Genitourinary Syndrome of Menopause (GSM): What is it & What are my Options?


Your feminine area feels dry, irritated, and even itchy sometimes. You need to urinate more often and it can even burn when you go. Sex is not as pleasurable as it used to be. If you’re experiencing one or more of these symptoms and wondering what’s going on, it could be GSM.

Welcome to Menopause

Menopause is defined as 12 months without a period, and is associated with dropping estrogen levels.  The average age when a woman experiences menopause is 51 and each woman’s menopause is unique.  Some may sail through the change with minimal issues while others may experience moderate to severe symptoms.

Through our mothers, sisters and friends, most women are familiar with the more common symptoms of menopause like hot flashes and night sweats.  About 75% of women experience hot flashes. While they may only last a few years, for some women they may persist into their 70’s. Night sweats may interrupt sleep, which can lead to mood changes, irritability and trouble concentrating.  Fortunately, many of these symptoms will improve with time, with or without treatment.

Genitourinary syndrome of menopause (GSM), however, if untreated, tends to worsen with time.  Decreased levels of estrogen contribute to vaginal atrophy—dryness, itching, discomfort and pain with sex.  GSM includes bothersome vaginal atrophy combined with urinary symptoms, such as frequency, urgency and discomfort with urination, and an increased incidence of urinary tract infections.  GSM may affect 50-70 percent of postmenopausal women.

Common Vaginal Changes

Here are the some of the changes a woman may notice with GSM.

  • Tissues become thin, dry and less elastic with decreased secretions and lubrication
  • Fragile tissues may tear or bleed, leading to pain with sex or pelvic exams
  • Vaginal infections may increase, as healthy acidic pH of the vagina becomes more alkaline
  • Pain with sex can lead to less frequent intercourse, which can cause the vagina to become shorter and narrower, which in turn leads to more discomfort.
  • For some women, this can trigger involuntary tightening of vaginal and pelvic muscles (vaginismus), and sex may no longer even be possible.

These symptoms may significantly affect a woman’s sexual satisfaction, her intimate relationships and her overall quality of life.  Because of the sensitive nature of this condition, it is sometimes difficult to discuss with your provider. But don’t be shy—there are many effective treatment options available.

Nonhormonal Treatments for GSM

  • Vaginal lubricants decrease friction and reduce discomfort with sex when the vagina is dry. Water-soluble or silicone-based products are recommended, and they’re available over the counter or online.
  • Vaginal moisturizers are intended for regular use, several times weekly at bedtime. They line the vaginal walls and maintain moisture.  Many options are available over the counter.
  • Regular sexual stimulation increases vaginal blood flow and secretions. “Use it or lose it!”
  • Expanding your views of sexual pleasure beyond traditional intercourse.
  • Pelvic floor exercises can help to strengthen weak muscles or relax tight ones.
  • Vaginal dilators are used to restore vaginalcapacity, to expand the vagina in width and depth, to provide elasticity to the tissues, and to allow for comfortable sexual activity.
  • CO2 laser treatment may increase blood flow and promote collagen growth, but they are not FDA approved for this indication, and safety and efficacy concerns remain.

Hormonal Treatments for GSM

  • Low-dose vaginal estrogen applied directly to the vagina can restore vaginal health and improve symptoms of GSM within a few weeks. A prescription is required in one of these forms:
    • Cream
      • 2-3 times per week
      • Estrace or Premarin
    • Insert
      • Twice a week
      • Imvexxy
      • Vagifem/Yuvafem
    • Vaginal ring
      • Changed every 3 months
      • Estring vaginal ring
    • Dehydroepiandrosterone (DHEA) is a steroid hormone produced by the adrenal gland that acts as a precursor to both estrogen and testosterone in the body. Intrarosa is a prescription FDA-approved synthetic DHEA vaginal insert, used nightly, for vaginal atrophy symptoms.  Blood levels of estrogen do not appear to increase with use of low-dose vaginal DHEA.
    • Ospemifene is an oral tablet taken daily to treat painful intercourse due to vaginal atrophy. It is an estrogen agonist/antagonist, meaning it works like estrogen in some tissues, like the vagina, and opposes estrogen in other tissues.  Unlike estrogen, Osphena may actually cause hot flashes or night sweats, but similar to systemic estrogen it may stimulate the lining of the uterus, increasing the risk for uterine cancer, blood clots and stroke.

If you are experiencing GSM symptoms, getting the best possible care means talking openly with your provider about it.  Your Women’s Care Florida provider can explain your treatment options and find one that works for you.