Understanding the Urinary and Vaginal Changes of Menopause
Genitourinary syndrome of menopause (GSM) is a medical term used to describe a collection of genital, sexual, and urinary symptoms that arise from declining estrogen levels (and, to a lesser extent, androgen levels) during and after menopause.
GSM was previously referred to as vulvovaginal atrophy, but that term failed to capture the entire scope of symptoms.
GSM is commonly characterized by vaginal dryness, burning, itching, irritation, pain with sexual activity (dyspareunia), and decreased lubrication. Other urinary symptoms can include urgency, frequency, burning with urination, recurrent urinary tract infections, and, in some cases, urinary incontinence.
Unlike vasomotor symptoms such as hot flashes, which tend to improve over time, GSM is typically progressive. Without treatment, it’s typical for symptoms to persist or worsen, significantly affecting quality of life, sexual satisfaction, and intimate relationships.
GSM is extremely common, affecting an estimated 27% to more than 80% of postmenopausal women.¹ It can also occur in younger individuals with low-estrogen states, including those who have undergone surgical menopause (ovary removal), chemotherapy, radiation, or who are using antiestrogen therapies. Despite its prevalence and impact, GSM is widely underdiagnosed and undertreated.
Treating GSM
Treatment options range from non-hormonal approaches to localized and systemic hormonal therapies.
A reasonable starting point for women with mild symptoms is using moisturizers and lubricants. Vaginal lubricants are used during sexual activity to reduce friction, irritation, and discomfort; vaginal moisturizers are applied regularly to help maintain all-day tissue hydration.
Neither reverses the underlying tissue disturbances of GSM, but both can provide symptomatic relief. Regular sexual activity or vaginal stimulation is also helpful for promoting blood flow, epithelial turnover, and natural lubrication.
Moderate to severe manifestations of symptoms typically respond well to local as well as systemic hormone replacement therapies (HRTs). Low-dose vaginal estrogen is applied directly to the vulva and vagina in the form of creams, tablets, inserts, or a vaginal ring to restore tissue thickness, elasticity, blood flow, and lubrication. They also help lower vaginal pH and improve the local microbiome. The application of estrogen locally does not raise systemic estrogen levels, and improvement can be felt within weeks, with continued gains over several months.
When GSM is combined with systemic menopausal symptoms such as hot flashes or night sweats, systemic HRT is likely a more appropriate course of action. Systemic estrogen is either used alone or in combination with progesterone, depending on uterine status, and addresses whole-body menopausal concerns.
You might also hear your provider talk about two other options: vaginal dehydroepiandrosterone (DHEA) and ospemifene. DHEA is converted within vaginal cells into small amounts of estrogen and androgens that support tissue health and reduce pain with sexual activity. Oral ospemifene, a selective estrogen receptor modulator (SERM), is an oral alternative and can be particularly effective for dyspareunia (pain with sex).
Adjunctive therapies (i.e., used alongside HRTs and non-hormonal therapies) can also be helpful. Pelvic floor physical therapy and Kegels can help with pain, muscle tension, or urinary symptoms. Many women have found relief with energy-based therapies, such as radiofrequency devices, and patient education around avoiding irritants can ease symptoms.
Speaking Up
For years, apprehension surrounding hormone therapy has influenced how GSM is discussed and treated. Much of this can be traced back to broad black box warnings placed on estrogen products following early interpretations of large studies from the early 2000s. These black box warnings have since been removed by the U.S. Food and Drug Administration (FDA), as they were largely unfounded.
The shift has meaningful implications for the future of GSM care. The black box warnings generated undue fear among patients about viable treatment options and frustration among clinicians who knew the labels were incorrect. Their removal opens the door to more honest, nuanced discussions about treatment and reinforces the importance of individualized, shared decision-making.
Perhaps most importantly, this change opens the door to a broader cultural shift: recognition that quality-of-life issues include S-E-X. GSM is not a minor inconvenience or an unavoidable consequence of aging, but a medical condition with well-studied mechanisms and effective treatments.
Conversations about female sexual health, especially later in life, are often minimized or stigmatized. Some women worry their concerns will be dismissed, while others assume that if symptoms were important, their clinician would ask. Many believe the changes they are experiencing are simply an inevitable part of aging that must be tolerated rather than treated. Others feel embarrassed, uncomfortable, or unsure how to describe their symptoms, particularly when they involve sexual pain or urinary changes.
The consequences of this lack of communication are significant. Untreated GSM can lead to chronic discomfort, avoidance of intimacy, recurrent infections, emotional distress, and reduced overall well-being.
If you are experiencing urinary discomfort or symptoms of GSM, schedule a consultation with a specialist like Dr. Taghechian at Georgia Urology
Resource:
Carlson, K., & Nguyen, H. (2024, October 5). Genitourinary Syndrome of Menopause. NIH National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559297/.
