Genitourinary Syndrome

In 2014, the term Genitourinary Syndrome of Menopause (GSM) was introduced to replace older terms like vulvovaginal atrophy and atrophic vaginitis. The word “atrophy” suggests a “wasting away,” which can be concerning when it comes to parts of the body like the vulva, vagina, and bladder.

This term was adopted to emphasise the presence of oestrogen receptors in the genitourinary system, which includes the vagina, vulva, bladder, and pelvic floor. In simple terms, as oestrogen levels decline during perimenopause and remain low in menopause, these areas undergo changes that can lead to various symptoms.

When oestrogen is lacking, several changes take place:

  • Loss of fat from the outer labia (labia majora).
  • Dryness in vulva and vaginal tissues (mucosa), resulting in reduced lubrication.
  • Decreased elastin and collagen, causing the vagina to lose its natural folds and increasing the risk of pelvic organ prolapse.
  • Shrinkage of vulva tissues, leaving the urethra (the entrance to the bladder) more exposed and susceptible to urinary tract infections.
  • The vulva and vagina may become pale, and the tissues can tear more easily.

What are the Symptoms & Effects?

As with all aspects of menopause, symptoms can vary from one woman to another. Common symptoms include:

  • Vaginal dryness, often leading to difficulty with tampon insertion.
  • Vulvar irritation or burning, prompting changes in underwear to avoid discomfort.
  • Painful intercourse due to reduced lubrication and loss of elasticity.
  • Reduced arousal, possibly linked to changes in clitoral sensitivity.
  • Increased frequency of urination, including night time awakenings.
  • Stress incontinence (urine leakage with coughing or sneezing) and urgency incontinence (sudden urge to urinate).
The lack of lubrication, arousal, and painful intercourse can result in reduced sexual activity, less satisfying sex, and avoidance of intimacy due to fear of discomfort. This can strain relationships, as partners may misinterpret these symptoms as a lack of attraction or interest. Many women mistakenly believe these symptoms are a natural part of aging. Approximately 70% of women experience these symptoms, yet only a minority receive proper treatment.

What treatments are available? What can I do to improve my symptoms?

  • Stay well-hydrated. Aim to urinate every 3-4 hours, with pale yellow urine as a goal.
  • Limit caffeine and alcohol intake, as they can exacerbate bladder issues.
  • Prevent constipation, as straining during bowel movements can weaken the pelvic floor.
  • Quit smoking, as it increases the risk of bladder problems.
  • Urinate after sexual activity to flush out bacteria.
  • Wipe from front to back after using the toilet to prevent bacterial transfer.
  • Take time to sit comfortably and allow your bladder to fully empty.
  • Exercise regularly to maintain a healthy weight, reduce constipation, and prevent bladder problems.
  • Do pelvic floor exercises, which can be aided by the NHS Squeezy App.
  • Learn relaxation techniques to ensure proper bowel and bladder emptying.
  • Avoid using harsh products like soap, bubble bath, fragrances, or antiseptics, as they can irritate sensitive vulvar tissues.
  • Use emulsifying ointment as a soap substitute.
  • Don’t over wash, once daily is usually sufficient.
  • Wash with your hands, avoiding abrasive flannels.
  • Gently pat dry with a soft towel, rather than rubbing.
  • Apply an unscented moisturizer to the vulva after washing and a vaginal moisturizer like Yes VM or Sylk Natural Intimate Moisturiser to protect vaginal pH and moisture balance. Vaginal moisturizers can be used every 2-3 days or more frequently if needed.
  • Use a lubricant like Sylk during sex to ease discomfort. Yes lubricants (water-based Yes WB and oil-based Yes OB) are recommended and can be used together.

Local oestrogen therapy in the vagina effectively alleviates GSM symptoms, usually within about 3 months. This treatment can be prescribed by your doctor and is generally safe for long-term use. If discontinued, symptoms often return. Two types of oestrogen, estradiol and estriol, are available in various forms: tablet, pessary, cream, gel, or ring.  Further guidance for health professionals can be found here.

BMS guidance recommends DHEA (i.e. Intrarosa (prasterone 6.5mg)) after failure of first line vaginal oestrogen’s.  The mechanism of action of Intrarosa (prasterone 6.5mg) in delivering both androgenic and oestrogenic effects, is likely to benefit women dissatisfied with oestrogen only VVA treatment, providing a much-needed alternative treatment option to restore their urogenital tissue quality, relieve symptoms, and improve quality of life.

CO2 or laser therapy is a newer treatment option for GSM. It may be beneficial for women who haven’t responded well to other treatments or when contraindications exist. While early studies show improvement, long-term safety and effectiveness data are pending. Note that this treatment is not available through the NHS. 

What should I do if symptoms persist?

Since women respond differently to oestrogen preparations, it’s crucial to make an individualised choice with your healthcare professional’s guidance. If symptoms persist after using prescribed medication for 3 months, seek a medical evaluation. Other conditions may affect the vulva and vagina, requiring alternative treatments. Always discuss unexpected vaginal bleeding with your doctor.

Self-awareness and self-examination is very important. We highly recommend these resources on self-examination.  There can be similar symptoms in Lichen Sclerosus that can often be under managed and misdiagnosed.