Genitourinary Syndrome of Menopause (GSM) refers to a range of symptoms that affect many women during the menopause transition. It’s a common condition but is often overlooked, even though it affects the daily lives of many menopausal and postmenopausal women. In one U.S. survey, 85% of women said their symptoms caused a loss of intimacy, and 80% of women in the VIVA study reported that vaginal discomfort negatively impacted their lives. Although GSM is widespread, symptoms can vary greatly, and recognizing them early can lead to much better treatment outcomes.(1)(2)(3)(4)
What is GSM?
GSM is a term used to describe the changes in genital, urinary, and sexual health that happen as women go through menopause. To understand GSM, it’s important first to know that genitourinary tissues are the parts of the body that make up the urinary and reproductive systems. These tissues play a key role in producing and eliminating urine, as well as in reproductive processes.(1)(2)(3)(5)
In the urinary system, genitourinary tissues include the following:
Kidneys
Ureters
Bladder
Urethra
In the reproductive system, they include the following:
In women: ovaries, fallopian tubes, uterus, cervix, vagina, and external genitalia (vulva)
In men: testes, epididymis, vas deferens, prostate, seminal vesicles, penis, and scrotum
These tissues are vital for regulating fluids, eliminating waste, and supporting reproduction. "Genitourinary" is commonly used to describe medical issues affecting these systems, like UTIs, reproductive health concerns, or hormonal changes.(1)(2)(3)(6)
As women go through menopause, a drop in estrogen and other hormones impacts the function of these tissues. This condition was once called vulvovaginal atrophy (VVA), but the term GSM is now used because it covers not just vaginal symptoms but also urinary and sexual health issues.
GSM Symptoms: Understanding the Signs and Impact
The symptoms and signs of GSM can vary in severity and affect multiple areas of the genitourinary tract. These symptoms are often grouped into three main categories: genital, urinary, and sexual. Each category can significantly impact a woman’s well-being and daily life.
Genital Symptoms
Vaginal Dryness: This is a common symptom that results from decreased moisture production in the vaginal tissues.
Burning: Women may experience a persistent burning feeling in the vulva or vagina.
Irritation: Increased sensitivity and irritation in the vaginal area can arise due to thinning of the tissues.
Itching: A decrease in lubrication and an altered pH balance in the vaginal area can lead to itching and discomfort.(1)(2)(3)(4)(5)(6)
Urinary Symptoms
Frequent Urination: A need to urinate more often, even without significant fluid intake, is common in women with GSM.
Urinary Urgency: This is characterized by a sudden and strong need to urinate, often accompanied by discomfort.
Urinary Tract Infections (UTIs): Due to anatomical changes and alterations in the pH of the urinary tract, women may experience recurrent UTIs.(1)(2)(3)(4)(5)(6)
Sexual Symptoms
Painful Intercourse (Dyspareunia): Reduced estrogen levels can lead to thinning of the vaginal walls, making intercourse painful.
Decreased Lubrication: The reduction in estrogen can impair natural lubrication during sexual activity.
Decreased Sexual Desire: Many women report a reduction in libido, which may be related to both hormonal changes and the physical discomfort caused by GSM.(1)(2)(3)(4)(5)(6)
Causes of GSM in Menopausal Women
GSM is most often linked to hormonal changes during menopause, but several predisposing factors may cause it to appear earlier in perimenopausal women.
Hormonal Changes
The main cause of GSM is the drop in estrogen that happens during menopause. Estrogen helps keep the vaginal and urethral tissues healthy by maintaining their elasticity, thickness, and moisture. When estrogen levels fall, the vaginal walls become thinner, less flexible, and more prone to dryness and irritation. These hormonal changes also affect the urinary system, leading to symptoms like frequent urination and urgency.(1)(2)(3)(6)
Anatomical Changes in the Genitourinary Tract
In addition to hormonal shifts, physical changes in the pelvic area can also contribute to GSM. Reduced blood flow to the vagina and a decrease in collagen make the tissues thinner and less elastic. The thinning of the vaginal lining makes it harder to produce natural lubrication, which can lead to friction during sex and a higher risk of infections.(1)(2)(3)(6)
Postmenopausal GSM
GSM is very common in postmenopausal women, though it’s often underreported due to the stigma around discussing sexual health. Research shows that 50%–70% of postmenopausal women experience GSM symptoms. Early signs, like vaginal dryness and changes in urinary habits, may begin during perimenopause when estrogen levels start to fluctuate. After menopause, as estrogen levels drop even more, these symptoms typically become more pronounced and persistent.(1)(2)(3)
Diagnosing GSM
Diagnosing GSM mainly involves understanding a patient’s symptoms, but it can sometimes be tricky due to its similarities with other conditions that affect the urinary system.
Clinical Features
A detailed medical history is essential for identifying GSM, especially in postmenopausal women experiencing symptoms like vaginal dryness, urinary incontinence, or painful intercourse. Physicians should ask about hormonal changes, any history of urinary tract infections, and sexual health to get a full picture of the patient’s situation.
Diagnostic Challenges
One of the primary challenges in diagnosing GSM is that its symptoms often overlap with other conditions, such as urinary incontinence or recurring UTIs. Additionally, many women may feel hesitant to discuss genitourinary symptoms with their healthcare providers, which can lead to delays in diagnosis and treatment. To address this issue, clinicians should take a proactive approach by regularly screening postmenopausal women for GSM symptoms and encouraging open, empathetic conversations about urinary health.
Physical Examination
A pelvic examination is an important step in diagnosing GSM, as it allows healthcare providers to evaluate the vaginal tissues, urethra, and surrounding areas. Common signs of GSM include thinning of the vaginal tissue, paler coloration, and a loss of elasticity. In some cases, lab tests may be necessary to rule out infections, especially for women with frequent UTIs.
GSM Treatment
The treatment of GSM focuses on relieving symptoms and restoring the function of the genitourinary tissues. There are several ways to manage GSM, including both hormonal and non-hormonal treatments.
Hormonal Treatments for GSM
Hormonal therapies remain the most effective way to manage GSM, especially for women experiencing severe symptoms due to estrogen deficiency. Estrogen therapy (ET) is at the heart of treatment and is offered in different forms, including both systemic and localized options.(6)
Systemic HRT: Systemic hormone therapy typically uses oral or transdermal estrogen products. This approach addresses not only the genitourinary symptoms of GSM but also other menopausal issues like hot flashes and mood swings. However, systemic ET is not usually recommended for GSM treatment alone. It’s best to discuss options with a healthcare provider if symptoms are limited to GSM.(1)(2)(3)(6)
Local Estrogen Therapy: Local estrogen therapy focuses on delivering estrogen directly to the vaginal tissues. Options like vaginal creams, tablets, or rings are used to target symptoms like dryness and irritation. This method is especially beneficial for women who can't or prefer not to use systemic estrogen.(1)(2)(3)(6)
Selective Estrogen Receptor Modulators (SERMs): SERMs are newer options that can mimic the effects of estrogen in certain tissues while blocking it in others. These medications are still under investigation for their effectiveness in treating GSM.(1)(2)(3)(6)
Non-Hormonal Treatments for GSM
Non-hormonal treatments can be helpful for women who prefer to avoid or cannot use estrogen therapy. These approaches focus on symptom relief and include simple lifestyle modifications.(6)
Lifestyle Changes: Staying active and eating a balanced diet can support overall genitourinary health. Drinking enough water and cutting back on irritants like caffeine and alcohol may also help with urinary symptoms.(3)(6)
Vaginal Moisturizers and Lubricants: These products can offer effective relief from dryness and discomfort, especially during sexual activity. However, since GSM is a long-term condition, managing hormonal changes, like low estrogen, is key for lasting improvement.(3)(6)
Lubricants: Lubricants provide quick, temporary relief and are especially useful during sex. They come in water-based, silicone-based, or oil-based forms, with water-based options being safe for use with condoms. Lubricants reduce friction and make sex more comfortable, but they don’t absorb into the skin.
Moisturizers: Vaginal moisturizers are absorbed into the skin and provide longer-lasting relief from dryness. They can be used regularly to help keep vaginal tissues hydrated.
Hyaluronic Acid (HA): HA is a naturally occurring substance that helps tissues retain moisture, soothing dryness and improving hydration levels.
Laser Therapy: New treatments like laser therapy are becoming more popular as non-invasive options for GSM. Lasers stimulate collagen production in the vaginal tissues, which can help restore moisture and elasticity. While more research is needed, early studies show laser therapy may be a promising, albeit costly, alternative to hormone treatments.(3)(6)
Importance of GSM Awareness and Early Intervention
Raising awareness of GSM is crucial for better diagnosis and treatment. Many women endure symptoms in silence, believing they are an unavoidable part of aging. Studies show that 75% of women suffering from GSM report negative effects on sexual intimacy and relationships, while 26% experience a decline in self-esteem. Self-educating about GSM and its treatments can empower women to seek the right care and improve their quality of life during and after menopause. By normalizing conversations about genitourinary health and ensuring access to proper care, healthcare providers can enhance the quality of life for many women during and after menopause.(1)(2)(3)(6)
Recognizing and addressing GSM early can help prevent symptoms from worsening and reduce their impact on sexual, urinary, and overall health. As research continues to advance in both hormonal and non-hormonal therapies, there is hope for more effective management and a deeper understanding of this condition.
If you’ve entered the menopause transition and are struggling with GSM issues, you don’t have to suffer in silence. Take our brief menopause quiz to see if you’re an eligible candidate for HRT. Get started with Winona to take the first step toward feeling better.
