Ryan Stewart, DO
Board-certified and fellowship-trained urogynecologist
Green Bay, Wisconsin
✓ Medically reviewed September 9, 2026
No financial ties to any device or drug maker

Genitourinary syndrome of menopause

If your vaginal or bladder symptoms started or got worse around menopause, there is a name for it: genitourinary syndrome of menopause, or GSM. It used to be called vaginal atrophy, but that term only described part of the problem. GSM affects the urinary tract as well as the vagina, and it is common, showing up in somewhere between a quarter and more than three-quarters of postmenopausal women depending on how it is measured.

Why it happens

Your vagina, urethra, and the base of your bladder are all rich in estrogen receptors. Estrogen keeps those tissues thick, elastic, and well supplied with blood. When estrogen falls during perimenopause and menopause, the tissues thin out, lose elasticity, and become more fragile and easily irritated.

Because the same hormone change affects both the vaginal and urinary tissues, the symptoms cluster together.

Symptoms

GSM usually shows up as some mix of:

Vaginal dryness, burning, or irritation
Pain or discomfort with sex
Urinary urgency and frequency
Recurrent urinary tract infections
New or worsening stress incontinence

Unlike hot flashes, these symptoms do not tend to improve on their own. GSM is a chronic condition, and it gets worse over time without treatment.

How I diagnose it

GSM is a clinical diagnosis. I make it based on your symptoms and a pelvic exam, where I look for the tissue thinning, loss of elasticity, and paleness that come with low estrogen. No blood test or biopsy is needed. If your main problem is recurrent urinary tract infections, I confirm those with urine cultures, because many women referred for recurrent UTIs turn out not to have culture-proven infections.

Treatment options

There is no single right answer, and I work through the options with each patient based on how bothersome the symptoms are and what fits their preferences.

Over-the-counter moisturizers and lubricants: for milder symptoms, regular vaginal moisturizers and lubricants for sex are a reasonable first step and can be used alongside anything else.
Vaginal estrogen: low-dose cream, ring, or tablet applied locally. This is the most effective and best-studied treatment for GSM. It restores tissue health without meaningfully raising the estrogen level in your blood, and improvement usually begins within one to two months. All the formulations work about equally well; the ring is replaced every three months and tends to have the best adherence.
Vaginal DHEA and ospemifene: a vaginal DHEA insert and the oral medication ospemifene are effective alternatives for women who prefer them or do not do well on estrogen.
What I do not recommend: vaginal laser and radiofrequency (“energy-based”) treatments are marketed heavily for GSM, but the current evidence does not support them, so I do not offer them for this purpose.

Vaginal estrogen is a large enough topic that I keep a separate set of pages on how it works, how to use it, and its safety:

A note on breast cancer

Many women are told to avoid all estrogen after a breast cancer diagnosis. Low-dose vaginal estrogen is a more nuanced decision than that. The evidence supports its use in breast cancer survivors when the symptoms warrant it and the decision is made together with your oncologist. I cover this in detail on a separate page.

When to see me

Consider an appointment if you have:

Vaginal dryness, irritation, or pain with sex that started around or after menopause
New or worsening urinary urgency, frequency, or leaking
Three or more urinary tract infections in a year
Symptoms that have not improved with moisturizers or lubricants

Learn about bladder problems during menopause

References

Kaufman MR, Ackerman AL, Amin KA, et al. Genitourinary syndrome of menopause: AUA/SUFU/AUGS guideline. American Urological Association. 2025.
Faubion SS, Kingsberg SA, Clark AL, et al. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020. doi:10.1097/GME.0000000000001609
Rahn DD, Carberry C, Sanses TV, et al. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstetrics & Gynecology. 2014. doi:10.1097/AOG.0000000000000526
Mitchell CM, Reed SD, Diem S, et al. Efficacy of vaginal estradiol or vaginal moisturizer vs placebo for treating postmenopausal vulvovaginal symptoms: a randomized clinical trial. JAMA Internal Medicine. 2018. doi:10.1001/jamainternmed.2018.0116

Frequently Asked Questions

What is genitourinary syndrome of menopause?

Genitourinary syndrome of menopause (GSM) is the group of vaginal and urinary changes that follow the drop in estrogen after menopause. It was previously called vaginal atrophy or atrophic vaginitis. Symptoms include vaginal dryness and irritation, pain with sex, and urinary urgency, frequency, or recurrent urinary tract infections.

Is GSM the same as vaginal atrophy?

GSM is the current name for what used to be called vaginal atrophy or atrophic vaginitis. The name changed because the condition affects the urinary tract as well as the vagina, so the older term only described part of it.

Does GSM go away on its own?

No. Unlike hot flashes, which often fade over time, GSM is chronic and tends to get worse without treatment because the underlying cause, low estrogen, does not reverse on its own. The good news is that treatment works well, and symptoms usually improve within a few months of starting vaginal estrogen.

What is the best treatment for GSM?

Low-dose vaginal estrogen is the most effective and best-studied option. Vaginal DHEA and the oral medication ospemifene are alternatives. Laser and radiofrequency devices are not currently supported by the evidence.