Genitourinary syndrome of menopause (GSM) describes a set of symptoms that affect the genitourinary tract, including vaginal dryness, painful intercourse, and urinary problems.
Menopause is a transitional period characterized by hormonal changes that can lead to a host of symptoms, such as changes in weight, fluctuations in mood, and more. Genitourinary syndrome of menopause (GSM) is a chronic condition that affects the vagina, vulva, and lower urinary tract.
Previously referred to as vulvovaginal atrophy or atrophic vaginitis, GSM is characterized by:
- vulvovaginal pain and discomfort
- pain during sex
- decreased libido
- urinary tract issues
In this article, we’ll explore GSM, including its causes, symptoms, treatment, and overall outlook for those with this condition.
In the years leading up to and including menopause, the ovaries reduce their production of estrogen. Estrogen is a sex hormone that plays a role in several key human functions, including puberty, menstruation, and bone health.
After menopause, and in those who may have hormonal imbalances not related to menopause, the production of estrogen from the ovaries is extremely low. Low estrogen levels are the primary cause of GSM symptoms.
Estrogen receptors
- vagina
- vulva
- urethra
- bladder
Decreasing estrogen levels can cause changes in the anatomy and function of these tissues, which can lead to GSM symptoms. Changes to these tissues include a reduction in:
- skin thickness
- elasticity
- muscle function
- blood flow
Certain people are more at risk for developing GSM than others, including those who:
- are undergoing or have undergone menopause
- have had an oophorectomy (surgery to remove the ovaries)
- have a history of smoking
- have a history of alcohol abuse
- do not engage in sexual activity often
- are undergoing certain cancer treatments
If you are concerned that you might be at risk for developing GSM, schedule a visit with a primary care physician or gynecologist to discuss your options.
GSM primarily affects the genitals and urinary tract and can cause a variety of symptoms, including:
- vaginal dryness
- vaginal itching or burning
- increased discharge
- pelvic pain or pressure
- painful intercourse
- reduced lubrication
- decreased arousal
- bleeding during or after sex
- loss of libido
- painful orgasms
- painful urination
- increased urinary urgency and frequency
- urinary incontinence
- urinary tract infections
- bladder dysfunction
GSM shares many symptoms with other conditions that affect the genitals or urinary tract, which can make it difficult to diagnose. However, the most commonly reported GSM symptoms are vaginal dryness and painful intercourse. If you have these symptoms, schedule a visit with a medical professional.
GSM remains largely underdiagnosed among people experiencing menopause, primarily because it can be embarrassing for some people to discuss the symptoms listed above — especially those traditionally described as a typical part of aging.
If a primary care doctor or gynecologist suspects you may have GSM, they will perform a physical examination and thorough review of your symptoms and medical history. They’ll also want to discuss when these symptoms began and may ask about your sexual history.
A physical examination of the vulvovaginal area — called a pelvic exam — can allow the doctor to manually feel for the physical changes associated with GSM.
Laboratory and diagnostic testing can also identify other underlying conditions that may be causing your symptoms, such as sexually transmitted infections (STIs).
Treatment of GSM aims to relieve symptoms and improve your quality of life. Common treatment options include:
Local estrogen therapy
Low dose vaginal estrogen therapy involves an estrogen supplement inserted directly into the vagina. Vaginal estrogen may come in the form of a suppository, an insert, or a ring, all of which are inserted into the vaginal canal.
Experts consider local estrogen therapy the “gold standard” treatment for GSM. People who receive local estrogen treatments typically see an improvement in symptoms within
DHEA therapy
Local administration of dehydroepiandrosterone (DHEA) may also help improve GSM symptoms. DHEA is a hormone metabolized in the vaginal tissue, where it can be converted into active estrogen.
Systemic estrogen therapy
Some people use menopausal hormone therapy (MHT) to manage menopause symptoms. MHT may be effective for
Ospemifene
Ospemifene has also been an effective option for reducing vaginal dryness and pain during intercourse in people with GSM. While not estrogen itself, ospemifene can act like estrogen in the vaginal lining. A 2019 review noted that it was effective in reducing vaginal dryness and painful intercourse and improving vaginal tissue health, sexual function, and pH balance.
Topical lubricants and moisturizers
Topical lubricants and moisturizers can help improve GSM symptoms by increasing hydration and lubrication of the vulvovaginal area. Lubricants and moisturizers are an important treatment option for those who may not be able to take estrogen.
However, it’s important to know that not every lubricant or moisturizer is effective for GSM. If you’re interested in using these products to alleviate symptoms, choose a lubricant or moisturizer that is pH-balanced and as close to natural lubrication as possible. Using products that are not properly balanced can potentially increase GSM symptoms.
The doctor is inMenopause Society Certified Practitioner Stacy Henigsman, DO, has this to say about personal lubricants:
“When selecting personal lubricants, look for ingredients that are gentle and nonirritating, such as aloe vera and hyaluronic acid. Avoid lubricants with potentially irritating ingredients, including:
- glycerin
- parabens
- fragrances
- propylene glycol
- sodium lauryl sulfate”
This is an excerpt from Unpaused, Healthline and Optum Now’s newsletter dedicated to helping people navigate menopause.
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Vaginal hyaluronic acid
Hyaluronic acid is a naturally occuring substance in the body that helps retain moisture. Some people use hyaluronic acid to reduce the appearance of wrinkles but it may also help with GSW symptoms like vaginal dryness or pain during sex.
A 2023 systematic review notes that hyaluronic acid is not as effective as estrogen in reducing GSW symptoms but is still an effective option for people who do not want to use estrogen. It’s available as a gel, cream, or suppository.
Experimental treatment options
Experimental treatments, such as laser therapies, are still under investigation. Initial results are promising. However, the most recent guidelines from the North American Menopause Society note that more long-term studies are required to fully understand their safety and efficacy.
GSM is a highly personal condition that can sometimes leave people feeling embarrassed and hesitant to reach out. However, you do not have to manage the symptoms of GSM alone — and you shouldn’t be ashamed to reach out for help.
Whether you are sexually active or not, the GSM symptoms can be uncomfortable, frustrating, and even debilitating. If you have been living with chronic symptoms of GSM, discuss this issue with a healthcare professional.
Once you receive a proper diagnosis, treatment options can help decrease symptoms and improve your overall quality of life.
GSM is a chronic condition that affects people in menopause. It often remains undiagnosed despite how much it can negatively affect someone’s quality of life. GSM can cause a wide variety of symptoms, including significant pain in the vulva, vagina, urethra, and bladder.
Local estrogen therapy is the gold standard treatment option for GSM. Other treatments, like systemic hormone therapy, ospemifene, and personal lubricants, can also help reduce symptoms.
If you have been experiencing symptoms of GSM, reach out to a medical professional for treatment.