Understanding Genitourinary Syndrome of Menopause (GSM)

Genitourinary Syndrome of Menopause (GSM) is a condition that affects many women, caused by reducing circulating oestrogen in the body. It can also be known as vaginal atrophy or atrophic vaginitis, but it is so much more than just vaginal dryness! It can significantly impact a woman’s quality of life, yet it often goes undiagnosed and undertreated in the majority of those with these symptoms.

GSM classically occurs in premature ovarian insufficiency, menopause and perimenopause, but vaginal dryness can also occur when breastfeeding due to the hormonal changes after pregnancy and with the depo contraceptive injection.

So it’s a common problem that sadly isn’t talked about enough, let alone treated!

Symptoms of GSM:

Ostrogen plays a crucial role in maintaining the health of the genitourinary tract, which includes the vagina, vulva, bladder, and urethra. As oestrogen levels decrease, these tissues become thin and dry, leading to the characteristic symptoms of GSM.

Vaginal dryness:

One of the hallmark symptoms of GSM is vaginal dryness, which can result in discomfort, itching, and pain during sexual intercourse.

Genital burning or irritation:

Women with GSM may experience a sensation of burning or irritation in the genital area, making daily activities uncomfortable.


Painful sex (aka dyspareunia), is common in women with GSM due to vaginal dryness and thinning of the vaginal tissues.

Urinary symptoms:

GSM can also affect the urinary tract, leading to symptoms such as urinary urgency, frequency, and recurrent urinary tract infections.

Vaginal wall prolapse:

The decrease in oestrogen levels can cause the vaginal tissues to become less elastic and resilient. It’s a myth that this only happens to women who have given birth vaginally.

Causes of GSM:

The primary cause of GSM is the decline in estrogen levels that occurs during menopause. Estrogen is essential for maintaining the health and function of the genitourinary tissues. As estrogen levels decline, the tissues become thinner, drier, and less elastic, leading to the symptoms associated with GSM.

Medical Treatment Options for GSM:


I like to start with HRT if a woman can have it. 10% of women also need vaginal oestrogen, but systemic HRT can help to alleviate many of the symptoms.

Vaginal oestrogen

There are many forms of vaginal oestrogen including gels, creams, pessaries, tablets and an oestrogen ring. These can also be used for GSM, dryness associated with breast feeding and contraceptive injection use. It can even be used for those who have had breast cancer in the past.

Vaginal DHEA

Intrarosa is a pessary that is inserted into the vagina and is licensed for symptoms of GSM but not dryness associated with breastfeeding or contraception. The active substance of Intrarosa, prasterone, is converted into oestrogens and androgens when inserted into the vagina. The hormone levels increase in the local area which boosts the cells of the tissues and relieves the symptoms.

Steroid cream

High potency steroid cream can be really helpful for severe itch symptoms while waiting for the oestrogen or DHEA to do it’s job!

Non-Medical Treatment Options for GSM:

Oestrogen would be my first go-to, but if you’re looking for an alternative or something to run alongside, try this:

Regular pH Balanced Moisturising

Products like Yes VM* are helpful for this. Moisturise “down there” every day (like you would for your face!)


Oil and water based lubricants* together can really help during sex (unless using condoms so should be water based only)

Lifestyle Changes and Respecting Your Intimate Area

Wearing cotton underwear, avoiding synthetic panty liners and not using anything other than water to wash with can help to keep the natural flora of the vagina healthy (be gone femfresh!!). Making lifestyle changes such as quitting smoking, staying hydrated and engaging your core muscles when lifting can all help.

Stress Incontinence Devices

Contrelle activgard* is a handy sponge-like device that can be inserted into the vagina for up to 16 hours to help with stress incontinence. They can be purchased from places like Boots or Kegal8.

Pelvic Floor Exercises

Pelvic floor exercises can help to strengthen the muscles of the pelvic floor and can improve sensations during sex too! There are lots of ways to do this now including pelvic trainers*, games and working with a physiotherapist.

Prolapse Devices

Vaginal ring pessaries come in all shapes and sizes and can help to hold up a vaginal wall prolapse. Some of them can be used during sex, while others would be less appropriate. They also need regular changing and have to be fitted by a trained healthcare professional.

New(ish) Treatment Options for GSM:

CO2 Laser

Lasers can help with vaginal wall prolapse, stress incontinence and vaginal dryness. For example the monalisa touch is a CO2 laser that gently acts on the vaginal walls causing painless micro-lesions that triggers production of new collagen and therefore improvement in symptoms.


Ospemifene is a selective oestrogen receptor modulator that has an oestrogen-like effect in the vagina. It is licensed in the UK for use in women who have completed their breast cancer therapy. There is a lack of long-term safety data from clinical trials though, so if this is something you’d like to try, a discussion with your breast cancer specialist would be a good idea first.

Final Thoughts

Genitourinary Syndrome of Menopause is a common yet often overlooked condition that can significantly impact a woman’s quality of life. By understanding the symptoms, causes, and treatment options for GSM, women can seek appropriate care and support to manage their symptoms effectively.

If you need help with this, book an appointment and we can create you a bespoke treatment plan.

Until next time,

Dr Nikki x



*this is an affiliate link which does not impact your costs whatsoever but helps to keep this website up and running!

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