Menopause care

Genitourinary Syndrome of Menopause

Dryness, painful sex and recurrent UTI — treatable

In short

Genitourinary syndrome of menopause (GSM) describes changes in the vaginal, vulval and urinary tissues caused by low oestrogen: dryness, burning, painful sex, urinary urgency and recurrent urinary infections. Unlike hot flushes it does not resolve with time and tends to progress, but it responds well to treatment, including low-dose local oestrogen.

Vaginal dryness, burning or discomfort is persistent
Sex has become painful
Urinary urgency or recurrent UTI is affecting life
Symptoms have continued despite general advice

A doctor discussing menopause care with a patient

01Understand

What GSM is

The tissues of the vulva, vagina, urethra and bladder base are rich in oestrogen receptors. When oestrogen falls, those tissues become thinner, less elastic and less well lubricated, blood flow reduces, and the vaginal environment becomes less acidic, which changes the bacterial balance. The result is a cluster of symptoms that used to be called vaginal atrophy, now more accurately described as genitourinary syndrome of menopause because it involves the urinary tract as well.

Typical symptoms include dryness, itching, burning, soreness, discomfort or pain during intercourse, bleeding after sex from fragile tissue, urinary frequency and urgency, discomfort passing urine, and recurrent urinary tract infections. Many women have several of these at once and have not connected them to menopause at all.

02Recognise

Why it is under-treated

Surveys internationally show that a large proportion of postmenopausal women experience these symptoms, and that only a minority raise them. In Indian consultations the barrier is often greater still: vaginal and sexual symptoms are difficult to bring up, appointments are short, and there may be no invitation to mention them. Women assume it is an inevitable part of ageing, or that treatment would involve hormones they have been told to avoid.

Unlike hot flushes, which usually improve over several years, GSM does not settle on its own and generally becomes more pronounced with time. Untreated, it affects sexual relationships, sleep, exercise, cycling, sitting comfortably, and the frequency of antibiotic courses for urinary infection. It is one of the most treatable conditions in menopause medicine and one of the least treated.

One transition, many signals

Symptoms rarely arrive in isolation.

A useful assessment connects the pattern across sleep, temperature, mood, cycles, bone and heart health rather than treating each symptom as a separate problem.

Hormonal transitionread as one pattern

Temperature

Sleep

Heart & bone

Mood & focus

03Assess

Treatment options

Low-dose vaginal oestrogen, available as cream, pessary or ring, is the mainstay for moderate to severe symptoms. It acts locally, with minimal systemic absorption at the doses used, and international menopause guidance regards it as suitable for most women, including many who cannot take systemic hormone therapy, and often including women with a history of breast cancer after discussion with their oncologist. It is used long term, because symptoms return if it is stopped.

Non-hormonal treatment matters too. Vaginal moisturisers used regularly are different from lubricants used at the time of sex, and both have a role. Prasterone and, in some countries, ospemifene are further options. Pelvic floor physiotherapy helps where muscle tension contributes to pain. Recurrent urinary infection may improve substantially once the tissues are treated, sometimes reducing the need for repeated antibiotics. Systemic hormone therapy helps some women but is often not sufficient on its own for genitourinary symptoms, so local treatment is frequently added.

04Treat

Painful sex deserves a proper assessment

Pain during intercourse after menopause is common and is frequently reduced to a single cause. In reality it may involve tissue changes from low oestrogen, pelvic floor muscle overactivity developed in response to anticipated pain, reduced arousal and lubrication, a skin condition such as lichen sclerosus, or a combination. Each of those has different treatment, and assuming the wrong one leads to disappointing results.

The consultation therefore covers the history in detail: where the pain is, whether it occurs at entry or deeper, when it began, what makes it better or worse, and what has been tried. Examination is arranged in person where it is needed to reach a diagnosis. The aim is to identify what is actually causing the pain rather than issuing a general prescription.

05Review

How treatment is monitored

Local oestrogen typically takes several weeks to produce noticeable change, with fuller benefit over around three months, so the first review is timed accordingly. Frequency is usually higher at the start and then reduced to a maintenance schedule. Any bleeding on treatment is assessed rather than assumed to be harmless.

Because this is long-term treatment, an annual review confirms that symptoms remain controlled, checks the regimen is still appropriate, and addresses anything new. These consultations are conducted online, and are often the first time a woman has been asked about these symptoms directly.

What is involved

Assessment before prescription.

Listen

Your symptoms, cycle, medical history and priorities, with a structured symptom score for a baseline.

Assess

Relevant risk factors, blood pressure and investigations where they change management.

Plan

A written, individual plan with safety-net advice and a clear review point.

Preparing

Worth noting before the consultation

Which symptoms you have, and how long they have been present
Whether sex is uncomfortable at entry, deeper, or both
Number of urinary infections in the past year
Products already tried, including moisturisers and lubricants
Any skin changes on the vulva
Past history of breast or gynaecological cancer

Common questions

Genitourinary Syndrome of Menopause: answers

Is vaginal oestrogen safe long term?+

At the low doses used locally, systemic absorption is minimal and international guidance supports long-term use for most women. Suitability after hormone-sensitive cancer is discussed with the treating oncologist.

Will these symptoms improve on their own?+

Unlike hot flushes, genitourinary symptoms usually persist and tend to progress without treatment, because the underlying tissue change does not reverse spontaneously.

Can vaginal oestrogen be used with systemic HRT?+

Yes. Systemic therapy alone does not always resolve genitourinary symptoms, and local treatment is commonly added.

Can recurrent urinary infections be related to menopause?+

They can. Falling oestrogen changes the vaginal and urethral environment, and treating the tissue change reduces recurrence for many women.

This page is general information about menopause care and is not a diagnosis, prescription or treatment recommendation for any individual. Medicines, doses and suitability are decided only in consultation.

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Genitourinary Syndrome of Menopause

What GSM is

Why it is under-treated

Symptoms rarely arrive in isolation.

Treatment options

Painful sex deserves a proper assessment

How treatment is monitored

Assessment before prescription.

Listen

Assess

Plan

Worth noting before the consultation

Genitourinary Syndrome of Menopause: answers

Perimenopause Care

Menopause Hormone Therapy

Premature Ovarian Insufficiency

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