Genitourinary syndrome of menopause (GSM) is a chronic condition that can affect the genitals and urinary tract in females. It typically results from hormonal shifts during menopause, though there can be other causes.

Earlier names for GSM were vulvovaginal atrophy, atrophic vaginitis, and urogenital atrophy. But in 2014, the International Society for the Study of Women’s Sexual Health and the North American Menopause Society renamed the condition to better reflect its range of symptoms.

GSM can have a significant effect on the quality of life, but due to a lack of awareness and screening, the syndrome is often underdiagnosed. However, several effective treatments exist.

This article explores the symptoms, causes, treatments of GSM, as well as related conditions.

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Hormonal changes cause GSM. Levels of female sex hormones drop in the lead-up to menopause, a period called perimenopause, and this can affect the genitals and urinary tract.

For example, the hormone estrogen helps lubricate the vagina, and reduced estrogen levels can cause the vagina to become dry, itchy, and tight.

After menopause, estrogen levels continue to be very low. GSM affects 27–84% of people who have gone through natural menopause.

GSM can also occur for other reasons, such as:

  • primary ovarian insufficiency, which causes the ovaries to stop functioning as they normally do before the age of 40
  • surgically induced menopause, which involves removing the ovaries in a procedure known as an oophorectomy
  • postpartum and breastfeeding-related hormone imbalances
  • cancer treatment, which may affect the function of the ovaries or cause sudden hormonal shifts
  • medications, such as gonadotropin-releasing hormone agonists or aromatase inhibitors

According to a 2019 review, the majority of females with GSM report symptoms in perimenopause and the early postmenopausal period. Vaginal dryness is one of the most common symptoms, and others include:

  • vaginal burning
  • vaginal itching or irritation
  • reduced vaginal lubrication
  • decreased elasticity of the vagina
  • impaired sexual function
  • pain during penetrative sex
  • pain during urination
  • greater sense of urgency and frequency in urination
  • increased risk of vaginal, urinary tract, and bladder infections

A person does not need to have all of these symptoms to meet the criteria for a GSM diagnosis.

A doctor first has a conversation with a person about their symptoms and medical history. Next, they may conduct a pelvic exam.

The doctor may also order laboratory tests to evaluate vaginal pH, which tells them how acidic the vagina is, or to assess vaginal maturation.

The vaginal maturation index is a way of measuring how estrogen levels are affecting the vagina, based on the idea that estrogen helps cells in the area mature fully. If there is a high number of immature cells, this may signal that there is not enough estrogen in the vagina.

There is no permanent cure for GSM, but various hormonal and nonhormonal treatments can reduce the symptoms.

Topical treatments

For milder symptoms, a doctor may recommend a nonhormonal vaginal lubricant for use during sex or a long-acting moisturizer to reduce discomfort more generally. Clinicians usually recommend using these moisturizers several times a week.

Some doctors may suggest hyaluronic acid for treating vaginal dryness. This acid is in many skincare products because it attracts moisture to the skin. But to date, there is no clear evidence that hyaluronic acid lubricants work better than other lubricants or moisturizers.

Hormone therapy

For more disruptive symptoms, doctors often recommend hormone therapy. This replaces the estrogen that the body is no longer producing.

Guidelines from 2020 state that hormone replacement therapy is the most effective way to treat GSM symptoms. Some options include:

  • low-dose estradiol-releasing intravaginal tablets
  • lower-dose estrogen vaginal inserts
  • intravaginal dehydroepiandrosterone (DHEA) or prasterone
  • vaginal DHEA inserts
  • oral ospemifene, a selective estrogen receptor modulator

Some people are concerned that estrogen replacement therapies may be unsafe and increase the risk of certain cancers. However, local estrogen therapy is well-researched and safe for most people.

Anyone with concerns and anyone who has had a hormone-sensitive form of cancer should discuss this with their doctor.

Pelvic floor physical therapy

Some people with GSM may benefit from this, in addition to other treatments. Pelvic floor physical therapy, sometimes called PFPT, can help strengthen muscles in the pelvic floor.

It may prevent urinary incontinence or leakage and improve sexual function for people with GSM.

Dilation therapy

People with GSM who experience tightness or pain during sex may benefit from dilation therapy. This involves using dilators to gradually train the pelvic floor muscles to relax and, therefore, increase the vagina’s capacity.

Laser technologies

In recent years, some GSM treatments have involved laser technologies, such as microablative fractional CO2 and nonablative vaginal erbium YAG laser therapies.

Preliminary research suggests that CO2 laser therapy may improve sexual function, the quality of life, and urinary symptoms for people with GSM.

However, the Food and Drug Administration (FDA) has warned against the use of CO2 laser therapy, especially for breast cancer survivors, until further studies show that it is safe.

In addition to pursuing medical treatments, people with GSM may benefit from:

  • Avoiding harsh products: The vagina is self-cleaning, so soaps and douches are not necessary for hygiene. Douching, in particular, may further dry the fragile tissue around the vulva and vagina, which may make GSM symptoms worse. It also raises the risk of infections. Instead, wash the outside of the vagina only with warm water.
  • Quitting smoking: Smoking is linked with a faster onset of GSM symptoms. Healthcare professionals can support people as they stop smoking, and anyone in the United States can also call 1-800-QUIT-NOW for free information and referrals to local resources.
  • Changing approaches to sex: Menopause and GSM can mean that arousal takes longer, and being aroused reduces the risk of dryness and pain during sex. Beyond using lubricants and moisturizers, people might benefit from spending longer on foreplay, taking things more slowly, and focusing on types of sex that are not penetrative. A sexual health practitioner can provide further advice about how to adapt to these changes.

Learn more about sex after menopause here.

Not everyone with dryness, itching, and pain during sex has GSM. Other factors that can lead to these symptoms include:

Anyone who experiences these symptoms should speak with a doctor. It is important to do so before making changes to any prescribed treatment plan.

GSM is a common condition in people going through menopause. It can also result from low estrogen levels caused by other factors, such as surgery to remove the ovaries or some cancer treatments.

GSM can cause vaginal dryness, itching, and pain during sex, among other symptoms. Various treatments and home care strategies can help.

However, GSM is often underdiagnosed because many people consider the symptoms to be a natural part of aging or are uncomfortable bringing them up with their doctor.

Effective and safe treatments are available. If possible, try to speak with a doctor who is knowledgeable about menopause-related conditions.