Genitourinary Syndrome of Menopause (GSM): Clinical FAQ for Primary Care

Genitourinary syndrome of menopause (GSM) encompasses a spectrum of genital and urinary symptoms resulting from hypoestrogenism after menopause. It affects more than half of postmenopausal women, yet most do not receive treatment, often due to stigma or underrecognition in clin

Symptoms are progressive rather than self-limiting, and their impact on sexual health, urinary comfort, and quality of life is comparable to other chronic conditions.⁴ Primary care clinicians are in a key position to identify, educate, and initiate effective management for GSM.

1. What is genitourinary syndrome of menopause?

GSM describes structural and functional changes to the vulva, vagina, urethra, and bladder associated with declining estrogen and other sex steroids.¹,² The term, introduced by an international consensus in 2014, replaced “vulvovaginal atrophy” and “atrophic vaginitis” to better capture the broad range of genital and urinary symptoms and to use less stigmatizing language.¹

GSM affects an estimated 50%–70% of postmenopausal women, but only about 1 in 4 seek care.³–⁵ Unlike vasomotor symptoms, which usually resolve, GSM is chronic and progressive, often worsening over time without treatment.¹,² Its burden on quality of life is substantial, interfering with intimacy, self-image, and daily comfort.⁶

2. What are the typical symptoms and underlying mechanisms of GSM?

Genital symptoms include dryness, irritation, itching, and dyspareunia, often accompanied by narrowing or loss of elasticity of the vaginal canal.³–⁵
Urinary symptoms may include urgency, frequency, dysuria, and recurrent urinary tract infections (UTIs).⁶

Estrogen deficiency leads to thinning of the vaginal epithelium, loss of collagen, reduced vascularity, and decreased glycogen production.¹,² These changes increase vaginal pH from a physiologic 3.5–4.5 to 5.5–7.0, encouraging pathogenic overgrowth and recurrent infection.¹,² Although the vaginal microbiome shifts after menopause, studies suggest it is not the primary driver of symptoms.⁷–⁹

3. How should clinicians diagnose and screen for GSM?

GSM is a clinical diagnosis based on compatible symptoms, examination findings, and menopausal context.¹⁰ Symptoms and physical signs may not always correlate; the purpose of examination is as much to rule out alternative conditions—such as lichen sclerosus, vulvodynia, or infection—as to confirm hypoestrogenic changes.¹⁰

Because embarrassment often prevents disclosure, clinicians should inquire proactively during wellness or chronic care visits.³–⁵ Approximately half of women report self-treating with over-the-counter products such as barrier creams or topical anesthetics, which may worsen irritation.¹¹

4. What nonhormonal treatments are available?

Nonhormonal options are appropriate for mild GSM or when hormonal therapy is contraindicated or declined.

• Vaginal moisturizers (polycarbophil or hyaluronic acid formulations) used two to three times weekly can improve dryness and sexual comfort and may provide similar benefit to low-dose estrogen in some studies.¹²,¹³
• Lubricants (water-, silicone-, or oil-based) are recommended for sexual activity; simpler formulations such as coconut oil or petroleum jelly minimize irritation.¹²
• Pelvic floor physical therapy (PFPT) can alleviate pain and improve sexual function when adherence is maintained, though long-term continuation rates are low.¹⁹,²⁰
• Vaginal DHEA (prasterone) and ospemifene, an oral selective estrogen receptor modulator, improve dyspareunia and vaginal function for moderate symptoms.¹⁴–¹⁶
• Laser and energy-based vaginal therapies have not demonstrated benefit over sham procedures in randomized trials and should not be recommended.¹⁷,¹⁸

5. What are the hormonal treatment options?

Low-dose vaginal estrogen remains the gold standard for moderate to severe GSM.¹⁴ Formulations include:

• Creams (estradiol or conjugated estrogens), used twice weekly
• Tablets/inserts (estradiol), used twice weekly
• Rings (estradiol), replaced every 3–4 months
• DHEA suppositories, used daily

Multiple randomized trials confirm that local estrogen effectively improves dryness, dyspareunia, and vaginal pH across formulations.²¹–²⁷ Despite proven efficacy, adherence is low—only 16%–44% of women continue therapy beyond the initial prescription.¹⁶ Addressing access, education, and comfort with self-application is crucial for sustained use.

6. How does local estrogen therapy affect urinary symptoms?

Vaginal estrogen reduces recurrent UTI incidence by roughly 50%, with some evidence suggesting creams may be more effective than tablets or rings.²⁸–³⁰ Topical therapy also improves urgency and incontinence symptoms, whereas systemic hormone therapy can worsen them.²⁸–³⁰ For postmenopausal women with recurrent UTI or overactive bladder, local estrogen should be considered first-line adjunctive therapy.

7. Is low-dose vaginal estrogen safe, including for breast cancer survivors?

Extensive data show no increased risk of cardiovascular disease, breast cancer, or endometrial pathology with low-dose vaginal estrogen.³³–³⁷ The Women’s Health Initiative observational data and several large cohort studies (>2 million women) found no elevation in cancer or cardiovascular events.³³,³⁴
Among breast cancer survivors, multiple population studies and meta-analyses show no increased recurrence risk with local therapy.³⁵ Given minimal systemic absorption, low-dose vaginal estrogen is considered safe and reasonable when GSM symptoms significantly affect quality of life.³⁵–³⁷

8. When should primary care clinicians refer?

Most GSM can be managed within primary care. Referral is appropriate for:

• Persistent or refractory symptoms despite first-line therapy
• Uncertain diagnosis (e.g., dermatoses, vulvodynia, malignancy)
• Complex comorbidities or severe anatomical changes
• Patient preference for specialist input

Because only 25% of affected women receive treatment,³–⁵ proactive inquiry and early management in primary care can close the treatment gap and markedly improve quality of life.⁶