Understanding Genitourinary Syndrome of Menopause (GSM)

Menopause brings many changes to a woman's body, but one condition that affects millions yet remains underdiagnosed and undertreated is Genitourinary Syndrome of Menopause (GSM). Based on the latest clinical guidelines from the American Urological Association, here's what every woman should know about this common but often overlooked condition.

What is GSM?

Genitourinary Syndrome of Menopause (GSM) describes the spectrum of symptoms and physical changes that occur in the genitourinary tract due to declining estrogen and androgen levels during menopause. Unlike hot flashes that may resolve over time, GSM symptoms typically worsen with age if left untreated.

The term GSM was introduced in 2014 to replace the more limited "vulvovaginal atrophy," better capturing the full range of symptoms that affect not just the vagina, but also the vulva, urethra, and bladder.

Who's Affected?

GSM is common, affecting upwards of four out of five postmenopausal women. However, it's not limited to natural menopause. Women at risk include:

• Those experiencing menopause between ages 40-45
• Patients with primary ovarian insufficiency (before age 40)
• Women who've had surgical menopause (bilateral oophorectomy)
• Those taking medications that suppress estrogen (like certain breast cancer treatments)
• Women using hormonal contraceptives that may cause GSM-like symptoms
  
  

Recognizing the Symptoms

GSM affects three main areas, and symptoms can overlap:

Vaginal/Vulvar Symptoms:

• Dryness, burning, and irritation
• Decreased lubrication during sexual activity
• Pain or discomfort with intercourse (dyspareunia)
• Postcoital bleeding

Urinary Symptoms:

• Urgency and frequency
• Painful urination (dysuria)
• Recurrent urinary tract infections
• Urinary incontinence

Sexual Symptoms:

• Decreased arousal and desire
• Reduced genital sensation
• Difficulty reaching orgasm
• Overall decreased sexual satisfaction
  
  

The Physical Changes

Specific physical signs include:

• Loss of vaginal moisture and elasticity
• Thinning of vaginal and vulvar tissues
• Narrowing of the vaginal opening
• Changes in vaginal pH (becoming less acidic)
• Urethral changes like prolapse or caruncles
  
  

Treatment Options: There's Hope

The good news is that GSM is highly treatable. The latest guidelines recommend several evidence-based approaches:

Hormonal Treatments (First-Line):

• Local low-dose vaginal estrogen (creams, tablets, rings) - considered the gold standard
• Vaginal DHEA - effective for dryness and pain during intercourse
• Ospemifene - an oral medication that acts like estrogen in vaginal tissues

Non-Hormonal Options:

• Vaginal moisturizers and lubricants - can be used alone or with other treatments
• Regular use helps maintain vaginal health
• Water-based products are generally recommended

What Doesn't Work:

Recent evidence shows that certain treatments lack sufficient evidence and may carry risks:

• Energy-based treatments (laser therapy, radiofrequency)
• Alternative supplements and herbal remedies
  
  

Special Considerations for Cancer Survivors

Women with a history of breast cancer often experience more severe GSM symptoms due to cancer treatments that lower estrogen. The guidelines now provide reassuring evidence that local low-dose vaginal estrogen does not increase breast cancer risk or recurrence rates, making it a viable option for many survivors when discussed with their oncology team.

The Importance of Seeking Help

Despite affecting millions of women, only about half of those with GSM symptoms discuss them with their healthcare providers. Many suffer in silence due to embarrassment or the mistaken belief that these symptoms are "just part of aging."

Why Treatment Matters:

• GSM significantly impacts quality of life and relationships
• Symptoms typically worsen over time without treatment
• Effective treatments are available and safe for most women
• Early intervention can prevent symptom progression
  
  

Moving Forward

If you're experiencing symptoms of GSM, know that:

1. You're not alone - This affects the majority of postmenopausal women
2. It's treatable - Multiple safe, effective options exist
3. It's worth discussing - Healthcare providers are trained to help with these concerns
4. Treatment is individualized - What works best varies from person to person
   
   

The key is open communication with your healthcare provider about your symptoms, concerns, and treatment preferences. Together, you can develop a treatment plan that improves your comfort, health, and quality of life.

GSM may be a common consequence of menopause, but suffering through it is not inevitable. With proper recognition, evaluation, and treatment, women can maintain their genitourinary health and continue to enjoy active, comfortable lives well beyond menopause.

Source: Kaufman, M.R., Ackerman, A.L., Amin, K.A., et al. Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline. American Urological Association Education and Research, Inc. Approved by the AUA Board of Directors April 2025. Copyright © 2025 American Urological Association Education and Research, Inc.