Genitourinary syndrome of menopause (GSM) is a chronic, progressive condition caused by declining estrogen levels after menopause. It affects the vaginal tissue, urinary tract, and sexual function, and somewhere between 27% and 84% of postmenopausal women experience it. Unlike hot flashes, which tend to fade over time, GSM gets worse without treatment.
Why the Name Changed
Before 2014, this condition was called vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. In 2014, the International Society for the Study of Women’s Sexual Health and the North American Menopause Society agreed those names were too narrow. They focused mainly on the vagina and implied infection (“vaginitis”) when none was present. The new term, genitourinary syndrome of menopause, captures the full scope: vaginal, urinary, and sexual symptoms that all stem from the same hormonal shift.
What Causes It
Estrogen plays a major role in keeping vaginal and urinary tract tissues healthy. It promotes blood flow to those tissues, helps maintain their thickness and elasticity, and supports the production of natural lubrication. It also helps maintain an acidic vaginal environment. In premenopausal women, vaginal pH sits around 4.0 and the tissue hosts high levels of protective bacteria. After menopause, pH rises to around 4.6 or higher, and populations of those protective bacteria decline. That shift makes the tissue more vulnerable to irritation and infection.
When estrogen drops during menopause, these tissues gradually thin, dry out, and lose elasticity. The urinary tract is affected by the same estrogen loss because the vagina and bladder share a common embryological origin, meaning their tissues respond to the same hormones. This is why urinary symptoms show up alongside vaginal ones.
The Three Categories of Symptoms
GSM symptoms fall into three overlapping groups: genital, urinary, and sexual.
Genital symptoms include vaginal dryness, burning, and irritation. The tissue may become noticeably thinner and more fragile, sometimes leading to light spotting or bleeding from minor friction. Some women notice a change in discharge or a persistent feeling of rawness.
Urinary symptoms include a frequent or urgent need to urinate, a burning sensation during urination, and recurrent urinary tract infections. Some women develop new or worsening stress incontinence, leaking small amounts of urine when they cough, sneeze, or exercise.
Sexual symptoms center on pain during intercourse, often described as a feeling of tightness, friction, or tearing. Reduced lubrication makes penetration uncomfortable, and over time the vaginal opening can narrow. Loss of arousal and decreased sensitivity are also common. These symptoms often feed into each other: pain leads to avoidance, which can reduce blood flow to the area and make the tissue changes worse.
Why It Goes Underreported
Despite how common GSM is, only about half of women with symptoms ever bring them up with a healthcare provider. Of those who do, most say the clinician didn’t initiate the conversation. Many women assume these changes are just a normal part of aging they have to live with, or they feel uncomfortable raising the topic. The result is that a highly treatable condition often goes untreated for years while it quietly progresses.
Non-Hormonal Treatments
Current guidelines recommend starting with non-hormonal options first. These include vaginal moisturizers used two to three times per week and lubricants used during sexual activity. Moisturizers and lubricants serve different purposes: moisturizers are applied regularly to rehydrate the tissue over time, while lubricants reduce friction in the moment.
Among non-hormonal ingredients, hyaluronic acid has the strongest evidence. It’s a compound the body naturally produces that draws and holds water in tissue. Vaginal products containing hyaluronic acid have been shown to improve dryness and pain during sex, and they’re well tolerated with minimal side effects. That said, systematic reviews suggest moisturizers and lubricants have a lower overall impact than vaginal estrogen. They work best for mild symptoms or as a complement to other treatments.
Local Estrogen Therapy
When non-hormonal options aren’t enough, low-dose vaginal estrogen is the standard next step. It comes in several forms: creams, tablets or capsules inserted vaginally, and flexible rings. A vaginal ring, for example, releases a small steady dose of estrogen over 90 days before being replaced. Vaginal tablets and capsules are typically used on a daily basis for the first couple of weeks, then reduced to a few times per week.
A common concern with vaginal estrogen is whether it raises hormone levels throughout the body. Research using sensitive measurement methods shows that the lowest available doses keep blood estrogen levels within the normal postmenopausal range. A 4-microgram vaginal insert, the lowest dose available, produces blood levels of only 3.6 to 3.9 picograms per milliliter, essentially unchanged from untreated postmenopausal levels. Higher vaginal doses do produce modestly higher blood levels, but none approach the levels seen with oral or skin-patch hormone therapy. Studies lasting up to 84 days show no accumulation over time with lower-dose products.
This distinction matters for women with a history of hormone-sensitive breast cancer, who are often told to avoid systemic estrogen. For these women, the decision to use even low-dose vaginal estrogen involves a careful conversation about individual risk, and non-hormonal options or the lowest available doses are typically preferred.
Other Prescription Options
Two additional prescription approaches exist for women who want alternatives to vaginal estrogen. One is a vaginal insert containing a precursor hormone (DHEA) that the vaginal tissue converts locally into both estrogen and testosterone, supporting tissue health without significant increases in blood hormone levels. The other is an oral tablet that acts selectively on estrogen receptors in vaginal tissue without stimulating breast or uterine tissue the way traditional estrogen does. Both are FDA-approved specifically for GSM symptoms, and they fill an important gap for women who can’t or prefer not to use estrogen directly.
Laser and Energy-Based Treatments
Vaginal laser therapy has gained attention as a non-hormonal option, particularly for breast cancer survivors who can’t use hormonal treatments. Two types of lasers are used: CO2 lasers and erbium lasers. Both work by creating controlled micro-injuries in the vaginal wall, prompting the tissue to regenerate with improved thickness and moisture.
A typical course involves about three treatment sessions. A scoping review of 20 studies found that 13 concluded both laser types are safe and effective, with results comparable to standard treatments in some cases. Side effects during the procedure include mild pain and a warm sensation. Serious complications after treatment are uncommon: 16 of 20 studies reported none, while a small number noted temporary discharge, itching, or swelling.
Laser treatment is not yet universally endorsed by major medical societies as a first-line option, and long-term data are still limited. But for women with restricted treatment choices, it represents a promising alternative.
Why Early Treatment Matters
GSM is progressive. The tissue changes that start with mild dryness can advance to significant thinning, narrowing of the vaginal opening, and chronic urinary problems. Unlike hot flashes, which typically diminish within a few years of menopause, GSM does not resolve on its own. The tissue continues to change as long as estrogen levels remain low, which for most women means the rest of their lives. Starting treatment early, even with something as simple as a regular moisturizer, can slow that progression and preserve tissue health before symptoms become severe.