You've heard about hot flashes. You've braced for the mood shifts. But nobody warned you that menopause would dry out your lady parts, shrink them, and aggravate your bladder as well, until you’re left an itchy, uncomfortable shell of your former self who has no interest in having sex, because it’s so very painful.
If you've been dealing with vaginal dryness, pain during sex, or a sudden urgency to rush to the bathroom, what you may be experiencing is called genitourinary syndrome of menopause, or GSM, and it affects up to 84% of postmenopausal women. (1)
The reason you might not have heard of it? Most women never bring it up with their doctor, and some doctors never think to ask. Or they throw around the term “GSM” but don’t thoroughly explain what’s going on or give you real solutions.
So let’s talk about it and get to the bottom of it, shall we?
What Is GSM Menopause?
GSM, which stands for genitourinary syndrome of menopause, is a medical term that describes a collection of symptoms affecting the vagina, vulva, and urinary tract that develop when estrogen levels decline during perimenopause and menopause. (2)
The name itself is somewhat new. Before 2014, these symptoms were grouped under the older term "vulvovaginal atrophy," which many women (and clinicians) found clinical, alarming, and frankly discouraging. The North American Menopause Society (NAMS) and the International Society for the Study of Women's Sexual Health (ISSWSH) co-sponsored a terminology consensus conference in 2013, and their respective boards formally endorsed the updated term, GSM, in 2014.
Their reasoning was straightforward: GSM is a more accurate and inclusive term that covers the full range of genital, sexual, and urinary symptoms, without necessarily implying stigma or pathology.
So when you see "GSM medical abbreviation" in a health article, it always refers to this condition: the physical changes that happen when estrogen-sensitive tissue in the genitourinary region (again, the vagina, vulva, and urinary tract) is no longer getting the hormonal signals it needs.
Here's what's happening on a biological level: estrogen keeps vaginal tissue thick, lubricated, and elastic — think of it like a ripe, well-hydrated piece of fruit. When estrogen is plentiful during your reproductive years, that tissue is robust, cushioned, and resilient. A juicy peach. As estrogen declines, the same tissue gradually dries out, thins, and loses its flexibility. Think dried apricot.
One reason for this is a shift in the type of collagen your body produces in that tissue.
Estrogen-rich tissue is high in Type III collagen, which is soft and elastic. Without estrogen, the balance tips toward Type I collagen, which is stiffer and less pliable. The practical result is tissue that is more fragile, less lubricated, and more prone to irritation and tearing.
This is why symptoms often feel like they come on slowly and then accelerate.
Estrogen also helps maintain the healthy pH balance and microbiome that protects the urinary tract and vagina. When it drops, the environment becomes less acidic, which disrupts the protective bacterial environment and raises the risk of infection, something we will come back to in the section on the vaginal microbiome below.
Unlike hot flashes, which tend to improve as you move further from the menopause transition, GSM symptoms typically persist and worsen over time without treatment. (3)
What Does GSM Feel Like? Recognizing the Symptoms
GSM menopause symptoms can range from mildly annoying to genuinely life-disrupting. Because the genitourinary system includes both the reproductive and urinary tracts, the symptoms can show up in several different ways.
Vaginal and vulvar symptoms
The most recognized sign of GSM is vaginal dryness. You might notice it as a persistent dryness or itching, a feeling of tightness, or a burning sensation, especially after sitting for long periods or wearing certain fabrics. For many women, the first clue is pain or discomfort during sex, which can range from mild friction to sharp pain.
Other symptoms of vaginal dryness related to GSM include:
Light spotting or bleeding after intercourse
Increased vaginal discharge (often watery or off-white)
A feeling of pressure or fullness in the vaginal area
Sensitivity or rawness around the vulva that makes everyday clothing uncomfortable
Urinary symptoms
Because the urinary tract shares tissue with the vaginal walls, estrogen loss affects it too. You might experience:
Increased urgency and frequency of urination
Burning when you urinate (without a urinary tract infection)
Recurrent UTIs that seem to come out of nowhere
Leaking a little urine when you laugh, sneeze, or exercise
If you've been cycling through antibiotics for recurring UTIs without addressing the underlying hormonal cause, GSM may be the missing piece of the picture.
Two supplements worth asking your provider about: vaginal or oral Lactobacillus-based probiotics, which can help restore the protective bacterial environment after antibiotics or during the menopause transition, and cranberry PACs, a naturally occurring sugar that has shown promise in supporting a healthy bladder.
Neither replaces treatment for an active infection, but both may help support your bladder environment.
Sexual symptoms
GSM women's health conversations often focus on vaginal dryness, but the sexual impact of this condition is significant and worth naming directly.
Decreased libido, reduced arousal, and painful intercourse (a condition called dyspareunia) are all part of the GSM picture, too.
What GSM Does to Your Vaginal Microbiome
During your reproductive years, a healthy vaginal microbiome is dominated by a genus of bacteria called Lactobacillus — particularly a strain called L. crispatus. These bacteria produce lactic acid, which keeps the vaginal environment acidic (a pH of roughly 3.5 to 4.5).
That acidity is protective. It suppresses the growth of harmful bacteria, reduces the risk of bacterial vaginosis and yeast infections, and helps guard against urinary tract infections.
When estrogen declines, the vaginal lining thins and produces less glycogen, the compound that feeds Lactobacillus. As those protective bacteria diminish, vaginal pH rises, the environment becomes more alkaline, and the door opens for opportunistic bacteria and yeast to move in.
This is why postmenopausal women are significantly more vulnerable to recurring infections, persistent discharge, and that characteristic odor that often accompanies GSM — even when no active infection is present.
It is worth noting that, unlike the gut, where microbial diversity is a sign of health, the vagina is one of the few ecosystems in the body where less diversity is better. A vagina dominated by Lactobacillus is a healthy vagina. Diversity in that environment typically signals imbalance.
This microbiome disruption also helps explain why recurring UTIs in menopause are so difficult to break with antibiotics alone. Antibiotics treat the acute infection but do nothing to restore the underlying hormonal and microbial environment that made you susceptible in the first place.
Addressing that root cause, through local hormonal therapy, vaginal probiotics, or both, is often what finally breaks the cycle.
How Is GSM Treated?
The good news is that GSM responds well to treatment. Whether you're looking for natural remedies, over-the-counter solutions, or prescription therapies, there's likely an approach that fits your comfort level and health needs.
Lifestyle And Natural Approaches
For mild symptoms or as a complement to other treatments, several strategies can help with vaginal dryness.
1. Vulvar Moisturizers
Vaginal dryness natural remedies start with moisture. Using a fragrance-free vaginal or vulvar moisturizer two to three times a week (not just during sex) can help with hydration in the tissues over time.
This is different from a lubricant — moisturizers are designed for daily tissue health, while lubricants are used specifically during sexual activity. According to NAMS, lubricants and moisturizers are recommended as first-line therapy for women with mild GSM symptoms. (4)
Coconut oil for vaginal dryness has become a popular home remedy, and there is some logic to it — coconut oil is a natural emollient with soothing properties. Many women find it helpful as a personal lubricant.
However, it is worth noting that clinical evidence for coconut oil on its own is largely anecdotal.
And it’s important to note that coconut oil can degrade latex condoms, so it is not compatible with latex protection.
I included coconut oil in Julva®, my patented vulvar moisturizer, after so many of my patients raved about using it.
2. Sexual Activity
Sexual activity itself, whether partnered or solo, also supports vaginal health by increasing blood flow to the tissue. This is not a cure, but regular activity can help slow tissue changes.
I often say that when it comes to vulvovaginal tissue, you either use it or lose it. When your tissues atrophy, that includes your labia and your clitoris. Many women are shocked to find that their labia shrink during this phase of life, and they’re equally disappointed by the power and quality of their orgasms because GSM takes those, too.
For midlife-specific guidance on how to get your desire back and start loving your sex life again, be sure to check out Sexual CPR, a self-study program for women and couples in midlife.
3. GSM No-Nos
What doesn’t help when it comes to GSM? Artificially fragranced soaps, douches, and perfumed products in the vaginal area. These irritate already-sensitive tissue and should be avoided entirely.
Truthfully, your vagina is a self-cleaning organ, and a splash of water is all you really need to clean your vulva.
Over-The-Counter Vaginal Dryness Cream
When natural approaches are not enough, a vulvar dryness cream can provide more consistent support.
The best cream for vulvar dryness is one you'll actually use consistently. Application frequency matters as much as the product itself — most OTC creams and gels work best when applied regularly rather than just when symptoms flare.
Check out the thousands of reviews from women who love Julva, my signature vulvar cream, here.
Hormonal Options: DHEA and Estrogen
For moderate to severe GSM, local hormonal therapy is often considered the gold standard treatment. (5) This means you apply hormones directly to the vulva or vaginal tissues.
In my practice, I often prescribe local estrogen therapy for women with GSM, and I also use Dehydroepiandrosterone (DHEA) as an over-the-counter option applied topically to the vulva.
Estrogen cream for vaginal dryness works by delivering a low dose of estrogen directly to the vaginal tissue, which helps restore thickness, elasticity, and moisture at the source. Prescription formats for vaginal estrogen include rings (replaced every three months) and tablets or suppositories inserted a few times per week — all delivering the same localized, low-dose benefit.
DHEA is a hormonal precursor to estrogen, testosterone, and even progesterone. When applied locally, it is a great option for women who can't or don't want to use estrogen, and it's also great in tandem with estrogen therapy. A pivotal phase 3 randomized controlled trial found that daily intravaginal DHEA produced significant improvements in dyspareunia, vaginal dryness, vaginal pH, and vaginal tissue health (all four of the FDA's coprimary endpoints) with no significant drug-related adverse events. (5)
Because the dose is low and the delivery is local, low-dose vaginal estrogen and DHEA do not raise blood estrogen levels above the normal postmenopausal range, and clinical evidence shows no increased risk of heart disease, stroke, or breast cancer at standard doses. (6,7)
The NAMS 2022 Hormone Therapy Position Statement notes that low-dose vaginal estrogen preparations are effective and generally safe for the treatment of GSM, with minimal systemic absorption, and are preferred over systemic therapies when treatment is needed only for genitourinary symptoms. (6)
And, the 2025 Guideline on Genitourinary Syndrome of Menopause recommends that clinicians offer vaginal DHEA as an option for women with GSM to improve vulvovaginal dryness and dyspareunia, and it explicitly states that vaginal DHEA does not increase the risk of breast cancer. (8)
That said, this is a conversation to have with your healthcare provider, especially if you have a history of hormone-sensitive conditions.
Ospemifene: the oral option
For women who prefer not to use any vaginal product at all, ospemifene is a once-daily oral tablet that acts as a selective estrogen receptor modulator (SERM), meaning it activates estrogen receptors in vaginal tissue without delivering estrogen systemically. It is FDA-approved for the treatment of moderate to severe dyspareunia and vaginal dryness associated with GSM. (8)
It’s important to note that about 10–25% of women who take systemic HRT will still have urogenital symptoms. These women may be directed to take vaginal hormones in addition to systemic HRT. (7)
None of these options are one-size-fits-all, and the right choice depends on your symptoms, health history, and personal preferences.
GSM in Menopause: Final Thoughts
Genitourinary syndrome of menopause is common, but it is treatable, and it is absolutely worth bringing up with your doctor — even if it feels awkward to start that conversation. If your provider is not asking about these symptoms, you are allowed to bring them up yourself.
Try a simple opening: "I've been experiencing vaginal dryness and some urinary changes. Could this be related to menopause, and what are my options?"
The days of tolerating these symptoms as an inevitable part of aging are over.
Your comfort matters. Your sex life matters. Your quality of life matters. And it is never too late to take charge of your body.
This post is for informational purposes only and is not a substitute for personalized medical advice. Please consult your healthcare provider for diagnosis and treatment.
References
- Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):1063–1068. https://pubmed.ncbi.nlm.nih.gov/25179577/
- PCORI Systematic Review: Genitourinary Syndrome of Menopause. Patient-Centered Outcomes Research Institute. https://www.pcori.org/research-results/2022/genitourinary-syndrome-menopause-systematic-review.
StatPearls (NCBI). Genitourinary Syndrome of Menopause. Updated October 2024. https://www.ncbi.nlm.nih.gov/books/NBK559297/
The NAMS 2020 Genitourinary Syndrome of Menopause Position Statement. Menopause. 2020;27(9):976–992. https://pubmed.ncbi.nlm.nih.gov/32852449/
Labrie F, Archer DF, Koltun W, et al; VVA Prasterone Research Group. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2016;23(3):243–256. https://pubmed.ncbi.nlm.nih.gov/26731686/
The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29(7):767–794. https://www.guidelinecentral.com/guideline/1971153/
BSSM Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM). British Society for Sexual Medicine, 2024. https://bssm.org.uk/wp-content/uploads/2024/03/BSSM-Position-statement-for-management-of-genitourinary-syndrome-of-the-menopause-GSM.pdf.
Kaufman MR, et al. Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline. American Urological Association, 2025. https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause
