Many women experience vaginal dryness, painful sex, bladder symptoms or recurrent urinary tract infections (UTIs) during the perimenopause and after menopause, yet these symptoms are often not discussed or treated.

Unlike hot flushes or night sweats, GSM symptoms usually do not improve without treatment. In fact, they often become progressively worse over time. The good news is that effective, evidence-based treatments are available.

What is Genitourinary Syndrome of Menopause (GSM)?

Genitourinary Syndrome of Menopause (GSM) is the medical term used to describe the changes affecting the vulva, vagina and lower urinary tract caused by declining oestrogen levels during the perimenopause and menopause.

Common symptoms include:

• Vaginal dryness

• Vaginal burning or irritation

• Itching

• Pain during sex (dyspareunia)

• Reduced natural lubrication

• Urinary urgency

• Frequent urination

• Recurrent urinary tract infections (UTIs)

• Stress urinary incontinence

  
  

Research suggests that up to 87% of peri- and postmenopausal women experience symptoms of GSM, making it one of the most prevalent long-term consequences of menopause.

Why does menopause cause vaginal and urinary symptoms?

Oestrogen plays a vital role in maintaining the health of the vaginal tissues, vulva, bladder and urethra. These areas contain a high concentration of oestrogen receptors, making them particularly sensitive to hormonal changes.

As oestrogen levels decline:

• The vaginal lining becomes thinner and more fragile.

• Natural lubrication decreases.

• The tissues lose elasticity.

• Blood supply to the vagina reduces.

• Vaginal pH becomes less acidic, increasing susceptibility to infection.

  
  

These changes contribute to symptoms such as vaginal dryness, irritation, discomfort and painful intercourse.

The urinary tract is equally affected. Oestrogen helps maintain healthy bladder and urethral tissues, and when levels fall many women experience:

• Urinary urgency

• Increased urinary frequency

• Recurrent urinary tract infections

• Worsening stress urinary incontinence

Symptoms of Genitourinary Syndrome of Menopause

Symptoms may develop gradually during the perimenopause or become more noticeable after menopause.

They commonly include:

• Persistent vaginal dryness

• Burning, soreness or itching

• Pain during sexual intercourse

• Light bleeding after sex

• Reduced sexual comfort and pleasure

• Frequent UTIs

• Bladder urgency

• Needing to pass urine more often

• Leakage of urine when coughing, sneezing or exercising

  
  

Unlike vasomotor symptoms, such as hot flushes, GSM symptoms rarely resolve without treatment and generally progress over time.

How does GSM affect quality of life?

Genitourinary Syndrome of Menopause can have a significant impact on both physical and emotional wellbeing.

Women frequently report:

• Reduced confidence

• Anxiety about intimacy

• Pain affecting sexual relationships

• Discomfort during exercise

• Difficulty wearing certain clothing

• Sleep disruption due to bladder symptoms

• Fear of recurrent urinary tract infections

  
  

Many women delay seeking help because they assume these symptoms are a normal part of ageing or feel embarrassed discussing intimate concerns. However, GSM is a recognised medical condition with highly effective treatment options.

Treatment for Genitourinary Syndrome of Menopause

The most appropriate treatment depends on symptom severity and individual circumstances.

Vaginal moisturisers and lubricants

For mild symptoms, regular vaginal moisturisers can improve hydration and reduce dryness.

Lubricants (water-based, silicone-based or oil-based where appropriate) can improve comfort during sexual activity.

Pelvic floor exercises

Pelvic floor muscle training may improve bladder control and help reduce symptoms of stress urinary incontinence.

Lifestyle measures

Simple changes can also help protect vulval and vaginal health:

• Avoid perfumed soaps and intimate washes.

• Wear breathable cotton underwear.

• Stay well hydrated.

• Maintain regular sexual activity if comfortable, as this can help support tissue health.

  
  

Vaginal (local) oestrogen

For many women, low-dose vaginal oestrogen is considered the most effective treatment for GSM.

Available as creams, pessaries, tablets or vaginal rings, local oestrogen restores hormone levels directly within the vaginal tissues. Treatment helps:

• Improve vaginal thickness

• Increase natural lubrication

• Restore elasticity

• Improve vaginal pH

• Reduce recurrent urinary tract infections

• Improve bladder symptoms

  
  

Because absorption into the bloodstream is minimal, local vaginal oestrogen is considered safe for long-term use for most women.

It is also important to know that approximately one in four women using systemic HRT continue to experience symptoms of GSM and benefit from adding local vaginal oestrogen alongside their existing HRT regimen.

When should you seek help?

If you are experiencing vaginal dryness, painful sex, bladder symptoms or recurrent UTIs during the perimenopause or after menopause, you do not need to simply accept these symptoms.

If self-care measures are not providing sufficient relief, speak to a healthcare professional about your treatment options, including vaginal oestrogen.

Healthcare professionals do not always ask about vaginal or urinary symptoms during menopause consultations, so it is important to raise these concerns yourself.

In the UK, some forms of vaginal (local) oestrogen are now available over the counter through participating pharmacies for eligible women aged over 50 who are postmenopausal.

Specialist Menopause Care

At Bristol Menopause & Wellwoman Clinic, we regularly assess and treat Genitourinary Syndrome of Menopause as part of our comprehensive menopause care.

If you are experiencing symptoms of GSM, our menopause specialists can provide an individual assessment and recommend the most appropriate evidence-based treatment to help improve your comfort, bladder health, sexual wellbeing and overall quality of life.

References

1. Portman DJ, Gass MLS. Genitourinary Syndrome of Menopause: New Terminology for Vulvovaginal Atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society. Menopause. 2014.

2. Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric. 2014.

3. The British Menopause Society. Management of Genitourinary Syndrome of Menopause. Updated consensus statement.

4. Kingsberg SA, et al. Vulvar and Vaginal Atrophy in Postmenopausal Women. J Sex Med. 2013.

5. National Institute for Health and Care Excellence (NICE). Menopause: Diagnosis and Management (NG23). Updated guidance.

6. The British Menopause Society. Management of the Menopause. Current clinical recommendations.