Genitourinary syndrome of the menopause

What is Genitourinary Syndrome of the Menopause? GSM is a common condition caused by declining oestrogen levels during and after menopause. It affects the vulva, vagina, bladder and urinary tract and can have a significant impact on comfort, sexual wellbeing and quality of life. You might notice vaginal dryness, an increasing need to pass urine or urine infections.

You may previously have heard terms such as vaginal atrophy, vulvovaginal atrophy or urogenital atrophy. These terms have largely been replaced by GSM because they do not fully reflect the wide range of vaginal, vulval, sexual and urinary symptoms women can experience.

Unlike hot flushes and night sweats, which often improve over time, GSM is a chronic condition that tends to worsen if left untreated. The good news is that effective treatments are available and many women experience significant improvement once treatment is started.

How Common is GSM?

GSM affects up to 80% of postmenopausal women. Despite being extremely common, many women do not seek help because they feel embarrassed, believe symptoms are a normal part of ageing or are unaware that treatment is available.

Many women suffer with symptoms for years before discussing them with a healthcare professional.

What Causes GSM?

Oestrogen helps maintain the health of the vulva, vagina, bladder and urethra.

When oestrogen levels fall:

• Vaginal tissues become thinner and more fragile
• Blood flow to the tissues decreases
• Natural lubrication reduces
• Vaginal elasticity decreases
• Vaginal pH changes
• Healthy vaginal bacteria decline
• Bladder and urethral tissues become less resilient

These changes can affect everyday comfort, sexual function and urinary health.

Symptoms of GSM

Symptoms can vary considerably between women.

Vaginal Symptoms

• Vaginal dryness
• Burning
• Soreness
• Irritation
• Itching
• Reduced lubrication
• Vaginal discharge
• Feeling of tightness

Vulval Symptoms

• Dryness around the vulva
• Burning or stinging
• Itching
• Sensitivity
• Discomfort when sitting or exercising

Sexual Symptoms

• Pain during sex
• Reduced pleasure during intercourse
• Bleeding after sex
• Difficulty becoming aroused
• Reduced confidence with intimacy
• Reduced libido related to discomfort

Urinary Symptoms

• Urinary urgency
• Needing to pass urine more frequently
• Getting up at night to pass urine
• Burning when passing urine
• Recurrent urinary tract infections
• Bladder discomfort
• Urinary leakage

Many women are surprised to learn that bladder symptoms are often caused by low oestrogen levels.

Who Can Develop GSM?

Although GSM is most common after menopause, it can occur whenever oestrogen levels are low.

This includes:

• Perimenopause
• Postmenopause
• Premature Ovarian Insufficiency (POI)
• Early menopause
• Surgical menopause
• Some cancer treatments
• Ovarian suppression therapy
• Breastfeeding
• Taking some progestogen only methods of contraception

How is GSM Diagnosed?

Diagnosis is usually based on your symptoms and a clinical assessment.

Your healthcare professional may ask about:

• Vaginal symptoms
• Sexual symptoms
• Bladder symptoms
• Menopausal symptoms
• Current medications
• Medical history

Women should always seek medical advice if they experience unexplained vaginal bleeding, persistent pelvic pain or new skin changes affecting the vulva.

Treatment for GSM

GSM is treatable. Many women benefit from a combination of treatments.

Vaginal Moisturisers

Vaginal moisturisers provide ongoing hydration to the vaginal tissues.

They do not contain hormones and can be used by women who cannot or do not wish to use hormonal treatments.

Moisturisers are usually applied every two to three days regardless of whether you are sexually active.

Benefits include:

• Improved vaginal hydration
• Reduced irritation
• Reduced dryness
• Greater day-to-day comfort

Examples include:

• YES VM
• Replens
• Sylk

Think of a vaginal moisturiser as being similar to a facial moisturiser. It improves hydration but does not reverse the hormonal changes causing GSM.

Vaginal Lubricants

Lubricants provide short-term relief from friction and discomfort during sexual activity.

They do not treat GSM itself but can significantly improve comfort. Using both a water based lubricant and an oil based one can provide a slip and slide natural lubrication making you much more comfortable.

Water-Based Lubricants

Water-based lubricants are easy to use and compatible with condoms.

Examples include:

• YES WB

Oil-Based Lubricants

Oil lubricants last longer and may be particularly helpful for women with significant dryness. They are not compatible with latex condoms.

Examples include:

• YES OB

Many women use lubricants alongside vaginal moisturisers and low dose localised vaginal /vulval oestrogen treatment.

Low dose localised Vaginal/vulval oestrogen

Vaginal/vulval oestrogen is considered the gold-standard treatment for GSM.

It contains a very low dose of oestrogen that is applied directly to the vaginal tissues. Unlike systemic HRT, it works mainly in the vaginal and urinary tissues with minimal absorption into the bloodstream.

Benefits include:

• Improved vaginal lubrication
• Reduced dryness and irritation
• Improved elasticity
• Reduced pain during sex
• Improved bladder symptoms
• Reduced risk of recurrent urinary tract infections

Many women notice improvement within a few weeks although maximum benefit may take up to four months. If it doesn’t work, go back and speak with your prescriber.

The table below compares the available forms to help you decide which might suit you.

Type	How it is used	Advantages	Things to be aware of
Tablet / pessary Vagifem, Vagirux GinaTM is available to buy from the pharmacy	Inserted into the vagina using an applicator, usually at night. Used daily for 2-4 weeks then twice weekly ongoing.	Clean and easy to use. Gina can be bought without prescription from the pharmacy for women over 50 years who have not had a period for 12 or more months.	Vagifem has a single-use blue plastic applicator. Vagirux requires reloading the tablet into the white reusable applicator.
Waxy bullet pessary Imvaggis	Inserted into the vagina using the fingers. Used daily for 3 weeks then twice weekly ongoing.	No applicator. The waxy texture has a lubricating effect that can help with dryness.	Can produce a slight waxy discharge. Can damage latex condoms
Cream Estriol 0.1% (0.5mls per dose) Estriol 0.01% (5mls per dose) Ovesse is available to buy from the pharmacy	Inserted into the vagina daily for 2-4 weeks then twice weekly. Can also be applied to the vulva with a finger	Soothing and can be applied with the applicator or a finger	Can be a bit messy The 0.1% cream does not affect a condom The 0.01% contains peanut oil so avoid if you or your partner has a peanut allergy and it can damage latex condoms
Gel Blissel	Inserted into the vagina daily for 3 weeks then twice weekly.	Rapidly absorbed and soothing	Mild itching or irritation when first using it usually settles.
Vaginal ring Estring	A soft silicone ring inserted into the vagina by you or a health professional. Stays in place and releases oestrogen continuously for 90 days.	You don’t need to remember to apply a regular cream or pessary	Does not usually interfere with sex, but you can remove it beforehand and reinsert afterwards
DHEA pessary Intrarosa	Inserted into the vagina once daily.	Does not contain oestrogen directly — prasterone (DHEA) is converted to oestrogen and testosterone within vaginal cells.	Can damage latex condoms

Other options include an oral tablet called Ospemifene.

If symptoms are not improving after two to four months, it is important to have an examination to rule out other causes for symptoms, such as lichen sclerosus. The dose of your low dose oestrogen product could be adjusted or you could try another product.

Women who have had a hormone-receptor-positive breast cancer are usually advised not to take systemic HRT, but vaginal oestrogen is increasingly considered safe in this group due to its minimal systemic absorption. Women using an aromatase inhibitor who develop GSM symptoms should speak to a menopause specialist.

How Often is Vaginal Oestrogen Used?

Most treatments start with a loading phase.

This usually involves:

• Daily use for two – four weeks

Followed by:

• Maintenance treatment two times weekly

Some women with severe symptoms may require more frequent use.

Treatment should always be tailored to individual symptoms. The dose can be adjusted by your Dr if necessary.

How long does vaginal oestrogen take to work take to work?

Usually about 2-4 months of regular use.

Can Vaginal Oestrogen Be Used Long Term?

Yes.

GSM is a chronic condition and symptoms often return when treatment stops.

Many women use vaginal oestrogen safely for years to maintain symptom control.

Does Vaginal Oestrogen Need Progesterone?

No.

The low doses used in vaginal oestrogen treatments do not usually require additional progesterone for endometrial protection, even if you still have a uterus.

Can Vaginal Oestrogen Be Used Alongside HRT?

Yes.

Many women using systemic HRT continue to experience vaginal dryness or bladder symptoms.

Vaginal oestrogen can be safely used alongside HRT and often provides additional symptom relief.

What About Laser Treatment?

Laser and energy-based treatments have been promoted for GSM.

Although some women report benefit, current evidence is limited and more research is needed. At present these treatments are not routinely recommended as first-line management.

Lifestyle Measures That May Help

Alongside medical treatment, the following may be beneficial:

• Regular sexual activity if comfortable
• Pelvic floor exercises
• Stopping smoking
• Staying physically active
• Maintaining a healthy weight
• Good hydration
• Managing constipation
• Avoiding perfumed intimate washes and irritants

Sexual activity, either with a partner or through self-stimulation, may help maintain blood flow and elasticity within the vaginal tissues.

The Bottom Line

Genitourinary Syndrome of Menopause is extremely common but often under-recognised. Symptoms such as vaginal dryness, irritation, painful sex, urinary urgency and recurrent urinary tract infections are not simply something women have to put up with. Effective treatments are available and many women experience a significant improvement in comfort, confidence, sexual wellbeing and quality of life once treatment begins. If you think you may have GSM, speak to a healthcare professional as early treatment can prevent symptoms from worsening and help restore vaginal and urinary health.

References:

• Menopause Research Education Fund leaflet
• WHC fact sheet: Vaginal dryness
• WHC fact sheet: urogenital atrophy
• BSSM – GSM
• Bladder and bowel incontinence POGP Pelvic, Obstetric, Gynaecological Physiotherapist
• NICE Menopause guidance GSM

Last updated June 2026 Dr Carys Sonnenberg Rowena Health

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