Genitourinary syndrome of menopause (GSM) refers to changes in the vaginal, vulvar, and urinary tissues that occur as estrogen levels decline. You may also hear this called vaginal or vulvovaginal atrophy.
GSM most commonly occurs during and after menopause, although similar changes can occur during other times of low estrogen, such as breastfeeding. Unlike some menopause symptoms, GSM often does not improve on its own and may worsen over time without treatment. Fortunately, there are several effective treatment options available.
GSM can affect the vulva, vagina, and urinary tract. Symptoms vary from person to person and may gradually become more noticeable over time.
Common symptoms include:
Vaginal or vulvar dryness, burning, or irritation
Decreased natural lubrication
Pain or discomfort with intercourse
Vaginal or vulvar itching or tenderness
Light spotting or bleeding with intercourse
Urinary urgency or frequency
Burning or discomfort with urination
Recurrent urinary tract infections (UTIs)
Not everyone experiences all of these symptoms, and similar symptoms can sometimes have other causes. If symptoms are new, persistent, or bothersome, we can help determine whether GSM or another condition may be contributing.
Treatment depends on your symptoms, their severity, and your medical history. Options include:
Vaginal moisturizers – Used regularly to help improve vaginal moisture and comfort over time.
Lubricants – Used during sexual activity to reduce friction and discomfort. Water- and silicone-based options are available.
Vaginal estrogen – A highly effective treatment for GSM that delivers a low dose of estrogen directly to the vaginal tissues. It is available as creams, tablets or inserts, and a vaginal ring.
Vaginal DHEA (prasterone/Intrarosa) – A prescription vaginal insert that can help improve painful intercourse related to menopause.
Ospemifene (Osphena) – A non-estrogen prescription pill that acts on estrogen receptors and can be used to treat vaginal dryness and painful intercourse.
Pelvic floor physical therapy – May be helpful when pelvic floor muscle tightness or pain is also contributing to discomfort with intercourse.
Systemic hormone therapy (HRT) may improve GSM symptoms when it is being used for other menopausal symptoms, but some people still need vaginal treatment for persistent dryness or discomfort.
What About Vaginal Laser or Other Energy-Based Treatments?
You may hear about laser or other energy-based treatments marketed as “vaginal rejuvenation.” These treatments use laser or radiofrequency energy with the goal of improving vaginal tissue and symptoms of GSM.
Some studies have shown improvement in vaginal dryness and discomfort, and these treatments may be of particular interest to patients who are unable or prefer not to use hormonal therapies. However, research is still evolving, and these treatments are not currently FDA-approved for the treatment of GSM or menopausal symptoms. Long-term safety and effectiveness are also not yet well established.
If you are considering one of these treatments, I recommend discussing it with your gynecologist so that you can review the potential benefits, limitations, costs, and other available treatment options.
Vaginal moisturizers and lubricants are nonhormonal options that can help improve comfort with GSM. They are available without a prescription and can be used alone or along with other treatments, including vaginal estrogen.
Moisturizers are used regularly, rather than only during sexual activity. They help maintain vaginal moisture and may improve dryness, irritation, and discomfort over time. Depending on the product, they are typically used several times per week.
Common options include:
Lubricants are used as needed during sexual activity to decrease friction and discomfort. Water-based and silicone-based lubricants are both reasonable options. Silicone-based products tend to last longer and may be especially helpful when dryness is significant. If you are prone to irritation, look for products without fragrances, flavors, warming agents, or other added ingredients.
Some people prefer simple oils, such as coconut oil or olive oil, as a lubricant. These can provide longer-lasting lubrication and may be a reasonable option if they do not cause irritation. Choose a plain product without added fragrances or other ingredients.
Oil-based products should not be used with latex condoms, because oils can weaken latex and increase the risk of condom breakage.
→ A quick reminder about Moisturizers vs. lubricants: Think of a vaginal moisturizer as part of your regular vaginal care routine, while a lubricant is used at the time of sexual activity. Many people benefit from using both.
Low estrogen can cause the vaginal and vulvar tissues to become thinner, drier, and more easily irritated. Vaginal estrogen delivers a small amount of estrogen directly to these tissues and is one of the most effective treatments for GSM.
It can improve dryness, burning, irritation, discomfort with intercourse, and some urinary symptoms, and may also help reduce recurrent urinary tract infections in some patients.
Low-dose vaginal estrogen results in very little estrogen being absorbed into the bloodstream and has a different safety profile than systemic hormone therapy. For most patients, it can be used safely long term. Progesterone is generally not needed when using low-dose vaginal estrogen, even if you still have a uterus. If you have a history of breast cancer or another estrogen-sensitive cancer, please discuss vaginal estrogen with your healthcare provider before starting treatment.
Vaginal estrogen is available in several forms, including:
Creams, such as estradiol (Estrace or generic) or conjugated estrogen (Premarin)
Vaginal tablets or inserts, such as Vagifem, Yuvafem, or Imvexxy
Vaginal ring (Estring), which remains in place for 90 days
All of these deliver low-dose estrogen directly to the vaginal tissues. The best option often depends on your preferences, insurance coverage, and how you prefer to use your medication.
Please note: Estring is different from Femring. Estring provides low-dose vaginal estrogen for GSM, while Femring provides systemic estrogen and is considered a form of systemic HRT.
How you use vaginal estrogen depends on the product you have been prescribed. Always follow the directions on your prescription, since dosing may occasionally be adjusted for your individual needs.
Vaginal Tablets & Inserts (Vagifem, Yuvafem, Imvexxy)
I typically recommend:
One vaginal tablet or insert every night for 2 weeks
Then decrease to twice weekly for maintenance
Insert the medication into the vagina according to the instructions provided with your specific product. Using it at bedtime is often easiest.
Vaginal Estrogen Cream
I typically recommend:
Every night for 2 weeks
Then every other night for 2 weeks
Then twice weekly for maintenance
The cream can be applied using the provided applicator or with a clean finger. If using your finger, place a small amount of cream from the tip of your finger to the first finger joint, similar to the amount of toothpaste you might put on a toothbrush. Gently apply the cream just inside the vaginal opening and around any external areas where you are experiencing dryness or irritation.
I generally recommend applying vaginal estrogen at bedtime. This gives the medication time to absorb overnight and can help minimize leakage. A little leakage or residue the following day can be normal, particularly when using vaginal estrogen cream. Wearing a pantyliner can be helpful if needed.
What About Sex?
You do not generally need to avoid sexual activity while using vaginal estrogen. If you plan to have intercourse on a night when your medication is due, I usually recommend using the vaginal estrogen afterward. This allows the medication to remain in place and avoids losing some of the product during intercourse.
Some people begin noticing improvement within the first few weeks, but it may take several weeks to a few months to experience the full benefit. Using your treatment consistently is important, particularly when first starting therapy. If your symptoms have not improved after a few months of regular use, please let us know.
GSM is usually a long-term condition related to low estrogen levels, rather than something that permanently resolves after a short course of treatment. Vaginal estrogen can generally be continued long term as long as it remains helpful and appropriate for you. If treatment is stopped, symptoms often return over time.
Vaginal dryness and other symptoms of GSM can be especially common in people with a history of breast cancer, particularly when taking medications that lower or block estrogen.
Nonhormonal treatments, such as vaginal moisturizers and lubricants, are often a good place to start. If these are not providing enough relief, low-dose vaginal estrogen may be an option for some patients. Vaginal estrogen results in much lower levels of estrogen exposure throughout the body than systemic hormone therapy.
If you have a personal history of breast cancer, I will typically recommend discussing the use of vaginal estrogen with your oncologist so that we can make a treatment decision that takes your cancer history and current medications into account.
Having a history of breast cancer does not mean that bothersome vaginal or urinary symptoms cannot be treated. We can work with you to find an option that is appropriate for your individual situation.
Please contact us if:
Vaginal or urinary symptoms are persistent, worsening, or affecting your quality of life
Over-the-counter moisturizers or lubricants are not providing enough relief
You continue to have symptoms despite using your prescribed treatment consistently
You develop new or worsening pelvic pain, vaginal discharge, odor, itching, or irritation
You experience vaginal bleeding or spotting after menopause, including bleeding after intercourse
You have recurrent urinary tract infections or persistent urinary symptoms
You have questions or concerns about how to use your vaginal estrogen or other prescribed treatment
GSM is common and treatable. If symptoms are bothering you, you do not need to wait until they become severe to ask about treatment options.
If you're unsure whether something you're experiencing is normal, please don't hesitate to reach out. For severe or urgent symptoms, please seek prompt medical evaluation rather than waiting for a MyChart response.
→ Bradford Clinic OB/GYN – Hawthorne