Understanding Genitourinary Syndrome of Menopause (GSM): Symptoms, Changes, and Treatment Options

What is it?

The term Genitourinary Syndrome of Menopause (GSM) was introduced in 2014 to replace older term such as vulvovaginal atrophy and atrophic vaginitis. Atrophy means “wasting away” – no one wants to think that any part of the body is wasting away, let alone the vulva, vagina and bladder!

The term was used to make clear the fact that women have estrogen receptors in the vagina, vulva, bladder and the pelvic floor – the genitourinary system. Put simply, as estrogen declines in perimenopause and remains low in menopause, the vulva, vagina, bladder and pelvic floor muscles change, and this can lead to symptoms.

What changes?

In the absence of estrogen the following changes occur:

• Loss of fat from the outer lips of the vulva, the labia majora
• Moist tissues of the vulva and vagina, the mucosa, become dry with reduced lubrication
• Elastin and collagen are lost so that the vagina loses its natural folds and pelvic organ prolapse becomes more likely
• Shrinkage of the tissues of the vulva leaves the urethra, the entrance to the bladder, more exposed and prone to urinary tract infection
• The vagina and vulva become pale, tissues tear more easily

What symptoms occur as a result?

Like all aspects of menopause, the symptoms vary from woman to woman. Common symptoms are:

• Vaginal dryness. Often the first symptom a woman will notice is difficulty with inserting a tampon
• Irritation or burning in the vulva. Often women have had to change the type of underwear worn to avoid friction and discomfort
• Painful intercourse. Reduced lubrication, combined with a loss of elasticity can make intercourse painful. Many women avoid intercourse as a result but have a repeat of symptoms when they attend for a cervical smear
• Reduced arousal. The clitoris is a vital organ in female orgasm. The clitoral hood can overgrow leading to reduced sensitivity or retract leading to over sensitivity to touch. This can adversely affect arousal and desire leading to poor orgasmic function
• Increased frequency of passing urine and getting up in the night to pass urine. The loss of collagen and elastin that support the pelvic floor can lead to leakage of urine with coughing or sneezing (stress incontinence) and also when rushing to pass urine (urgency incontinence)

What are the effects?

A lack of lubrication and arousal, combined with painful intercourse can lead to women having sex less often, with less satisfying sex and the avoidance of intimate contact for fear that this will lead to intercourse. In turn this can have a detrimental effect on relationships with partners misreading the lack of lubrication and arousal to equate to a lack of attraction and interest. Women are often misguided in thinking that these symptoms are a natural part of growing older. Around 70% of women will have symptoms, only a minority receive the correct treatment.

What can be done to help?

Caring for the bladder

To care for the bladder, you should:

• Drink lots of water. Daily requirements vary but in general you should aim to pass urine every 3-4 hours. The urine should be pale yellow in colour
• Limit caffeine and alcohol – these can make bladder problems worse
• Avoid constipation – this can put pressure on the bladder and straining to open the bowels can weaken the pelvic floor
• Stop smoking – bladder problems are more common in people who smoke
• Urinate after sex. Sexual activity can transfer bacteria from the bowel or vagina to the urethra, the opening into the bladder. Passing urine after sex helps to flush these bacteria out
• Wipe from front to back after using the toilet to avoid the transfer of bacteria from the bowel to the bladder opening
• Take time to sit comfortably in a relaxed position and allow the bladder to fully empty. Hovering over the toilet seat makes it difficult for the pelvic floor to relax, it is best to sit down
• Exercise regularly. This maintains a healthy weight, reduces constipation and can help prevent bladder problems
• Exercise your pelvic floor. Download the NHS Squeezy App to help in your daily practice of pelvic floor exercises. Pilates is good physical exercise that helps to strengthen the pelvic floor muscles.
• Learn how to relax the pelvic floor. Breathing exercises can help with this. Relaxation helps to ensure the bowel and bladder empty correctly

Caring for the vulva

To care for the vulva, you should:

• Avoid the use of soap, bubble bath, shower gels, talcum powder, cleansing wipes, feminine wipes, perfumes, deodorants, antiseptics, fragranced washing powders or fabric conditioners and panty liners. These can irritate the sensitive tissues of the vulva
• Use emulsifying ointment as a soap substitute
• Avoid washing too often, once daily is usually adequate
• Wash with your hands and avoid the use of flannels which can scratch the skin
• Gently pat dry with a soft towel, do not rub
• After washing, apply an unscented moisturiser to the vulva and apply a vaginal moisturiser – Yes VM and Sylk Natural Intimate Moisturiser are both recommended as they protect the acid pH of the vagina and provide the correct balance of moisture. Vaginal moisturisers can be applied every 2-3 days or more often if required
• Use a lubricant. Sylk can also be used as a lubricant to ease sex. Yes lubricants are available as a water-based lubricant, Yes WB, and an oil-based lubricant, Yes OB. These can be used together with the oil-based lubricant applied first, followed by the water-based lubricant. Oil based lubricants should be avoided if condoms are being used for contraception

Treatment with local estrogen

The use of local estrogen in the vagina is a very effective solution that relieves symptoms of GSM usually after about 3 months. This can be prescribed by your doctor and can safely be used for most women on a long-term basis, if it is stopped, symptoms usually return. There are two types of estrogen – estradiol and estriol – and several methods of using it so you can choose the one that best fits your needs.

Local estrogen can be used as a tablet, pessary, cream, gel or ring:

In addition, Intrarosa is a pessary that does not contain estrogen but does contain prasterone which is converted to estrogen and testosterone in the body. It can be used once daily in the vagina to help women who are suffering from painful sex. It is easy to use but can damage latex condoms.

Use vaginal estrogen for 6 weeks prior to a cervical smear if you have previously experienced pain while having a cervical smear, you can use local vaginal estrogen for 6 weeks prior to your next smear. This will help to ensure that you are more comfortable while having this very important screening procedure.

Can I use HRT and vaginal estrogen together?

Yes. Many women on an adequate dose of HRT will get relief from the symptoms of GSM. However around 1 in 5 women will also require the addition of local vaginal estrogen to bring their symptoms under control. It is safe to use HRT and local vaginal estrogen in combination.

Vaginal laser treatment

Laser therapy using CO2 or Erbium Yag laser are both recently developed treatments for GSM and can be helpful for women who have failed to show an adequate response to treatment or in women where other treatments are contraindicated. Early studies have shown improvements in women but long-term study results reporting safety and effectiveness are awaited. This treatment is not available on the NHS.

What to do if things are not getting better

Like all other aspects of HRT, women respond differently to the various forms of estrogen, so it is important to make an individualised choice with the help of your healthcare professional. Some women find benefit from the estradiol but not estriol and vice versa. It is worth a trial of a different preparation if you do not have success with your first choice.

If you have used your medication as prescribed for 3 months and you continue to have symptoms you should see your healthcare professional for examination. Other conditions can affect the vulva and vagina and may need alternative treatment, it is important to ensure that a correct diagnosis is made.  Any unexpected vaginal bleeding should always be discussed with your doctor.

Last updated: June 2026