Hot flashes dominate the menopause conversation. A second cluster of symptoms affects more women, persists longer, and in most cases worsens rather than resolves over time. These symptoms have a name: genitourinary syndrome of menopause, or GSM.

The term was updated in 2014 from "vulvovaginal atrophy" to reflect how broad the syndrome actually is. GSM covers genital, urinary, and sexual symptoms that share a single root cause: the decline of estrogen in tissues that depend on it heavily.[1]

How Common Is This?

Estimates vary because researchers measure different symptoms with different tools. Across the literature, somewhere between 27% and 84% of postmenopausal women are affected.[2] Even at the conservative end, it is one of the most prevalent conditions associated with menopause.

The more striking statistics concern how rarely it gets discussed. An estimated 60% of women with GSM do not raise it with a healthcare provider; most assume the symptoms are a normal, unchangeable part of aging. Studies show only 7% of healthcare providers proactively ask women about these symptoms.[3]

What GSM Actually Involves

GSM is not simply vaginal dryness. It covers three overlapping domains.[1][4]

Genital symptoms: dryness, burning, irritation, and decreased lubrication. The vaginal walls thin and lose elasticity as estrogen-dependent tissue atrophies. Vaginal pH rises as the protective lactobacilli that depend on estrogen-driven glycogen decline, increasing susceptibility to infections.

Sexual symptoms: painful intercourse (dyspareunia), post-intercourse spotting, and reduced sensitivity. These follow directly from tissue changes. Penetration that causes minor friction in well-estrogenised tissue causes pain and microtrauma in atrophied tissue.

Urinary symptoms: urgency, frequency, nocturia, dysuria, and recurrent urinary tract infections. The urethra and bladder trigone are also estrogen-sensitive. As local estrogen declines, the urethral mucosa thins, urinary urgency increases, and the microenvironment that protects against uropathogens is disrupted.

These three domains often co-exist and reinforce each other.

Why GSM Differs From Hot Flashes

Hot flashes typically peak during perimenopause and early postmenopause, then diminish for most women over time. GSM follows the opposite trajectory.

Prevalence and severity increase with time after menopause.[5] Without treatment, vaginal atrophy progresses as tissue continues to be deprived of estrogen. Women who are five years postmenopausal typically have more severe GSM than those who are one year out, assuming no intervention.

This is why the "it will pass" approach does not apply. GSM is a progressive condition in the absence of treatment.

Treatment Options

Treatment ranges from non-hormonal over-the-counter products to prescription local hormonal therapy. The choice depends on symptom severity, personal preference, and whether the woman has any history of hormone-sensitive cancer.

Non-hormonal first-line options

For mild to moderate symptoms, two categories of non-prescription products are clinically supported.[6]

Vaginal moisturizers are used regularly (typically two to three times per week) and work by maintaining tissue hydration and normalizing vaginal pH over time. They are not for use only during intercourse; regular use maintains the vaginal environment more effectively than acute application. Look for products with hyaluronic acid, polycarbophil, or hypromellose as active ingredients.

Lubricants provide immediate relief during sexual activity but do not treat the underlying tissue changes. Water-based lubricants are broadly compatible with condoms and sex toys. Silicone-based lubricants last longer and suit penetrative activity better. Oil-based lubricants are incompatible with latex condoms.

Hyaluronic acid-based vaginal preparations have short-term efficacy comparable to topical estrogen for managing GSM symptoms, making them a viable option for women who cannot or prefer not to use hormones.[7]

Local (vaginal) estrogen therapy

Local estrogen is applied directly to vaginal tissue in small doses via cream, pessary, or ring. Because it acts locally rather than systemically, systemic absorption is minimal. Multiple guidelines, including those from the North American Menopause Society and NICE, consider local vaginal estrogen the most effective treatment for moderate to severe GSM.[3][8]

For most healthy women, local vaginal estrogen does not carry the same risk profile as systemic HRT. It does not raise circulating estrogen levels and does not require a progestogen alongside it (unlike systemic HRT in women with a uterus).

For women with a history of hormone-receptor-positive breast cancer, local estrogen remains a complex area and should be discussed individually with an oncologist.

Ospemifene

Ospemifene is a selective estrogen receptor modulator (SERM) taken orally. It acts on vaginal tissue as an estrogen agonist while having neutral or antagonist effects at breast tissue. It is approved for moderate to severe dyspareunia due to GSM and is a non-hormonal prescription option for women who prefer or require oral treatment.[4]

Intravaginal DHEA (prasterone)

Prasterone is a precursor hormone that converts locally in vaginal tissue to both estrogens and androgens. Available as a vaginal insert, it has evidence for improving dyspareunia, dryness, and urinary symptoms without significantly raising systemic hormone levels.[4]

Talking to Your Doctor

Most women with GSM are not being asked about it and are not raising it themselves. If vaginal dryness, pain during sex, increased urinary urgency, or recurrent UTIs are part of your experience, these are treatable symptoms and a legitimate reason for a clinical conversation.

Questions worth raising: - Are my symptoms severe enough to consider local estrogen, or should I start with non-hormonal options? - If I have a history of breast cancer or am on aromatase inhibitors, what are my safest options? - Should I be using a vaginal moisturizer regularly rather than only during intercourse?

GSM has a clear physiological cause and multiple treatment pathways.

References

[1] Portman, D. J., Gass, M. L. S. (2014). Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause, 21(10), 1063-1068. Cited in: Gandhi, J., et al. (2016). Genitourinary syndrome of menopause: An overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. https://www.ncbi.nlm.nih.gov/books/NBK559297/

[2] Palacios, S., Combalia, J., Emsellem, C., Garrido, N., Khorsandi, D. (2023). Genitourinary syndrome of menopause: A narrative review focusing on its effects on the sexual health and quality of life of women. Nutrients, 15, 823. https://pmc.ncbi.nlm.nih.gov/articles/PMC10692865/

[3] The Menopause Society (NAMS). (2020). Position Statement on Genitourinary Syndrome of Menopause. https://menopause.org/wp-content/uploads/default-document-library/2020-gsm-ps.pdf

[4] Alvisi, S., Gava, G., Orsili, I., et al. (2020). Vaginal health in menopausal women. Medicina, 56(9), 491. https://pmc.ncbi.nlm.nih.gov/articles/PMC7558330/. See also: StatPearls review https://www.ncbi.nlm.nih.gov/books/NBK559297/

[5] Nappi, R. E., Martini, E., Cucinella, L., et al. (2022). Addressing vulvovaginal atrophy (VVA)/genitourinary syndrome of menopause (GSM) for healthy aging in women. Frontiers in Endocrinology, 12. https://pmc.ncbi.nlm.nih.gov/articles/PMC7212735/

[6] Sarmento, A. C. A., Costa, A. P. F., Vieira-Baptista, P., et al. (2022). Use of moisturizers and lubricants for vulvovaginal atrophy. International Journal of Environmental Research and Public Health, 19(9). https://pmc.ncbi.nlm.nih.gov/articles/PMC9580673/

[7] Jokar, A., Davari, T., Asadi, N., Ahmadi, F., Foruhari, S. (2016). Comparison of the hyaluronic acid vaginal cream and conjugated estrogen used in treatment of vaginal atrophy of menopause women. Iranian Journal of Nursing and Midwifery Research, 21(1). Cited in: https://pmc.ncbi.nlm.nih.gov/articles/PMC9408661/

[8] NICE Guideline NG23. (2023). Menopause: Diagnosis and Management. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ng23