Dr Philippa Vincent

Medscape

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Understanding Genitourinary Syndrome of the Menopause (GSM): Recognition, Assessment, and Management

“Genitourinary Syndrome of the Menopause (GSM) is a condition that affects up to 80% of postmenopausal women, leading to significant discomfort and a decline in quality of life. Previously referred to as atrophic vaginitis or vulvovaginal atrophy, GSM encompasses a broader range of symptoms, including vaginal dryness, urinary urgency, and pain during sex.

GSM results from Oestrogen deficiency, which affects tissues in the vagina, urethra, bladder, and pelvic floor.

Symptoms can include:

Vaginal dryness, itching, or burning

Pain or discomfort during sex

Urinary urgency and frequency

Recurrent urinary tract infections (UTIs)

Vulval soreness

Changes in vaginal discharge

Unlike other menopausal symptoms that may improve over time, GSM tends to worsen with age. Additionally, GSM can mimic other conditions such as UTIs, lichen sclerosus, and vulvovaginal candidiasis, making accurate diagnosis essential.

Assessment and Diagnosis

A thorough history and physical examination are crucial in diagnosing GSM. While some women exhibit visible signs such as vaginal atrophy, thinning of vaginal tissue, and inflammation, others may have a normal exam despite experiencing symptoms. In select cases, further investigations like vaginal pH testing or direct-access (trans vaginal) ultrasound scans may be necessary to rule out malignancies.

Management of GSM

Early treatment is essential to prevent irreversible tissue changes and improve symptoms. Management strategies include hormonal and nonhormonal options, as well as lifestyle modifications.

Hormonal Treatments

Vaginal Oestrogen – Available as creams, gels, pessaries, or rings, vaginal Oestrogen is highly effective for GSM symptoms and can be used long-term without requiring progestogen supplementation.

Systemic Hormone Replacement Therapy (HRT) – While systemic HRT is not the primary treatment for GSM, it may be beneficial in some women who also experience other menopausal symptoms.

Vaginal Dehydroepiandrosterone (DHEA) – A newer option that converts to androgens and Oestrogens locally, showing promise for symptom relief.

Ospemifene – An oral selective Oestrogen receptor modulator (SERM) approved for women who cannot use local Oestrogen.

Nonhormonal Treatments

For women who cannot or prefer not to use hormonal therapies, the following options are available:

Vaginal moisturizers – Provide long-lasting hydration and balance vaginal pH, used at least twice weekly.

Vaginal lubricants – Reduce discomfort during sexual activity, available in water-, oil-, silicone-, or plant-based formulations. Although saliva can work well for women who wish not to use vaginal lubricants.

Carbon Dioxide Laser Therapy – An emerging nonhormonal treatment that increases vaginal blood supply and tissue thickness, though more research is needed.

Lifestyle Modifications

Regular sexual activity – Helps maintain vaginal elasticity and blood flow.

Pelvic floor exercises – Strengthen pelvic muscles and improve urinary symptoms.

Smoking cessation – Smoking worsens GSM by reducing Oestrogen levels.

Regular physical activity – Linked to a lower prevalence of GSM symptoms.

BMS states: ‘A sedentary lifestyle has been observed to be associated with an increase in prevalence of GSM. 

Special Considerations: GSM in Breast Cancer Patients

Women with breast cancer, particularly those on aromatase inhibitors, should use vaginal moisturizers and lubricants as first-line treatments. Vaginal Oestrogen should only be considered under specialist guidance. Ospemifene and DHEA require further study in this population.

Conclusion

GSM is a common yet underdiagnosed condition that significantly impacts postmenopausal women. Early recognition and treatment can greatly improve quality of life. Whether through hormonal, nonhormonal, or lifestyle interventions, managing GSM effectively requires a personalized approach tailored to each woman’s needs.”

 

 

Dr Philippa Vincent Explains the Role of Primary Care in Recognising and Managing Genitourinary Syndrome of the Menopause, With Reference to PCWHF and BMS Guidance

 Genitourinary syndrome of the menopause (GSM) was previously known as atrophic vaginitis or vulvovaginal atrophy, but neither of these terms adequately encompasses all of the symptoms that can arise during the menopause. In 2014, the term GSM was proposed; it is considered to be a more accurate term as it also takes into account urinary symptoms, which are common in postmenopausal women.

GSM develops as a result of oestrogen deficiency, which is most commonly associated with the menopause. Oestrogen receptors are present in the vagina, urethra, bladder, and pelvic floor, so oestrogen deficiency impacts normal function in these areas. However, the sexual and urinary consequences of oestrogen deficiency may be difficult or embarrassing for patients to raise with their GPs, leading to underdiagnosis and undertreatment of GSM and unnecessary suffering for many people with the condition.

This article discusses the prevalence, symptoms, differential diagnoses, and management of GSM with reference to updated guidance from the Primary Care Women’s Health Forum (PCWHF) and the British Menopause Society (BMS). It highlights the condition’s effects on postmenopausal women and outlines hormonal, nonhormonal, and lifestyle interventions to improve quality of life.

Prevalence

The exact prevalence of GSM is unclear, but evidence suggests that it affects up to 80% of postmenopausal women. Although other menopausal symptoms tend to improve over time, GSM is a chronic, progressive condition that often worsens with age.

GSM is most likely to be present in postmenopausal women, but it can also arise in younger women. Around 12.5% of pre- or perimenopausal women are thought to be impacted by GSM.1

GSM may arise in younger women who have undergone surgical menopause following bilateral oophorectomy, have primary ovarian insufficiency, have undergone chemotherapy, or are breastfeeding. In particular, breast cancer survivors are at increased risk as a result of treatments that contribute to the early onset of GSM symptoms.

Symptoms

GSM encompasses a wide variety of symptoms, including:

  • urinary frequency
  • urinary urgency
  • recurrent urinary tract infections (UTIs)
  • vaginal dryness, itching, or burning
  • decreased pleasure, or pain, during sex
  • vulval soreness at other times, including while sitting, walking, or cycling
  • increased or decreased vaginal discharge.

GSM is under-reported, and primary care clinicians have a role to play in encouraging patients to discuss their symptoms through sensitive enquiries.

Examination and Investigations

Examination is essential to rule out differential diagnoses; however, a normal examination does not rule out GSM. GSM findings on examination can include:

  • atrophy of the vagina or vulva
  • paleness of the vaginal epithelium due to reduced blood supply
  • petechial haemorrhages
  • thinning of the vaginal epithelium, with loss of the ridges and elasticity usually present
  • shortening of the vagina
  • increased vaginal discharge
  • inflammation around the introitus
  • prominence or prolapse of the urethra, or a urethral caruncle
  • adhesions and stenosis.

Investigations are not usually required.  If a woman’s cervical smear is overdue, then this should be performed. If it is not possible to do so because of pain or discomfort, even with extra lubrication, topical oestrogen should be prescribed for a few months to enable the smear to be done at a later date.

For women aged 55 years and over with unexplained symptoms of vaginal discharge, the PCWHF and NICE recommend consideration of a direct-access ultrasound scan for endometrial cancer.

 Differential Diagnoses

GSM can imitate, predispose patients to, and coexist with, a range of conditions, in some cases delaying diagnosis and treatment.

The differential diagnoses of GSM include the following:

  • Allergic conditions
    • Contact dermatitis
    • Desquamative inflammatory vaginitis
  • Inflammatory conditions
    • Lichen sclerosus
    • Erosive lichen planus
    • Cicatricial pemphigoid
  • Infections
    • Vulvovaginal candidiasis
    • Bacterial vaginosis
    • Trichomoniasis
    • Herpes simplex virus
    • Chlamydia
    • Gonorrhoea
    • Urinary tract infection
  • Trauma
  • Foreign bodies
  • Malignancy
  • Vulvodynia
  • Vestibulodynia
  • Chronic pelvic pain
  • Provoked pelvic floor hypertonia (previously called vaginismus)
  • Other medical conditions
    • Diabetes
    • Lupus erythematosus
    • Crohn’s disease
  • Psychological disorders.

Urinary Conditions

The incidence of UTIs increases around the menopause, and they are common in women aged over 65 years. Women with GSM are more likely to experience UTIs; however, they are also more likely to experience symptoms of frequency, urgency, or discomfort with no bacterial growth. The PCWHF recommends urine dipstick testing and microscopy for women who present with urinary symptoms. The BMS agrees, stating: ‘Urinalysis is important and depending on the results, a midstream sample should be sent to microbiology for microscopy and culture. If negative, clinicians should not prescribe antibiotics and should instead treat the underlying GSM; even if the results are positive and confirm recurrent UTIs, the underlying GSM should still be treated in order to reduce the risk of future UTIs.

Urinary symptoms can also lead to the misdiagnosis of GSM as overactive bladder, although the two conditions can coexist.

Vulvovaginal Candidiasis

Vulvovaginal candidiasis (thrush) is also a differential diagnosis of GSM, but thrush is not common in postmenopausal women. Primary care practitioners should examine the woman and take swabs; if a postmenopausal woman does have thrush, then her glycated haemoglobin (HbA1c) level should be checked, as diabetes is the most common underlying predisposing factor for thrush in this age group.

Lichen Sclerosus

Vulvar lichen sclerosus (VLS) is estimated to develop in 0.1–3.0% of postmenopausal women, and most commonly presents between the ages of 52 and 60 years. It is a chronic, progressive inflammatory disease, with similar symptoms to GSM, and appears as flat white patches, often in a characteristic ‘figure-of-eight’ pattern.

It is important to examine and diagnose lichen sclerosus: women with VLS have an estimated lifetime risk of squamous cell carcinoma of 2–5%, and there is a background of VLS in up to 65% of vulvar carcinomas. Treatment for 3 months with a high potency topical corticosteroid is recommended, and referral to a gynaecologist is essential.

Vulvar Intraepithelial Neoplasia

There are two different types of vulvar intraepithelial neoplasia (VIN): usual-type VIN (uVIN), and the less common differentiated-type VIN (dVIN). The latter is usually found in postmenopausal women and is associated with chronic inflammation, typically lichen sclerosus.

VIN typically involves multifocal lesions, which are usually white and raised but can also be flat and red, grey, or pigmented. Referral to a gynaecologist for early excision is essential. Recurrence is common, and dVIN is associated with squamous cell carcinoma.

Other Dermatological Conditions

Dermatological conditions, such as eczema or psoriasis, can also affect the vulva. In addition, dermatitis herpetiformis (DH) can affect the vulva, although it is not common. A coeliac screen is required if a rash is suggestive of DH.

Management

Management of GSM aims to ameliorate symptoms and repair urogenital tissues and can significantly improve a woman’s quality of life. Treatment should be started early to avoid irreversible damage. Treatment options for GSM include:

  • hormonal interventions
  • nonhormonal interventions
  • lifestyle modifications
  • a combination of the above.
  • These options and the evidence supporting their use are discussed in more detail in the following sections.
  • Hormonal Treatments
  • Vaginal Oestrogen
  • Vaginal oestrogen can improve urinary symptoms but may take a few months to start working and symptoms will likely recur if treatment is stopped.Both NICE and the NHS state that vaginal oestrogen can be used for as long as needed to relieve symptoms.
  • Vaginal oestrogen is available as creams, gels, pessaries, or vaginal rings. Creams, gels, and pessaries should be used daily for 2 or 3 weeks depending on the product and then twice weekly thereafter. Vaginal rings should be used for 3 months and then replaced.
  • A year’s supply of vaginal oestrogen is equivalent to one 1-mg tablet of oral hormone-replacement therapy (HRT). Hence, women do notneed any investigations for endometrial thickening or to take progestogens, even when using vaginal oestrogen for many years, and vaginal oestrogen can be used alongside systemic HRT. Absolute contraindications to the use of vaginal oestrogen are undiagnosed vaginal or uterine bleeding (see also the section Women with Breast Cancer, below).
  • Vaginal oestrogen should be considered alongside other treatments for prolapse; it has been shown to reduce local pressure from rings or pessaries and alleviate symptoms of pressure from the prolapse. Vaginal oestrogen should also be considered in combination with anticholinergic drugs for women with overactive bladder.
  • Systemic HRT
  • Systemic HRT is not recommended for women who are experiencing GSM in the absence of other troublesome menopausal symptoms. Systemic HRT does not resolve GSM in all women, and 10–25% will also need vaginal oestrogen.
  • Vaginal Dehydroepiandrosterone
  • Vaginal dehydroepiandrosterone (DHEA) is licensed for use in the UK for vulvovaginal atrophy. It is delivered vaginally in the form of a daily 6.5-mg pessary, where it is converted to androgens and oestrogens in the vagina. Use of systemic HRT does not contraindicate use of vaginal DHEA for GSM.
  • Initial studies observed a reduction in dyspareunia, but the evidence of benefit over placebo was unconvincing. However, a systematic review conducted in 2024 identified a statistically significant benefit of vaginal DHEA compared with vaginal oestrogen for vulvovaginal dryness and dyspareunia.
  • Ospemifene
  • Ospemifene is an oral selective oestrogen receptor modulator (SERM). It is licensed for use in the UK in postmenopausal women with moderate-to-severe symptomatic GSM who are not candidates for local oestrogen therapy. The recommended dose is one 60-mg tablet once daily with food, to be taken at the same time every day. Ospemifene represents an alternative treatment option for women who are ineligible for vaginal oestrogen or who prefer oral treatment. As a SERM, ospemifene is oestrogenic in some tissues (particularly urogenital tissues) and anti-oestrogenic in others. Its side effects include hot flushes. It is not advisable to use it alongside HRT.
  • Trial evidence suggests that ospemifene is effective for dyspareunia and other localised symptoms of GSM. Studies have also shown that ospemifene is well tolerated, and that patients are more likely to continue it compared with vaginal treatments. There is some evidence of improved bone health and reduced overactive bladder symptoms. However, evidence for its long-term use is lacking, and ospemifene has not been trialled against vaginal oestrogen, only placebo, so it is difficult to assess its relative benefits.
  • Nonhormonal Treatments
  • Vaginal Moisturisers
  • Vaginal moisturisers are bioadhesive and attach to the vaginal wall where they retain water and balance vaginal phatagin moisturisers are suitable for long-term, regular use—at least twice weekly, irrespective of sexual activity.They can be used in combination with, but ideally at a different time to, vaginal oestrogen. They are a first-line treatment option for women in whom oestrogen is contraindicated. Both prescription and over-the-counter products are available.

Vaginal Lubricants

A variety of vaginal lubricants are available that can be applied to the vulva, vagina, and to a partner’s penis if required. Used for the short-term relief of vaginal dryness and to reduce friction and discomfort during sex, vaginal lubricants can be water, oil, silicone, or plant based. Use of oil-based lubricants should be avoided with condoms if these are being used as contraception. Vaginal lubricants can be used in combination with vaginal oestrogen, are available both on prescription and over the counter, and are a first-line recommended treatment for women in whom oestrogen is contraindicated.

The BMS notes that it may be useful to combine water- and oil-based lubricants to achieve a ‘double-glide’ effect.

Laser Therapy 

Carbon dioxide laser treatment is an alternative treatment option for women in whom other treatment options are contraindicated, inconvenient, or ineffective, and has been shown to increase the vascularity of the vagina and thickness of the vaginal stratified squamous epithelium. However, laser therapy for GSM is not currently available as a treatment on the NHS, and the BMS states that although cardon dioxide laser treatment ‘may be a valuable, non-hormonal method of treating [GSM], better quality evidence is required from randomized controlled trials.’

Lifestyle Modifications

The PCWHF advises that the following lifestyle changes can help to reduce symptoms of GSM:

  • stopping smoking
  • regular exercise
  • regular sexual activity
  • pelvic floor exercises.

In addition, the BMS states: ‘A sedentary lifestyle has been observed to be associated with an increase in prevalence of [GSM].

Women With Breast Cancer

Women with breast cancer, particularly those taking aromatase inhibitors, are advised to use vaginal moisturisers and lubricants as first-line treatments for GSM. If these are not sufficiently successful, vaginal oestrogen can be considered; however, women on aromatase inhibitors should avoid even low-dose vaginal oestrogen, and prescription should only take place following discussion between the patient, her primary healthcare team, and the breast specialist team.

DHEA has not been studied in women with active or past breast cancer and use in this population is contraindicated, although it may be considered on an individual basis following a discussion with the breast specialist team.

Studies suggest that ospemifene is safe for use in women with a history of breast cancer, but there are no data on its use in women with current breast cancer.