Genitourinary syndrome of menopause: Common problem, effective treatments

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After menopause, about half of all women experience genital, sexual, and urinary symptoms associated with decreases in estrogen, termed genitourinary syndrome of menopause. First-line therapies are nonhormonal vaginal lubricants and moisturizers. For persistent symptoms, prescription estrogen in cream and ring formulations is effective.


  • Practitioners can use the patient’s most bothersome symptom and her vaginal pH level to assess clinical responses to therapy.
  • The diagnosis is based on clinical signs and symptoms from the medical history and physical examination.
  • If the symptoms are not bothersome to the patient, the syndrome does not require treatment.



For many women, the postmenopausal loss of estrogen is associated with uncomfortable genitourinary symptoms, collectively referred to as the genitourinary syndrome of menopause (GSM). But despite the prevalence of GSM and the availability of treatments, most women do not seek relief.

This article reviews the syndrome and offers advice on how to talk about it with patients and what treatment options to consider.


The term GSM and its definition were approved by the North American Menopause Society and the International Society for the Study of Women’s Sexual Health in 2014. 1 It replaces older terms such as vulvovaginal atrophy, urogenital atrophy, and atrophic vaginitis.

GSM refers collectively to the symptoms associated with estrogen loss after menopause that adversely affect the vulvovaginal area and lower urinary tract. The most common symptoms are vulvovaginal dryness, burning, or irritation; sexual pain from inadequate lubrication; and urinary urgency, dysuria, or recurrent urinary tract infection. 1,2

The definition notes that symptoms are self-reported as bothersome and are not the result of another disorder. Symptoms may be chronic and progressive, are not likely to resolve without treatment (pharmacologic or nonpharmacologic), and can have a significant negative impact on a woman’s quality of life and sexual health. 1,2


From 40% to 60% of postmenopausal women experience GSM, but few seek treatment. 3 Nevertheless, most postmenopausal women remain sexually active. In a 2008 survey of 94,000 postmenopausal women ages 50 to 79, 52% reported that they had been sexually active with a partner in the past year. 4 However, 45% of postmenopausal women experienced unpleasant vaginal symptoms, according to a 2012 international survey of 3,520 postmenopausal women ages 55 to 65. 5 In this survey, most respondents (75%) felt that vaginal symptoms had a negative impact on their life, but only 4% connected their symptoms to the vulvovaginal atrophy that resulted from loss of estrogen after menopause. Moreover, almost half were unaware of management options. 5

These findings were supported by a 2013 survey of more than 3,000 US women who reported unpleasant vulvar and vaginal symptoms. 6 From 60% to 85% noted negative sexual consequences from vulvovaginal symptoms, 47% felt their relationship suffered, and 27% felt it had a negative impact on their general enjoyment of life. In this study, 24% attributed their symptoms to menopause and 12% to hormonal changes. Although 56% had discussed GSM symptoms with a healthcare provider, only 40% were using GSM-specific topical treatments, mostly over-the-counter preparations.

Male partners of symptomatic women also note adverse emotional and physical effects. 7 In an online survey of 4,100 men and 4,100 women ages 55 to 65, 52% to 78% of men and 58% to 64% of women expressed the negative effects of vulvovaginal symptoms on intimacy, libido, and sexual pain.

GSM is a progressive disorder. Women may note symptoms many years before menopause or have no symptoms until several years after menopause. One study found the prevalence of GSM to be 4% during perimenopause, rising after menopause to 25% after 1 year and to 47% after 3 years. 8


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