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Genitourinary Syndrome of Menopause (GSM)

Genitourinary syndrome of menopause (GSM) is a chronic, progressive condition resulting from declining estrogen and androgen levels during the menopausal transition, affecting the vulva, vagina, urethra, and bladder. It affects approximately 27–84% of postmenopausal women in the NAMS 2020 estimate[3] (ACOG estimates that up to 50% of menopausal women have symptoms associated with GSM[4]) and is widely underdiagnosed and undertreated.[1][2][3] The term was introduced in 2014 by the International Society for the Study of Women's Sexual Health and the North American Menopause Society to replace the narrower term "vulvovaginal atrophy."[4] Urinary symptoms can coexist with GSM and warrant evaluation for UTI, OAB, and other causes; local estrogen may treat coexisting GSM around pelvic floor procedures.[10] The 2026 EVA trial reported subjective benefit without improved anatomical or composite surgical success; see the POP evidence summary and perioperative estrogen evidence.

Definition and terminology​

GSM encompasses the full constellation of genital, sexual, and urinary symptoms associated with hypoestrogenism, not limited to vaginal atrophy alone. Unlike vasomotor symptoms, which may resolve over time, GSM symptoms are typically progressive and unlikely to resolve spontaneously without treatment.[5][2]

Similar genitourinary symptoms can occur in premenopausal hypoestrogenic states, including postpartum and lactation, hypothalamic amenorrhea, and use of antiestrogenic medications such as aromatase inhibitors, GnRH agonists, and tamoxifen.[6][4]

Pathophysiology​

The underlying mechanism is estrogen deficiency leading to anatomic and physiologic changes throughout the genitourinary tract:[6][7][9]

  • Vaginal epithelium becomes thin, pale, and less elastic, with decreased perfusion and loss of rugae.
  • Vaginal pH rises above 4.5 (from the normal premenopausal range of 3.5–4.5), creating an environment less hospitable to Lactobacillus species.
  • Vaginal microbiome shifts from Lactobacillus-dominant communities to diverse anaerobic flora. Postmenopausal women have low-Lactobacillus communities at approximately 50% of visits, compared with approximately 21% in premenopausal women.[8] Lactobacillus-dominated communities are associated with lower odds of vaginal atrophy and dryness.[8][9]
  • Estrogen receptors are present in the urethra and bladder; urinary frequency, urgency, dysuria, and recurrent UTI can accompany GSM.[10]
  • Estrogen receptors (ERα and ERβ) are present throughout the vagina, urethra, bladder trigone, and pelvic floor musculature, explaining the broad symptom profile.[7][9]

Clinical presentation​

Symptoms span three domains:[6][4][2]

  • Genital: vaginal dryness, burning, itching, irritation, vaginal discharge, introital narrowing
  • Sexual: dyspareunia, decreased lubrication, post-coital bleeding
  • Urinary: urgency, frequency, dysuria, nocturia, recurrent urinary tract infections

Patients often do not volunteer these symptoms spontaneously; proactive screening is recommended at clinical encounters.[6][1]

Diagnosis​

Diagnosis is clinical when bothersome genital, sexual, or urinary symptoms are not explained by another condition: obtain a focused history and genitourinary examination, recognizing that a specific atrophic sign is not required.[10] Assess for coexisting UTI, vaginitis, vulvar dermatoses and pelvic floor dysfunction; obtain urinalysis and culture when UTI is suspected.[6][10]

  • Examination findings: thin, pale, or erythematous vulvar or vaginal epithelium; loss of rugae; introital narrowing; decreased tissue elasticity; urethral caruncle; resorption of labia minora
  • Vaginal pH >4.5 in untreated postmenopausal patients supports the diagnosis
  • Routine biopsy is unnecessary for uncomplicated GSM; suspicious focal lesions, persistent unexplained symptoms, or bleeding require evaluation for other diagnoses and biopsy when indicated.
  • No consensus exists on the number or type of symptoms needed for formal diagnosis[10]

Management​

The 2025 AUA/SUFU/AUGS Guideline and the 2020 NAMS Position Statement provide management frameworks.[10][3] Treatment is guided by symptom severity, goals, contraindications, and patient preference; a mandatory failure of nonhormonal treatment is not required for every patient before considering local low-dose estrogen.

Nonhormonal options, alone or with other treatment​

  • Vaginal moisturizers (polycarbophil-based, hyaluronic acid) used 1–3 times per week[6][3][11]
  • Vaginal lubricants (water-, silicone-, or oil-based) used during intercourse[3][11]
  • Avoidance of vulvar irritants[6]

Local estrogen and other prescription options​

AUA/SUFU/AUGS 2025 recommends offering local low-dose vaginal estrogen for GSM-related vulvovaginal discomfort, dryness and dyspareunia . In patients with GSM and recurrent UTI, it recommends local low-dose vaginal estrogen to reduce future UTI risk ; with coexisting OAB, it may be offered to improve genitourinary symptoms .[10] The guideline finds too little comparative evidence to rank the hormonal therapies and does not support a stepwise progression through them; the choice follows shared decision-making.[10][1][3]

Creams, inserts, and the low-dose estradiol ring offer different application and cost options. Absorption depends on the product, dose, and tissue state; no formulation has demonstrated superior breast-cancer safety. Use the estrogen pharmacology hub for product-specific dosing and precautions rather than substituting one formulation's schedule for another.

A 2024 systematic review in the Annals of Internal Medicine confirmed that vaginal estrogen, vaginal DHEA (prasterone), oral ospemifene, and vaginal moisturizers may all improve some GSM symptoms in the short term, though long-term comparative effectiveness data remain limited.[12]

Alternative pharmacologic agents: AUA/SUFU/AUGS 2025 recommends offering the option of vaginal DHEA for GSM-related dryness or dyspareunia and says clinicians may offer ospemifene for the same symptoms .[10] Product-specific indications and cautions follow:

  • Vaginal DHEA (prasterone / Intrarosa): FDA-approved for moderate to severe dyspareunia due to menopausal vulvovaginal atrophy. Its label warns about current or past breast cancer; conversion to estrogen and limited survivor data preclude assurances of safety during aromatase-inhibitor treatment.[19]
  • Ospemifene (Osphena): Oral SERM approved for moderate to severe dyspareunia or vaginal dryness due to menopausal vulvovaginal atrophy. It is not an approved OAB/UUI treatment. Review endometrial and thromboembolic warnings; its US label advises against use in patients with known, suspected, or previous breast cancer.[21]

AUA/SUFU/AUGS 2025 recommends counseling that local low-dose vaginal estrogen (Statement 22) and vaginal DHEA or ospemifene (Statement 23) do not increase the risk of endometrial hyperplasia with atypia or endometrial cancer . For vaginal estrogen the trial data span 8 to 36 weeks and are supplemented by observational follow-up. Ospemifene is systemic and can cause endometrial proliferation, although hyperplasia with atypia and cancer were not seen in the trials; counsel patients accordingly.[10]

The guideline advises against endometrial surveillance solely because a patient uses local low-dose vaginal estrogen, vaginal DHEA, or ospemifene . Any postmenopausal bleeding still warrants evaluation; see endometrial evaluation. After treatment starts, reassess symptom response and tolerability; ongoing therapy and follow-up may be needed for this chronic condition (Statements 25–26; Clinical Principles).[10]

Adjunctive therapies​

Energy-based therapies (laser and radiofrequency)​

Fractional CO₂ laser and erbium:YAG laser have been studied for GSM. A 2025 systematic review found that CO₂ laser compared with sham showed little to no difference in dyspareunia, dysuria, or quality of life (low certainty of evidence), and similarly showed no significant difference compared with vaginal estrogen.[14] A meta-analysis found no statistically significant differences between laser and vaginal estrogen on several outcomes, with important heterogeneity.[15] The NAMS 2020 position statement concluded there are insufficient placebo-controlled trials to make treatment recommendations for energy-based therapies.[3] AUA/SUFU/AUGS 2025 counsels that the evidence does not support CO₂ laser, Er:YAG laser or radiofrequency for GSM-related vulvovaginal dryness, discomfort or irritation, dysuria, dyspareunia, quality of life, change in bothersome symptoms, or treatment satisfaction .[10] In the context of shared decision-making, Statement 18 says clinicians may consider CO₂ laser treatment for patients who are not candidates for, or prefer alternatives to, FDA-approved treatments for GSM-related vulvovaginal dryness, vulvovaginal discomfort/irritation, dysuria, and/or dyspareunia, with disclosure that the treatment is experimental outside clinical trials.[10] The 2026 VA/DoD menopause guideline suggests against vaginal lasers for GSM (Recommendation 29; Weak against).[24]

For the dedicated cross-indication review (GSM, SUI, lichen sclerosus, vaginal laxity, breast-cancer-survivor data, FDA / ACOG / AUA / ESSM positions), see Vaginal Laser Therapy.

Special population: breast cancer survivors​

  • ACOG 2021 position: nonhormonal methods are first-line for patients with a history of estrogen-dependent breast cancer.[16]
  • ACOG 2021 position: if nonhormonal treatments fail, low-dose vaginal estrogen may be used after shared decision-making, including patients on tamoxifen. For patients on aromatase inhibitors, shared decision-making among patient, gynecologist, and oncologist is recommended.[16]
  • AUA/SUFU/AUGS 2025 : tell patients there is no evidence linking local low-dose vaginal estrogen to the development of breast cancer (Statement 19). For a personal history of breast cancer, clinicians may recommend local low-dose vaginal estrogen within multidisciplinary shared decision-making (Statement 20). The guideline advises counseling that neither vaginal DHEA nor ospemifene increases breast cancer risk (Statement 21), but notes little data in survivors, so their use is likewise a shared decision with the oncologist. The FDA states that ospemifene should not be used in women with known or suspected breast cancer, and the DHEA label carries a breast cancer warning (above).[10]
  • A 2025 meta-analysis pooled eight observational studies. Recurrence analysis included 24,060 patients (unadjusted OR 0.48; 95% CI 0.23–0.98); separate mortality analyses also found no increase.[17] AUA highlights an increased recurrence association in the Danish cohort's concurrent AI subgroup, supporting particular caution and oncology involvement during AI treatment.[17][10]
  • A 2026 review discusses low-dose vaginal estrogen absorption and oncologic outcomes.[18] FDA label changes occurred through product-specific approvals beginning in February 2026[23]; see the regulatory update in the estrogen hub.
  • Lower-dose inserts or the low-dose estradiol ring may be considered to limit systemic exposure, with formulation choice agreed with the oncology team.[10]

VEMORA (July 2026): symptom benefit is not proof of oncologic safety. This open-label RCT randomized 23 aromatase-inhibitor users to vaginal estrogen or moisturizer for 24 weeks. Estrogen improved dryness and dyspareunia more; two late estradiol elevations occurred in participants reporting AI nonadherence. The study was too small and short to establish breast-cancer recurrence safety. Continue oncology-informed shared decision-making, especially during AI therapy.[20]

See Also​

  • Vaginal & Topical Estrogen. Formulation pharmacology, systemic absorption, breast-cancer counseling, product-specific FDA updates, and the July 2026 TAPER application trial.
  • Vaginal DHEA (Prasterone). Approved indication, hormone metabolism, and breast-cancer safety limitations.
  • Ospemifene. Oral SERM for menopausal dryness or dyspareunia, endometrial and VTE risks, and drug interactions.
  • Recurrent UTI. In peri- and postmenopausal women with recurrent UTI, the AUA/CUA/SUFU 2025 guideline recommends vaginal estrogen to reduce future UTI risk when it is not contraindicated .[22]
  • Preoperative Hormonal Priming. IMPROVE trial; role of local estrogen before pelvic floor surgery.

Podcasts​

AUA Guidelines: Genitourinary Syndrome of Menopause
AUAUniversity Podcast, Ep. 339 (2025)
cme.auanet.org
New Guidelines for Genitourinary Syndrome of Menopause
BackTable OBGYN, Ep. 89 (2025) · Melissa Kaufman, Giulia Ippolito
backtable.com

References​

1. Faubion SS, Sood R, Kapoor E. "Genitourinary Syndrome of Menopause: Management Strategies for the Clinician." Mayo Clin Proc. 2017;92(12):1842–1849. doi:10.1016/j.mayocp.2017.08.019

2. Crandall CJ, Mehta JM, Manson JE. "Management of Menopausal Symptoms: A Review." JAMA. 2023;329(5):405–420. doi:10.1001/jama.2022.24140

3. North American Menopause Society. "The 2020 Genitourinary Syndrome of Menopause Position Statement of the North American Menopause Society." Menopause. 2020;27(9):976–992. doi:10.1097/GME.0000000000001609

4. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. "Female Sexual Dysfunction: ACOG Practice Bulletin, Number 213." Obstet Gynecol. 2019;134(1):e1–e18. doi:10.1097/AOG.0000000000003324

5. Phillips NA, Bachmann GA. "The Genitourinary Syndrome of Menopause." Menopause. 2021;28(5):579–588. doi:10.1097/GME.0000000000001728

6. Ringel NE, Iglesia C. "Common Benign Chronic Vulvar Disorders." Am Fam Physician. 2020;102(9):550–557. PMID 33118795

7. Szymański JK, Słabuszewska-Józwiak A, Jakiel G. "Vaginal Aging — What We Know and What We Do Not Know." Int J Environ Res Public Health. 2021;18(9):4935. doi:10.3390/ijerph18094935

8. Shardell M, Gravitt PE, Burke AE, Ravel J, Brotman RM. "Association of Vaginal Microbiota With Signs and Symptoms of the Genitourinary Syndrome of Menopause Across Reproductive Stages." J Gerontol A Biol Sci Med Sci. 2021;76(9):1542–1550. doi:10.1093/gerona/glab120

9. Qi W, Li H, Wang C, et al. "The Effect of Pathophysiological Changes in the Vaginal Milieu on the Signs and Symptoms of Genitourinary Syndrome of Menopause (GSM)." Menopause. 2020;28(1):102–108. doi:10.1097/GME.0000000000001644

10. Kaufman MR, Ackerman AL, Amin KA, et al. "The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause." J Urol. 2025;214(3):242–250. doi:10.1097/JU.0000000000004589

11. Chang JG, Lewis MN, Wertz MC. "Managing Menopausal Symptoms: Common Questions and Answers." Am Fam Physician. 2023;108(1):28–39. PMID 37440735

12. Danan ER, Sowerby C, Ullman KE, et al. "Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause: A Systematic Review." Ann Intern Med. 2024;177(10):1400–1414. doi:10.7326/ANNALS-24-00610

13. Steinman MA. "Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria®." J Am Geriatr Soc. 2025;73(9):2657–2677. doi:10.1111/jgs.19500

14. Zerzan NL, Greer N, Ullman KE, et al. "Energy-Based Interventions for Genitourinary Syndrome of Menopause: A Systematic Review of Randomized Controlled Trials and Prospective Observational Studies." Menopause. 2025;32(2):176–183. doi:10.1097/GME.0000000000002465

15. Jang YC, Leung CY, Huang HL. "Comparison of Severity of Genitourinary Syndrome of Menopause Symptoms After Carbon Dioxide Laser vs Vaginal Estrogen Therapy: A Systematic Review and Meta-analysis." JAMA Netw Open. 2022;5(9):e2232563. doi:10.1001/jamanetworkopen.2022.32563

16. American College of Obstetricians and Gynecologists. "Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-Dependent Breast Cancer: Clinical Consensus." Obstet Gynecol. 2021;138(6):950–960. doi:10.1097/AOG.0000000000004601

17. Beste ME, Kaunitz AM, McKinney JA, Sanchez-Ramos L. "Vaginal Estrogen Use in Breast Cancer Survivors: A Systematic Review and Meta-Analysis of Recurrence and Mortality Risks." Am J Obstet Gynecol. 2025;232(3):262–270.e1. doi:10.1016/j.ajog.2024.10.054

18. Mainar LB, Nieto-Pascual L, Bravo EI, et al. "Safety of Vaginal Estrogen in Breast Cancer Survivors: Current Evidence on Systemic Absorption and Oncologic Outcomes." Maturitas. 2026;208:108914. doi:10.1016/j.maturitas.2026.108914

19. INTRAROSA (prasterone). US prescribing information, revised July 2026. DailyMed label.

20. Niravath P, Rimawi M, Sun K, et al. "VEMORA: Vaginal Estrogen versus non-hormonal MOisturizer in women Receiving Aromatase inhibitors: a randomized, controlled trial." Breast Cancer Res Treat. 2026;218(2):25. doi:10.1007/s10549-026-08025-0

21. OSPHENA (ospemifene). US prescribing information. DailyMed label.

22. American Urological Association, Canadian Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. "Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2019, Confirmed 2022, Amended 2025)." 2025. Guideline.

23. U.S. Food and Drug Administration. "FDA Approves Labeling Changes to Menopausal Hormone Therapy Products." February 12, 2026. FDA announcement.

24. U.S. Department of Veterans Affairs and U.S. Department of Defense. "VA/DoD Clinical Practice Guideline for Menopause." Version 1.0. 2026. Guideline.