What is Genitourinary Syndrome of Menopause?
Genitourinary Syndrome of Menopause (GSM) is the modern term for the vaginal, vulval, bladder, and pelvic-floor changes that occur when oestrogen levels fall. Unlike symptoms such as hot flushes, GSM symptoms do not improve over time without treatment. They tend to worsen with age, but the good news is that highly effective treatments are available.
GSM reflects the fact that oestrogen receptors are found throughout the lower genital and urinary tract. As oestrogen declines during perimenopause and menopause, these tissues become thinner, drier, and more prone to irritation, infection, and discomfort.
What changes happen?
Falling oestrogen affects several structures:
- The vulva loses natural fat pads and the skin becomes more delicate.
- The vaginal lining becomes dry, less stretchy, and less able to lubricate.
- Collagen and elastin reduce, so the vagina loses its natural folds.
- The urethra and supporting tissues thin, increasing susceptibility to urinary symptoms and infections.
- The pelvic floor may weaken, contributing to leakage or prolapse.
- Scar tissue from childbirth can become more sensitive as hormonal support reduces.
These physical changes can begin in perimenopause, during breastfeeding, or with some contraceptives. They can also appear years after periods stop, which can catch many women off guard.
Common Symptoms
Symptoms vary widely. You may experience some or all of the following:
- Vaginal dryness or irritation
- Burning or itching in the vulva
- Discomfort inserting tampons
- Painful sex, especially with penetration
- Reduced arousal or changes in clitoral sensitivity
- Bladder urgency or frequency
- Leaking with coughing, laughing, or exercise
- Recurrent urinary tract infections (UTIs)
These symptoms can have a significant impact on confidence, intimacy, and overall wellbeing, but they are highly treatable.
What Helps?
Caring for the Bladder
Simple measures can make a real difference:
- Drink enough water so urine is pale yellow.
- Reduce caffeine and alcohol which can irritate the bladder.
- Maintain regular bowel habits and avoid constipation.
- Stop smoking – it worsens bladder symptoms and increases UTI risk.
- Pass urine after sex to flush out bacteria.
- Wipe front to back.
- Sit down fully to empty the bladder – hovering makes the pelvic floor tense.
- Keep active to support bowel regularity and weight management.
- Strengthen the pelvic floor (the NHS Squeezy app is an excellent resource).
- Practice pelvic-floor relaxation, especially if pain during sex is an issue.
Caring for the Vulva
Gentle care helps protect vulnerable skin:
- Avoid soaps, bubble baths, wipes, scented products, deodorants, and talc.
- Use an emollient or gentle, unfragranced wash instead.
- Wash once daily and pat dry – don’t rub.
- Apply an unperfumed moisturiser to the vulva after washing.
- Use a vaginal moisturiser every 2–3 days to maintain hydration.
Recommended vaginal moisturisers:
Yes VM and Sylk Natural Intimate Moisturiser can be bought cheaply, or simple coconut oil or Vaseline can also work well.
Vaginal Moisturisers and Lubricants
These are different products and work in different ways:
Vaginal moisturisers
Used regularly (every 2–3 days), they improve baseline hydration and comfort.
Lubricants
Used for sexual activity or vaginal examinations.
Options include:
- Water-based lubricants (e.g. Yes WB, most over the counter lubricants)
- Oil-based lubricants (e.g. Yes OB, or coconut oil – avoid with condoms)
- Using both together can give long-lasting comfort (oil first, then water-based).
Bringing your preferred lubricant to smear tests or internal examinations is encouraged.
Local Oestrogen Treatments
Local vaginal and vulva oestrogen is the most effective treatment for GSM.
- It restores moisture, elasticity, blood flow, and pH.
- Improvements are usually noticeable within 4–12 weeks.
- Safe for long-term use.
- Very low absorption; it does not raise the risks associated with systemic HRT.
- If stopped, symptoms gradually return.
Types of vaginal oestrogen
You can choose the option that best fits your needs – most have a recommended frequency of use e.g. every night for 2 weeks then twice weekly long term, but are safe to use more often if needed:
Vaginal oestrogen tablets (Vagifem, Vagirux)
A tiny tablet inserted high into the vagina using a plastic applicator.
Clean, simple and effective. Vagirux has a reusable applicator. Vagifem uses disposable applicators.
Vaginal pessaries (Imvaggis or Estriol creamy pessary)
Small bullet-shaped pessaries inserted with a finger.
Good for women who prefer not to use an applicator. May cause a light discharge.
Vaginal and vulval cream (Estriol)
Inserted using an applicator and can also be applied to the vulva.
Some women notice mild irritation at first if the vulva is very dry and sore.
Vaginal and vulval gel (Blissel)
Inserted using an applicator and can also be applied to the vulva.
Quickly absorbed. Particularly soothing when the vagina or vulva feels very dry.
Vaginal ring (Estring)
A small very flexible silicone ring inserted into the vagina and left in place for 90 days.
Ideal for women who prefer a low maintenance ‘fit and forget’ option, though some can feel it during sex.
Prasterone (Intrarosa)
A vaginal pessary that changes in oestrogens and testosterone in the vaginal tissues.
Useful for painful sex.
Avoid with latex condoms.
Before a cervical smear
Using vulval and vaginal oestrogen for 6 weeks before a smear can make the procedure more comfortable.
Can you use HRT and vaginal oestrogen together?
Yes. Around 20 percent of women on systemic HRT still need additional local oestrogen.
Managing Recurrent UTIs
Oestrogen deficiency is one of the leading causes of recurrent UTIs after menopause.
To reduce risk:
- Use vaginal and vulva oestrogen if recurrent UTIs are an issue – strongly supported by evidence.
- Stay hydrated.
- Avoid irritants (scented products, tight clothing).
- Empty the bladder fully and take time when weeing.
- Treat constipation.
- Urinate after sex.
Making Sex Comfortable and Pleasurable Again
Painful sex is common with GSM, but it is treatable and you should never feel you have to simply put up with it.
Helpful approaches include:
- Regular use of vaginal moisturisers
- Lubricants during sex
- Local oestrogen treatment
- Exploring non-penetrative intimacy while symptoms improve
- Using gentle stretching with dilators if tightness has developed
- Using a small vibrator to regularly massage around the vulva
- Addressing pelvic-floor tension with a specialist physiotherapist
- Considering sex therapy if fear, avoidance, or relationship concerns have developed
Pleasure and comfort matter; restoring both is an important part of wellbeing.
If Symptoms Aren’t Improving
If you’ve used treatment as recommended for 3 months and symptoms persist:
- Review with your healthcare professional.
- Another preparation or dose may work better – response varies.
- Other conditions (such as lichen sclerosus, infection, or dermatological issues) may need specific management.
- Any unexpected vaginal bleeding should always be assessed.
Summary
GSM is extremely common, affects quality of life, and often goes untreated – but it does not have to be tolerated. Excellent, safe, and effective treatments are available, and even small changes can make a big difference.
If you would like personalised advice or support with symptoms, we’d be very happy to help you explore the options that best suit your needs.
