What Is Genitourinary Syndrome of Menopause (GSM)?
What genitourinary syndrome of menopause is, which symptoms it covers, why it happens and what the treatment options are.
Short answer: Genitourinary syndrome of menopause (GSM) is a medical term describing the changes that declining oestrogen causes in the vulva, vagina, urethra and bladder during menopause. It covers vaginal dryness, burning, pain during intercourse and urinary symptoms. Unlike hot flushes, it doesn't resolve on its own, but it can be managed with several treatment options.
What Is Genitourinary Syndrome of Menopause?
GSM was adopted in 2014 by the North American Menopause Society (NAMS) and the International Society for the Study of Women's Sexual Health (ISSWSH) to replace the older terms "vulvovaginal atrophy" or "atrophic vaginitis". Because the vulva, vagina, urethra and bladder share a common embryological origin, all of these tissues carry a high density of oestrogen receptors, so when oestrogen drops during menopause, all of them are affected together.
Which Symptoms Does It Cover?
GSM presents with a wide range of symptoms in the lower genital and urinary tract:
- Genital and vaginal symptoms: vaginal dryness, burning, irritation, itching, a sense of discomfort, abnormal discharge, pressure in the pelvic area
- Sexual symptoms: lack of natural lubrication, pain during or after intercourse (dyspareunia), reduced sexual desire, spotting after intercourse
- Urinary symptoms: burning during urination (dysuria), frequent urination, sudden urinary urgency, waking at night to urinate (nocturia), urinary incontinence and recurrent urinary tract infections
Why Does It Happen?
With menopause (or other situations where oestrogen drops, such as surgical menopause, chemotherapy, breastfeeding, or certain medications), oestrogen levels fall. This leads to the following changes in the tissue:
- Thinning of the epithelium and loss of elasticity: Collagen, elastin and hyaluronic acid levels in the tissue drop; the vaginal walls thin, lose elasticity, and blood supply decreases.
- Disruption of the microbiome and pH balance: As the thinning tissue loses its glycogen stores, the protective Lactobacillus bacteria that keep the vagina acidic decline. The normally acidic vaginal environment becomes more alkaline, which creates conditions favourable for infection.
How Common Is It, and Does It Resolve on Its Own?
GSM affects more than half of postmenopausal women, and around three-quarters of women who remain sexually active after menopause.
It does not resolve on its own. While symptoms such as hot flushes or night sweats may ease over time, GSM follows a chronic and progressive course if left untreated; dryness and narrowing can increase as time goes on.
What Are the Treatment Options?
Treatment is planned in stages, based on symptom severity and the individual's health status:
- First-line for mild symptoms: Regularly used hyaluronic-acid-based vaginal moisturisers and water-based lubricants used during intercourse. Regular sexual activity or pelvic floor exercises can also help maintain tissue blood flow.
- Most effective option for moderate-to-severe symptoms: Low-dose local (vaginal) oestrogen, applied as a cream, tablet or ring. Because absorption into the bloodstream is very low, additional progestogen for uterine protection is usually not required. Intravaginal DHEA is another local hormonal option.
- Systemic options: If hot flushes are also present, systemic hormone therapy may be considered; for women with vaginal symptoms alone, local treatment is the priority. Certain oral selective receptor modulator medications are another option.
- Energy-based devices (laser, radiofrequency): These aim to increase collagen production and tissue thickness through controlled heating of the tissue. While studies report improvements in tissue quality, international guidelines (FDA, ACOG, ESHRE) do not yet recognise these technologies as a routine first-line approach for GSM; they are regarded as a supportive or investigational option.
Outcomes of any surgical or interventional procedure can vary from person to person. It's recommended to get detailed advice from your doctor before the procedure.
Frequently Asked Questions
Does GSM only affect sexually active women?
No. Vaginal dryness, burning and urinary symptoms can also occur in women who are not sexually active; the urinary symptoms of GSM can appear independently of sexual activity.
Is local oestrogen treatment safe?
Absorption of low-dose vaginal oestrogen into the bloodstream is very low, which is why it's considered to have a strong safety profile. Your doctor will assess whether it's suitable for your individual health situation.
When should treatment start?
Because GSM can progress over time, seeing a doctor as soon as symptoms are noticed both eases discomfort and can slow the progression of tissue changes.