Genitourinary syndrome of menopause, usually shortened to GSM, describes a group of vaginal, vulval, sexual and urinary changes that can happen as oestrogen and other sex hormone levels fall around menopause.
Despite the name, GSM isnโt only about the vagina and it isnโt only about sex. It can affect everyday comfort, the vulva, bladder and urinary tract as well as sexual activity.
Symptoms can include vaginal dryness, burning, itching, pain during sex, urinary urgency and recurrent urinary tract infections.
GSM is very common, but many people donโt realise their symptoms are connected or that treatment is available. Unlike hot flushes, which often become less frequent over time, GSM symptoms can persist or become more noticeable after menopause if they arenโt treated.
The good news is that there are several effective ways to manage GSM, ranging from moisturisers and lubricants to prescription vaginal oestrogen and pelvic health treatment where appropriate.
Key takeaways
- GSM is a group of vaginal, vulval and urinary changes associated with falling sex hormone levels around and after menopause.
- It can cause dryness, burning, irritation, painful sex, urinary urgency and recurrent urinary tract infections.
- Symptoms can begin during perimenopause and often continue after menopause.
- GSM isnโt simply another name for vaginal dryness. Dryness is one possible symptom of the broader condition.
- Vaginal moisturisers can help ongoing dryness and lubricants reduce friction when needed.
- Low-dose vaginal oestrogen is one of the most effective treatments for GSM when symptoms are related to lower oestrogen.
- Pelvic floor physiotherapy can help when muscle tension, weakness, pain or bladder symptoms are also involved.
- Laser and radiofrequency treatments marketed for vaginal rejuvenation arenโt currently approved in Australia for this use.
- Unexpected bleeding, persistent pain, unusual discharge or blood in the urine shouldnโt simply be assumed to be GSM.
On this page
- What is genitourinary syndrome of menopause?
- Why does GSM happen?
- What are the symptoms of GSM?
- Is GSM the same as vaginal dryness?
- GSM, thrush, BV and UTIs: whatโs the difference?
- How can GSM affect sex and intimacy?
- How is GSM treated?
- Vaginal oestrogen for GSM
- What if youโve had breast cancer?
- GSM and the pelvic floor
- What about vaginal laser or radiofrequency treatment?
- What about trans men and people using testosterone?
- When should you see a doctor?
- Frequently asked questions
What is genitourinary syndrome of menopause?
Genitourinary syndrome of menopause, or GSM, is the term used for changes affecting the vulva, vagina and lower urinary tract that can occur as sex hormone levels decline around menopause.
The term was introduced because older names such as โvaginal atrophyโ, โvulvovaginal atrophyโ and โatrophic vaginitisโ focused almost entirely on vaginal tissue.
They didnโt capture the fact that lower hormone levels can also affect the vulva, urethra, bladder, sexual comfort and urinary health.
GSM is now the broader term used to describe this collection of symptoms and tissue changes.
How common is GSM?
Itโs very common.ย Australasian Menopause Society information estimates that GSM affects somewhere between 40% and 90% of postmenopausal women, depending on how symptoms are measured and which population is studied.
Symptoms can also begin during perimenopause, before periods have stopped completely.
Despite how common it is, GSM is still frequently under-recognised and undertreated. Some people assume dryness, urinary symptoms or painful sex are simply inevitable parts of ageing and donโt realise that treatments are available.
Why does GSM happen?
Oestrogen and other sex hormones help maintain the structure, blood supply, elasticity and moisture of genital and urinary tissues.
As ovarian hormone levels decline around menopause, several changes can occur.
Vaginal tissue can become thinner and drier
The vaginal lining can become thinner, less elastic and more easily irritated.
There may also be less natural moisture and lubrication.
This can create a dry, tight, burning or sore feeling and may make friction more uncomfortable.
Vulval tissue can change too
The vulva can become drier and more sensitive.
Changes in collagen, skin thickness and local secretions can make the tissue more susceptible to irritation or small tears.
Some people also notice changes in the appearance or fullness of the labia over time.
Vaginal pH and bacteria change
Oestrogen helps support an acidic vaginal environment and bacteria such as Lactobacillus species.
As oestrogen declines, vaginal pH tends to rise and the vaginal microbiome can change.
This doesnโt mean youโll automatically develop an infection, but it forms part of the broader GSM picture.
The urethra and bladder can be affected
The urinary tract also contains hormone-sensitive tissue.
Changes around the urethra and bladder can contribute to urinary urgency, frequency, discomfort and recurrent urinary tract infections in some people.
What are the symptoms of GSM?
GSM doesnโt look the same for everyone.
You might have one symptom or several, and symptoms may be mild, intermittent or significant enough to affect daily life.
| Area | Possible symptoms |
|---|---|
| Vaginal | Dryness, tightness, burning, itching, irritation or reduced lubrication |
| Vulval | Dryness, sensitivity, soreness, itching or irritation around the external genital area |
| Sexual | Pain or discomfort during penetration, reduced lubrication, soreness after sex or reduced desire because sex has become uncomfortable |
| Urinary | Urgency, frequency, burning or discomfort when urinating and recurrent urinary tract infections |
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Some people also notice discomfort when inserting a tampon, menstrual cup, disc, dilator or another internal product.
GSM symptoms often develop gradually, so it can be easy to adapt to them without realising how much theyโve changed.
Is GSM the same as vaginal dryness?
No.
Vaginal dryness is one of the most common symptoms of GSM, but GSM is the broader condition.
You can have vaginal dryness for reasons unrelated to menopause, including breastfeeding, some medicines, cancer treatments, irritation or other health conditions.
And you can have GSM without dryness being your main complaint. Urinary urgency, recurrent UTIs or painful sex may be more noticeable.
If dryness is your main concern, see our guide to vaginal dryness for a more detailed look at moisturisers, lubricants and treatment options.
GSM, thrush, BV and UTIs: whatโs the difference?
GSM can sometimes feel similar to an infection because symptoms overlap.
Burning, irritation, discomfort when urinating and changes in discharge can all have more than one possible cause.
Thrush
Thrush is caused by an overgrowth of Candida yeast.
It can cause significant itching, burning and discharge, but it isnโt the same thing as GSM.
Thrush actually tends to become less common after menopause unless other risk factors are present.
Bacterial vaginosis
Bacterial vaginosis, or BV, involves a change in vaginal bacteria and often causes a distinctive discharge or odour.
Vaginal microbiota also change with menopause, so diagnosis isnโt always as simple as assuming every pH change or discharge means BV.
Urinary tract infections
UTIs are bacterial infections of the urinary tract.
GSM can increase susceptibility to recurrent UTIs in some postmenopausal people because lower oestrogen affects tissue around the vagina and urinary tract.
But burning when you urinate doesnโt automatically mean you have either GSM or a UTI.
If urinary symptoms are new, significant or persistent, itโs worth getting them assessed rather than treating yourself repeatedly for an assumed infection.
Likewise, unusual discharge, a persistent unpleasant smell or intense itching deserves proper assessment.
Our guide to vaginal discharge and how it changes may help you work out whatโs worth checking.
How can GSM affect sex and intimacy?
GSM can have a significant effect on sexual comfort, but this often gets reduced to the phrase โvaginal drynessโ.
There can be more to it than that.
Lower oestrogen may contribute to:
- less natural lubrication during arousal
- greater sensitivity to friction
- pain at the vaginal opening
- deeper discomfort during penetration
- small tears or soreness after sex
- a feeling of tightness
- reduced interest in sex because sex has become uncomfortable
Needing lubricant doesnโt mean you arenโt aroused, attracted to your partner or interested in sex.
Lubrication and desire arenโt the same thing.
And pain isnโt something you should have to push through.
If penetration is painful, dryness may be one factor but pelvic floor muscle tension, vulval skin conditions, infection and other causes should also be considered.
Read our guide to painful intercourse and dyspareunia for more.
How is GSM treated?
Treatment depends on your symptoms, how much theyโre affecting you and your individual health history.
You donโt necessarily need to start with the strongest treatment or work through every option in a particular order.
For some people, moisturiser and lubricant are enough. For others, prescription vaginal oestrogen makes a much bigger difference.
Vaginal moisturisers
Vaginal and intimate moisturisers are designed to help with ongoing dryness rather than only being used during sexual activity.
Depending on the product, theyโre usually used regularly several times a week.
Some are intended for internal vaginal use, while others are designed for the external vulval area, so check the product instructions.
A moisturiser may help mild to moderate dryness but it doesnโt replace the oestrogen that has been lost from vaginal tissue.
Personal lubricants
Lubricants provide temporary slip and reduce friction.
They can be used during sex, masturbation or when inserting a cup, disc, dilator or other device.
Water-based lubricants are versatile and generally compatible with latex condoms and most products.
Silicone-based lubricants usually last longer, although compatibility with silicone toys or devices should be checked.
Oil-based products can damage latex condoms.
See our guide to choosing a lubricant for more detail.
Gentle vulval care
If vulval tissue is dry or irritated, simpler is usually better.
You may find it helpful to:
- wash externally with water or a simple fragrance-free product if needed
- avoid douching
- avoid fragranced intimate washes, wipes and deodorants
- stop using products that sting or trigger irritation
- choose clothing that doesnโt create unnecessary friction
The vagina doesnโt need to be washed internally.
Vaginal oestrogen for GSM
When GSM is being driven by lower oestrogen, low-dose vaginal oestrogen is one of the most effective treatments available.
Rather than treating the whole body, vaginal oestrogen is placed directly onto or into the vaginal tissue.
It can help restore some of the moisture, thickness, elasticity and function of the tissue and may improve both genital and urinary symptoms.
Depending on the product available and prescribed, vaginal oestrogen may come as a cream, vaginal tablet, pessary or ovule.
What symptoms can vaginal oestrogen help?
It may help with:
- vaginal dryness
- burning or irritation
- pain during sex
- reduced tissue elasticity
- urinary urgency and discomfort associated with GSM
- recurrent UTIs in some postmenopausal people
Is vaginal oestrogen the same as MHT?
Not quite.
Systemic menopausal hormone therapy, or MHT, is designed to circulate through the body and treat symptoms such as hot flushes and night sweats as well as some other menopause symptoms.
Low-dose vaginal oestrogen acts mainly on local vaginal and urinary tissues.
Only a very small amount is absorbed into the bloodstream when standard low-dose vaginal products are used as recommended.
At standard local doses, a progestogen generally isnโt required simply because you have a uterus.
Can you use vaginal oestrogen if you already use MHT?
Yes, sometimes.
Systemic MHT doesnโt always fully relieve GSM. Australasian Menopause Society information notes that some people continue to have vaginal symptoms even while using systemic hormone therapy.
Vaginal oestrogen can sometimes be added specifically to treat those local symptoms.
Your GP or menopause clinician can advise whether that is appropriate for you.
How quickly does vaginal oestrogen work?
It isnโt necessarily instant.
Some people notice improvement fairly quickly, while tissue changes can take several weeks to improve more fully.
Treatment often needs to continue to maintain the benefits because GSM is associated with ongoing lower hormone levels rather than a temporary injury that simply heals and disappears.
What if youโve had breast cancer?
GSM can be particularly troublesome after breast cancer because chemotherapy and hormone-blocking treatments can reduce oestrogen levels substantially.
Moisturisers and lubricants are usually the first options to try.
Pelvic floor physiotherapy and vaginal dilators may also be helpful depending on the symptoms.
If these approaches arenโt enough, low-dose vaginal oestrogen may sometimes be considered after an individual discussion with your GP, oncologist or breast cancer specialist.
This is particularly important for people taking aromatase inhibitors, because these medicines are designed to keep circulating oestrogen very low.
The decision needs to take into account your cancer history, treatment and how much GSM is affecting your quality of life.
Having had breast cancer doesnโt mean severe vaginal or urinary symptoms simply have to be endured.
GSM and the pelvic floor
GSM and pelvic floor problems can occur at the same time, but they arenโt the same thing.
Lower oestrogen affects genital and urinary tissue. Pelvic floor dysfunction involves the muscles and connective tissues that support the pelvic organs and contribute to bladder, bowel and sexual function.
Some people have pelvic floor weakness and leakage.
Others have tight or overactive muscles that make penetration painful.
Some have a mixture of both.
This is why simply doing more Kegel exercises isnโt always the right solution.
A pelvic health physiotherapist can assess whether your pelvic floor needs strengthening, relaxation, coordination work or another approach.
You can use Period Shopโs directory to find a pelvic health physiotherapist.
Our pelvic floor and Kegel guide also explains the basics.
What about vaginal laser and radiofrequency treatments?
Laser and radiofrequency treatments have been marketed for GSM, vaginal dryness, urinary leakage, painful sex and so-called vaginal rejuvenation.
In Australia, the regulatory position has changed significantly.
The Therapeutic Goods Administration reviewed energy-based devices marketed for vaginal rejuvenation and found insufficient clinical evidence to support their therapeutic use and long-term safety.
Following that review, the TGA or device sponsors cancelled the relevant vaginal rejuvenation devices from the Australian Register of Therapeutic Goods.
There are currently no energy-based devices included in the ARTG that are approved for vaginal rejuvenation.
If youโre considering laser or radiofrequency treatment for GSM, discuss the evidence and established treatment alternatives with your healthcare professional first.
What about trans men and people using testosterone?
Some trans men, transmasculine people and non-binary people using testosterone develop genital or vaginal dryness, tissue sensitivity or pain with penetration.
These changes can resemble some of the tissue changes seen in GSM because testosterone can create a lower-oestrogen environment in local genital tissue.
However, testosterone-related menstrual suppression or genital changes arenโt automatically the same as natural menopause or GSM.
Depending on symptoms and preferences, options may include lubricant, moisturiser and sometimes low-dose local oestrogen.
Low-dose local oestrogen has very little systemic absorption and generally isnโt expected to reverse the desired masculinising effects of testosterone.
For more on periods, genital changes, pregnancy risk and menstrual suppression while using testosterone, read our guide to periods, testosterone and transition for trans men and transmasculine people.
When should you see a doctor?
GSM is common, but not every vaginal, vulval or urinary symptom during menopause is caused by GSM.
Itโs worth arranging an assessment if symptoms are new, persistent, worsening or affecting your everyday comfort or quality of life.
See your GP or another appropriate healthcare professional if you have:
- persistent vaginal or vulval pain
- significant or ongoing itching or burning
- painful sex or penetration
- unusual or persistent vaginal discharge
- a strong or unusual odour
- pain or burning when urinating
- blood in your urine
- repeated urinary tract infections
- new vulval skin changes
- a vaginal bulge, heaviness or dragging sensation
What about bleeding?
Bleeding during perimenopause can change as cycles become less predictable, but some bleeding patterns still deserve assessment.
Talk with your GP about bleeding between periods, bleeding after sex or bleeding that is unusually heavy or significantly different from your normal pattern.
Any vaginal bleeding after menopause needs medical assessment, even if it is only light spotting or happens once.
If youโre not sure how to start the conversation, our guide to talking with a doctor about vaginal concerns may help.
Frequently asked questions
What does GSM stand for?
GSM stands for genitourinary syndrome of menopause. It describes vaginal, vulval, sexual and urinary changes associated with declining sex hormone levels around and after menopause.
Is GSM just another name for vaginal atrophy?
GSM replaced older terms such as vaginal atrophy, vulvovaginal atrophy and atrophic vaginitis because those terms focused too narrowly on the vagina. GSM also recognises changes affecting the vulva, urinary tract and sexual function.
Can GSM begin during perimenopause?
Yes. GSM becomes increasingly common after menopause but symptoms such as dryness, irritation and changes in sexual comfort can begin during perimenopause while hormone levels are fluctuating.
Does GSM go away on its own?
It often doesnโt. Unlike hot flushes and night sweats, which commonly become less frequent with time, GSM symptoms may persist or become more noticeable after menopause. Effective treatments are available, so you donโt need to simply wait and hope symptoms disappear.
Is GSM the same as thrush?
No. GSM is caused by hormonal and tissue changes, while thrush is a Candida yeast infection. Both can cause itching or burning, so recurrent symptoms are worth having properly assessed rather than repeatedly treating yourself for thrush.
Can GSM cause recurrent UTIs?
GSM can contribute to recurrent urinary tract infections in some postmenopausal people because lower oestrogen affects vaginal and urinary tissues and the local microbiome. Low-dose vaginal oestrogen may help reduce recurrent UTIs for some people.
Can GSM cause urinary urgency even if I donโt have a UTI?
Yes. GSM can affect the urethra and bladder and may contribute to urgency, frequency or discomfort even when there isnโt an infection. Because urinary symptoms can have several causes, new or persistent symptoms should still be checked.
Do moisturisers treat GSM?
Vaginal moisturisers can improve dryness and comfort and are a useful non-hormonal option, particularly for mild symptoms. They donโt replace the oestrogen lost from the tissue, so some people with persistent GSM find prescription vaginal oestrogen more effective.
Whatโs the difference between vaginal moisturiser and lubricant?
A vaginal moisturiser is used regularly to help with ongoing dryness. Lubricant provides temporary slip during sex or insertion. Many people with GSM use both.
Is vaginal oestrogen safe?
Low-dose vaginal oestrogen has very low systemic absorption and is considered a safe and effective GSM treatment for most people. A progestogen generally isnโt required with standard local doses. People with a history of breast cancer or another hormone-sensitive condition should discuss treatment with their healthcare team.
Can I use vaginal oestrogen if Iโm already using MHT?
Sometimes, yes. Systemic MHT doesnโt resolve GSM for everyone and vaginal oestrogen can sometimes be added to specifically treat persistent local vaginal or urinary symptoms.
Do Kegel exercises treat GSM?
No. Kegel exercises strengthen pelvic floor muscles but donโt reverse the hormone-related tissue changes of GSM. Pelvic floor physiotherapy can still be useful if muscle weakness, tension, pain, bladder leakage or prolapse symptoms are also present.
Does having GSM mean I have to stop having sex?
No. Lubricants, moisturisers, vaginal oestrogen, different sexual activities and pelvic floor treatment can all improve comfort depending on what is contributing. Persistent pain shouldnโt be pushed through, though, and deserves assessment.
Does vaginal laser treat GSM?
Energy-based laser and radiofrequency devices have been marketed for GSM, but the Australian TGA found insufficient evidence to support their therapeutic use and long-term safety for vaginal rejuvenation. There are currently no energy-based devices included in the ARTG for that indication.
GSM is common, but you donโt have to live with it
One of the biggest problems with GSM is that people often donโt talk about it.
Dryness, painful sex, urinary urgency or recurrent UTIs can gradually become something you organise your life around without realising that treatment may make a substantial difference.
There isnโt one right treatment for everybody.
For some people, lubricant or a good vaginal moisturiser is enough. Others find that low-dose vaginal oestrogen transforms their comfort. Pelvic health physiotherapy can make a significant difference when muscle tension, leakage or pain is also part of the picture.
GSM is common, treatable and worth talking about.
Related reading
- Vaginal health in perimenopause: what to expect & what helps
- How to deal with vaginal dryness
- Menopause: symptoms, stages & treatment options
- Painful intercourse: causes, symptoms & treatments
- Choosing the right personal lubricant
- Vaginal discharge: whatโs normal and how it changes
- Light bladder leakage: what you can do
- Periods, testosterone & transition: a guide for trans men & transmasculine people
Sources and further reading
- Australasian Menopause Society: Genitourinary syndrome of menopause
- Australian Government: Menopause treatment options
- healthdirect: Vaginal dryness
- Australasian Menopause Society: Breast cancer and menopause
- Therapeutic Goods Administration: Review of energy-based vaginal rejuvenation devices
This article provides general educational information and isnโt a substitute for individual medical advice.