Genitourinary syndrome of menopause (GSM) affects approximately half of postmenopausal individuals, yet it’s often underdiagnosed. Introduced in 2014 to widen the narrower term vulvovaginal atrophy (VVA), the term GSM encompasses a range of vaginal, vulvar, and lower urinary tract symptoms, including VVA. These symptoms can range from mild discomfort and dryness to severe pain and recurrent infections. Fortunately, effective treatments are available to restore tissue health and relieve discomfort.

Read on as we cover what you need to know about GSM and its treatment options, including nonhormonal methods and hormone replacement therapy (HRT).

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Understanding GSM

GSM represents a collection of genital, sexual, and urinary symptoms including dryness and pain. These issues present in the lower genitourinary tract, which includes the:

• Labia 
• Clitoris
• Vaginal opening (introitus)
• Vagina
• Urethra
• Bladder

The role of estrogen in GSM

GSM largely stems from an estrogen deficiency in menopause, which can cause genitourinary tissues to become fragile, thinner, and less elastic. However, the exact impact varies depending on the area.

Estrogen acts on specific receptors found in the tissues of the lower genitourinary tract. It stimulates the production of collagen and elastin in the tissues, maintaining flexibility and thickness of the vaginal walls. It also promotes healthy blood flow to the region, which keeps the tissues capable of natural lubrication and helps maintain blood supply to the urethra for normal bladder control. 

Estrogen also stimulates the production of sugar (glycogen) your body keeps in reserve for energy. This glycogen feeds beneficial bacteria in your genitourinary tract, which produces lactic acid, keeping your vaginal pH acidic to lower your risk of urinary tract infections (UTIs). 

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Identifying GSM symptoms across 3 categories

In 2025, several major urology, pelvic medicine, and urogynecologic organizations published a comprehensive GSM guideline. The guideline covers how clinicians evaluate and treat patients presenting with signs and symptoms of GSM. 

Key parts of the equation include assessing symptoms and performing a physical examination. Your doctor will rule out any potential alternative causes of these symptoms. However, there isn’t a consensus on the number or type of symptoms required for a GSM diagnosis.

Doctors evaluate these three symptom categories:

GSM treatments

Your doctor will help you find the right treatment path for your body. Here are some options they might discuss with you.

Nonhormonal treatments

Many patients with GSM try over-the-counter, nonhormonal products before progressing to prescription interventions. Nonhormonal treatments may provide sufficient relief for those with mild symptoms. These can include:

• Vaginal lubricants: Water, oil, or silicone-based products may relieve friction during intercourse.
• Vaginal moisturizers (Replens®, Revaree®): Gels or creams containing moisturizing ingredients like natural polymer adhesives (bioadhesive polymers) or hyaluronic acid may relieve vaginal dryness and related symptoms.
• Vaginal dilators: Physical inserts increase in size to stretch the vagina to improve comfort during sex.
• Pelvic floor muscle therapy: Targeted exercises and movements like kegels and pelvic tilts as well as manual massage and bladder retraining can improve bladder control and reduce pelvic pain.
• Irritant avoidance: Products like scented soaps and flavored or warming lubricants can exacerbate GSM symptoms like burning and irritation. Your care team will let you know exactly what to look out for. 

HRT

According to The Menopause Society, HRT is the most effective treatment for GSM. It works by supplementing the hormones that decline during menopause, including estrogen. There are different types of HRT, and they’re categorized by how widely they travel through the body.

Local HRT

Local HRT delivers a low dose of hormones directly to the affected tissues of the lower genitourinary tract. The medication’s effects are largely limited to this area, carrying minimal impact on the wider body and bloodstream. This approach treats isolated symptoms like vaginal dryness, irritation, or pain during intercourse without exposing the rest of the body to higher hormone levels. Common examples include vaginal estrogen creams like Premarin® and Estrace®, tablets and inserts like Vagifem® and Imvexxy®, and a vaginal ring like Estring®.

Prasterone (DHEA)

Prasterone is a non-estrogen local therapy delivered via a daily vaginal insert. It contains dehydroepiandrosterone (DHEA), a natural steroid your body uses as a building block to make sex hormones like estrogen and testosterone. Once applied, local vaginal cells convert DHEA into both active estrogens and androgens (testosterone) as needed. This can help build tissue thickness and elasticity without direct hormone administration. Intrarosa® is currently the only FDA-approved prescription DHEA.

Systemic HRT

Systemic HRT absorbs into the bloodstream to circulate throughout the entire body. Doctors may consider systemic HRT if you’re experiencing whole-body menopause symptoms alongside GSM, such as frequent hot flashes, night sweats, or early bone loss (osteoporosis). Oral tablets and transdermal patches are two main types. Oral medications include options like Premarin® and Estrace®, and transdermal patches include Vivelle-Dot® and Dotti®.

While estrogen is the active hormone treating GSM, doctors recommend adding a progestogen to treatment if you have a uterus. Taking systemic estrogen alone thickens the uterine lining, which increases the risk of endometrial cancer. Progestogens protect the uterus by keeping the lining thin and stable. A transdermal patch like the Combipatch® contains estradiol and norethindrone. The oral medication Prempro® contains conjugated estrogens and medroxyprogesterone acetate, while Activella® contains estradiol and norethindrone acetate.

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Medical treatments beyond HRT

Your doctor may consider treatment options other than HRT, such as:

• Ospemifene (Osphena®): This prescription oral tablet is classified as a selective estrogen receptor modulator (SERM). Rather than introducing hormones directly, it acts like estrogen in specific tissues, stimulating the cellular lining of the vagina to relieve moderate-to-severe dyspareunia and vaginal dryness.
• Vaginal laser therapy: Energy-based therapies include fractional micro-ablative CO₂ lasers and erbium YAG lasers. The process involves inserting a small probe into the vagina to deliver controlled heat to the tissues. Heat stimulates a micro-injury healing response, which may promote collagen production, increase blood supply, and improve tissue elasticity. However, the FDA is still evaluating long-term safety and efficacy of this treatment for GSM specifically.

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Can GSM start before menopause?

GSM can occur at any stage in the menopause transition, though it’s more common postmenopause. An article in StatPearls notes that roughly 15% of individuals experience symptoms of vaginal atrophy before menopause, while approximately 55% of postmenopausal individuals report bothersome symptoms. 

Postmenopausal women experience a sustained 95% reduction in estrogen production when left untreated. Symptoms tend to become more pronounced as estrogen levels remain consistently low.

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Navigating GSM with Maven Clinic

At Maven Clinic, we place a team of specialists in your corner, including OB/GYNs, urogynecologists, and menopause specialists to address your unique GSM experience. We take a personalized, whole-person approach to GSM care, building treatment plans that address everything from localized tissue thinning to UTIs.

Like our patient, Debbie, expressed: "What stood out immediately was how understood I felt.

The providers didn't dismiss my symptoms. They helped me make sense of the changes happening in my body and gave me practical, personalized support."

Discover our approach to hormone care.

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