Genitourinary Syndrome of Menopause (GSM): The Symptoms No One Talks About

There is a group of menopause symptoms that women rarely raise, often out of embarrassment or a belief that this is simply something to put up with. I want to change that. Genitourinary Syndrome of Menopause, or GSM, describes the ongoing changes to the vulva, vagina and urinary tract that happen when oestrogen levels fall. The term was introduced in 2014 to replace older labels such as vaginal atrophy, and it matters because these symptoms are common, they are not trivial, and they respond very well to treatment.

How common is GSM?

GSM mainly affects women after the menopause, with around half to two thirds of postmenopausal women experiencing symptoms. It can also affect younger women, roughly one in seven before the menopause, often linked to surgery or other causes of low oestrogen. Sadly it is frequently missed, because many women assume the discomfort is a normal and unavoidable part of ageing. It is not, and you do not have to live with it.

What makes GSM more likely?

Alongside the natural menopause, several factors raise the risk, including surgery to remove the ovaries, smoking, alcohol misuse, a lack of regular physical activity, reduced sexual activity, and never having given birth vaginally. Recognising these helps me identify who might benefit from earlier support.

Why it happens

The tissues of the vulva, vagina and urinary tract are rich in oestrogen receptors. As oestrogen falls, these tissues become thinner, drier and less elastic, blood supply reduces and the natural acidity of the vagina changes. That is why the symptoms tend to be persistent, and why, unlike hot flushes, they often worsen over time rather than settling on their own.

The symptoms to look out for

• Vaginal dryness, itching or a feeling of soreness
• Pain or discomfort during sex, and reduced natural lubrication
• Bleeding after sex, or reduced desire and arousal
• Discomfort or burning when passing urine
• Needing to pass urine more urgently or more often
• Stress or urge leakage, and recurrent urinary tract infections

Vaginal dryness becomes more common the further you are past the menopause, and dryness and painful sex are usually the symptoms that cause women the most distress. Any bleeding after sex or any new bleeding after the menopause should always be checked promptly, so please do not wait on that one.

The impact is real

GSM can affect far more than physical comfort. It can chip away at confidence, strain intimacy and lead some women to avoid sex altogether. Naming the problem is the first step towards fixing it, and in my clinic these are conversations I welcome, not ones to be embarrassed about.

How GSM is diagnosed

Diagnosis is usually straightforward and based on your history and, where appropriate, a gentle examination. Because symptoms can be vague, it often helps simply to describe what you are noticing, even if it feels awkward at first. There is nothing here I have not heard many times before.

Non-hormonal options

• Washing with a gentle emollient rather than soap, and avoiding perfumed products, antibacterial washes and non-cotton underwear that can irritate delicate tissue
• Vaginal moisturisers used regularly to improve day-to-day comfort, such as Replens or Yes
• Lubricants during sex, water, silicone or oil based, for immediate relief
• Pelvic floor physiotherapy, which is valuable where there is bladder trouble or pelvic floor tension

Hormonal treatment

For many women the most effective treatment is vaginal oestrogen, a low-dose tablet, cream or ring used directly where it is needed. It restores the health, moisture and natural acidity of the tissues, and because very little is absorbed into the rest of the body, it is suitable for most women and can be used long term. For those with wider menopausal symptoms, systemic HRT may be appropriate, and vaginal oestrogen can be added alongside it if needed. If you prefer to explore options beyond standard HRT, I have written about alternatives to HRT too.

Newer treatments

Other options exist for selected situations, including vaginal DHEA, the oral medication ospemifene for women who find vaginal treatments difficult to use, and vaginal laser therapy. Laser treatment tends to give shorter-lived results because the underlying oestrogen deficiency remains, so I always discuss the evidence and realistic expectations before recommending anything.

“GSM is common, it is not your fault, and it is highly treatable. No woman should quietly endure pain or discomfort because she feels unable to raise it.”

Dr Itunu Johnson

Discomfort during sex also overlaps with wider sexual wellbeing, which I cover in my guide to sexual health and safer sex. If any of this sounds familiar, timely help makes a real difference to how you feel.

If you would like a confidential, unhurried conversation about menopause symptoms including GSM, you can book a consultation or read more about my menopause care.