the main treatments for GSM.
The choice of medicine depends on the severity of symptoms. Lifestyle changes can also make GSM more manageable.
Hormonal Treatments
Prescription hormonal medicines for GSM include the following:
- Topical Estrogen Therapy Low-dose hormone therapy replaces some of the estrogen your body no longer makes. This treatment comes as a tablet, ring, insert, or cream. Estrogen thickens tissue and increases lubrication inside the vagina. It also improves the pH, which helps prevent UTIs. Topical estrogen works for mild symptoms like irritation, dryness, and pain during sex. It has fewer side effects than oral hormone therapy, because very little is absorbed into the bloodstream. But talk to your oncologist before using estrogen therapy if you have a history of breast cancer or blood clots.
- Systemic Estrogen Therapy More severe symptoms may need treatment with estrogen pills, which work throughout the body to treat GSM and other menopause symptoms.
- Synthetic DHEA DHEA is a sex hormone that your body converts into estrogen and testosterone. A synthetic version of DHEA, prasterone (Intrarosa), can be inserted vaginally once a day at bedtime to relieve vaginal dryness, burning, and pain.
Nonhormonal Treatments
These nonhormonal products may be used with hormone therapy or on their own for mild symptoms.
- Vaginal Lubricants These over-the-counter options are often the first treatment for mild GSM symptoms. Lubricants reduce friction and pain, and increase comfort during sex. They are either water-based (K-Y, Astroglide) or oil-based. Some oil-based lubricants can damage latex condoms and increase the risk of STIs.
- Vaginal Moisturizers These over-the-counter products (Replens, Sliquid) absorb moisture through the skin and trap it in the lining of the vagina to treat dryness and thinning. Because their effects last longer than lubricants, moisturizers are applied two to three times a week.
- Selective Estrogen Receptor Modulators (SERMs) SERMs are nonhormonal treatments that can both activate and inactivate estrogen in different tissues. Ospemifine (Osphena) is a SERM that acts like estrogen on tissues of the vagina to improve dryness and pain without increasing breast cancer risks. You need a prescription for this medication, and it’s taken as a pill.
Other Treatments
The following can be used as additional or alternative treatments to lubricants, moisturizers, and medications.
- Pelvic Floor Therapy Pelvic floor exercises strengthen muscles that support the bladder and uterus, making them stretchier and preventing urine leaks. A physical therapist can teach you how to do pelvic floor exercises and you can do them at home.
- Vaginal Laser Ablation A newer GSM treatment uses a laser or radiofrequency energy to treat the vaginal lining. The energy stimulates the production of collagen — a protein that improves skin firmness — and promotes the growth of new tissue. Laser treatment works quickly and it doesn't use hormones. But while early studies showed that it helped with symptoms like pain during sex, newer research hasn't found any benefit. Plus, this treatment can cause side effects like scarring and chronic pain. The American Urological Association says there isn't enough evidence to support the use of laser treatment for GSM, but it may be an option for people who can't use hormone therapy or who prefer an alternative.
Though you can't prevent GSM, you can manage symptoms and avoid complications like chronic vaginal dryness and repeat UTIs.
About 70 percent of people with GSM symptoms don't report their symptoms to their doctor.
Many are too embarrassed to ask for help or think their symptoms are a normal part of the aging process. Don’t be afraid to speak with your doctor about these symptoms and changes. Your doctor can help you find treatment or suggest lifestyle practices that may help preserve vaginal health.
Make Time for Sexual Activity
Have safe sex as often as possible.
Penetrative sex increases blood flow to the vagina, maintains a healthy vaginal lining, and stimulates the release of natural lubricants. Sex doesn't have to involve a partner. Using a device like a vibrator works just as well.
Use a Vaginal Dilator
A
vaginal dilator stretches out the walls of the vagina and makes them more elastic so that sex is more comfortable.
Dilators are sold online and in some stores. A physical therapist or a specialist in sexual medicine can show you how to use it.
Quit Smoking
People who smoke start menopause earlier and have more severe symptoms.
Quitting smoking isn't easy, but tools like nicotine replacement therapy, prescription medicines, and transcranial magnetic stimulation can help reduce the urge to smoke.
Avoid Irritants
Clean your vagina with only water and gentle soap. Avoid cleansers, douches, bubble baths, and feminine hygiene sprays.
These products may contain ingredients that irritate sensitive tissues and worsen GSM symptoms like dryness and pain.
Stay Hydrated
Without treatment, GSM will get worse.
See a gynecologist for a diagnosis and get treated early. Relieving GSM symptoms can improve both your quality of life and sex life.
Over-the-counter vaginal lubricants and moisturizers are often enough to manage mild GSM. Moderate to severe symptoms may require estrogen therapy or other prescription medications.
Untreated GSM could lead to complications like chronic vaginal dryness, painful sex, urinary incontinence, repeated UTIs, and other infections.
These problems not only affect day-to-day life, but they can lead to emotional distress and relationship issues.
A few conditions often go together with GSM. These include:
- Painful Sex (Dyspareunia) Less lubrication and thinner tissues inside the vagina make sex uncomfortable, and even painful.
- UTIs A thinner vaginal lining and changes in the pH balance increase the risk for urinary tract infections.
- Urinary Incontinence A more frequent or urgent need to pee is another problem linked to GSM.
- Low Libido Having lubrication in the vagina makes sex comfortable. Dryness and thinning tissue cause discomfort that makes some people lose their desire for sex.
The Menopause Society
This nonprofit organization is devoted to improving the health of women during menopause. Its website offers information on choosing a doctor and navigating menopause symptoms.
Let's Talk Menopause
The aim of this organization is to reduce the stigma surrounding menopause through education. Let's Talk Menopause empowers women to take control over their symptoms, and offers a support community.
Rachel Green
Rachel Davis
Derek Schulz
Sophia Martinez
Dr. Amara Okafor