Let's Get Real About Down There: The Genitourinary Syndrome of Menopause

Here’s a topic that doesn’t get nearly enough airtime — and yet, so many women experience it.Let’s dive into something called genitourinary syndrome of menopause, or GSM for short.

What is GSM?

GSM is the medical term for a collection of symptoms that can happen when estrogen levels drop during and after menopause. You might’ve heard it called “atrophic vaginitis” or “vaginal atrophy” in the past — but GSM is a better, more inclusive term that captures all the changes that can happen in the vagina, vulva, bladder, and urinary tract.

In plain language: when estrogen declines, the tissues in these areas can become thinner, drier, and less elastic — and that can lead to a range of uncomfortable symptoms.

Common symptoms

Every woman’s experience is a little different, but GSM can cause things like:

• Vaginal dryness, burning, itching, or irritation

• Pain with sex

• Frequent urinary tract infections (UTIs)

• Urinary urgency, frequency, or leakage (stress incontinence)

• A feeling of pelvic heaviness or prolapse

  
  

If any of this sounds familiar — you are not alone, and more importantly, there are treatments that actually work.

Why it happens

Estrogen plays a big role in maintaining the health of the vaginal and urinary tissues. When it drops during perimenopause and into menopause, those tissues can become thin and fragile. The vaginal canal can narrow, the bladder and urethra can weaken, and the labia and vaginal opening can change in appearance and sensitivity.

The left shows the tissues of the vulva and vagina in an estrogen rich environment compared to changes that occur in the absence of estrogen on the right.

It’s not just “part of getting older” — it’s a hormone-related condition that can and should be treated.

The good news: GSM is treatable

Here’s where things get better. There are several effective ways to treat GSM, depending on your symptoms and preferences.

1. Vaginal estrogen

This is the gold standard treatment — and it’s not the same as taking estrogen pills or patches for hot flashes. Vaginal estrogen is low-dose, used locally, and not absorbed systemically, meaning it’s safe for pretty much everyone (even those who can’t take systemic estrogen for other health reasons).

You don’t need progesterone with it, and it can be used alongside systemic hormone therapy if needed.

Common options include:

• Vaginal cream (like Estrace): Apply nightly for two weeks, then 2–3 times per week.

• Vaginal tablets or softgels (like Vagifem, Yuvifem, Imvexxy): One daily for two weeks, then twice a week.

• Vaginal ring (Estring): Insert once every three months — super low-maintenance.

  
  

2. Other hormone-based options

• DHEA (Intrarosa): A daily vaginal suppository that helps improve lubrication and tissue health.

• Ospemifene (Osphena): A non-estrogen oral medication (technically a SERM) that can help reduce pain with intercourse and improve vaginal health.

  
  

3. Non-hormonal options

If you prefer to avoid hormones or can’t use them, there are still great alternatives:

• Vaginal moisturizers and lubricants (especially those with hyaluronic acid)

• Pelvic floor physical therapy — this can make a big difference in comfort, bladder control, and sexual function

• Regular sexual activity or use of vaginal dilators — yes, really! It helps maintain blood flow and elasticity

What the experts say

The American Urological Association (AUA) recently released updated guidelines on GSM — and their message is clear: These symptoms are common, important, and treatable.

They recommend:

• Low-dose vaginal estrogen as first-line therapy

• DHEA or ospemifene as alternatives

• Referral to a pelvic floor therapist for urinary or sexual function concerns

• Addressing psychosocial and sexual wellbeing as part of care

  
  

For women with recurrent UTIs, using vaginal estrogen can even cut the number of infections in half. That’s huge.

Bottom line

If you’ve noticed vaginal dryness, discomfort, or more frequent UTIs since menopause — it’s not “just you,” and it’s not something you have to live with.GSM is incredibly common, and thankfully, very treatable.

You deserve to feel comfortable in your body again — in every way.

If you think you might have GSM or want to talk about your options, reach out. There are safe, effective treatments that can help you feel like yourself again.