Genitourinary syndrome of menopause

What it is

The vulva, vagina, urethra and bladder are rich in estrogen receptors. After menopause, tissues become thinner, drier and less elastic, the vaginal pH rises and protective lactobacilli decline. Unlike hot flashes, GSM tends to worsen over time without treatment.

Symptoms

• Dryness, burning or irritation

• Pain or bleeding with sex

• Urinary urgency and frequency

• Recurrent urinary tract infections

How it's diagnosed

Your history and a gentle exam usually make the diagnosis. Clinicians also look for infections, lichen sclerosus and other skin conditions that can look similar.

Treatment

Start with regular vaginal moisturizers and a lubricant for sex. Low-dose vaginal estrogen (cream, tablet, insert or ring) is highly effective with minimal absorption into the bloodstream, and it lowers the risk of recurrent UTIs. Other options are vaginal DHEA (prasterone) and oral ospemifene. Pelvic floor physical therapy helps when pain and muscle guarding persist.

Clinical pearls

• Vaginal estrogen can be used long term; symptoms return when it stops.

• The AUA recommends vaginal estrogen for peri- and postmenopausal women with recurrent UTIs.

• Breast cancer survivors can often use non-hormonal options first and discuss vaginal estrogen with their oncologist.