Genitourinary Syndrome of Menopause (GSM)

The Genitourinary Syndrome of Menopause (GSM) is a constellation of symptoms that impact the genital and urinary tracts in women as a consequence of hormonal changes during menopause. These symptoms include vaginal dryness, irritation, pain during intercourse, and urinary symptoms such as frequency, urgency, burning with urination and recurrent urinary tract infections. These symptoms can have a significant effect on quality of life and on intimate relationships. The prevalence of GSM varies, but likely affects more than half of menopausal women. Similar symptoms can occur in premenopausal women and others with low estrogen, including those in the postpartum period. Unlike hot flashes, another common symptom related to low estrogen levels, GSM does not improve over time in postmenopausal women.  

GSM is primarily driven by the decline in estrogen levels during menopause. Estrogen is important for maintaining the health and elasticity of the vaginal and urinary tissues. As estrogen decreases, these tissues may become thinner, drier, and more prone to irritation.  This decline in estrogen, which is related to age and postmenopausal status, also affects the vaginal environment, including the normal bacteria and the pH. Because the urethra and bladder also have estrogen receptors, low estrogen levels also cause urinary symptoms and increase the risk of urinary tract infection.  

Diagnosing GSM involves a comprehensive assessment by your healthcare provider. Other conditions (e.g., overactive bladder, urinary tract infections, vaginal infections) can cause similar symptoms and may coexist with GSM.  

• Medical History Review: Understanding your symptoms and medical history. 
• Physical Examination: A thorough examination, likely including a pelvic exam, will show certain findings that will help your provider make the diagnosis 
• Laboratory and additional tests: While lab tests are not needed to make the diagnosis, they may be useful to evaluate for other conditions which may cause similar urinary, vaginal, vulvar or sexual symptoms.  In some cases, your healthcare provider may recommend additional testing to assess for those conditions. 

Non-Hormonal Treatments: limited data supporting use 

• Moisturizers: 

• Regular Use: Applying moisturizers regularly to vaginal dryness. 
• Commercially available products available without prescription 
• Long-lasting Formulas: Some moisturizers provide extended relief. 

Some contain hyaluronic acid which helps in retaining moisture.  

• Lubricants: 

• Typically used prior to intercourse 
• Water-Based: Suitable for daily use and during sexual activity. 
• Oil-based: Easier spread, not compatible with latex based condoms. 
• Silicone-Based: Longer-lasting lubrication for sexual comfort. 

• Regular sexual activity, with or without a partner,  
• Vaginal Dilators, vibrators: help maintain vaginal elasticity and reduce discomfort with intercourse. 
• Local anesthetic gels or ointments may help with pain with penetration 

 

• Hormone Therapy: 

• Estrogen: Low dose local estrogen applied directly to the vaginal tissues is a safe method to alleviate dryness and discomfort.  

• Formulations available in some countries by prescription may include: 

• Estradiol cream 
• Estradiol vaginal tablets 
• Estradiol ring that releases hormone slowly over three months 
• Conjugated estrogen creams 

• Estriol cream (Europe) 

• Improvement may not begin for a few weeks or months 
• Local estrogen is likely safe for even women with a history of breast cancer after a discussion with your primary care provider or oncologist 

• Other local hormones 

• DHEA has been shown to be an effective treatment for GSM 

• Systemic Estrogen Replacement:  

• Systemic Estrogen therapy (with progesterone in patients with a uterus) can help with both systemic symptoms of menopause (eg hot flashes) and GSM symptoms, though some patients may benefit from additional local estrogen therapy. For GSM symptoms only, local estrogen is preferred and may be more effective. 
• Selective Estrogen Receptor Modulators (SERMs) e.g., ospemifene, an oral medication, can restore hormonal balance to the vagina. 

• Vaginal Laser Therapy: 

• While laser treatment has been promoted as a non-invasive procedure to improve tissue health by generating mild trauma to the vagina, it has not been shown in studies to be an effective treatment. 

Your healthcare provider will provide detailed information on the benefits and risks of each option, tailoring the treatment plan to your specific needs and preferences.