Genitourinary syndrome of menopause (GSM): symptoms, treatment and support

If you have found your way here, something brought you.

Maybe dryness, soreness or burning that started in perimenopause and has slowly become part of daily life. Maybe sex that used to be easy and is not any more. Maybe a string of UTIs that no one has joined up to your hormones. Maybe a body that feels different in ways you have not quite known what to do with. Maybe years of not raising it with anyone, including your GP.

Whatever brought you here, this is one of the most common, most underreported and usually most treatable parts of menopause. You do not have to live with it.

What is GSM?

Genitourinary syndrome of menopause (GSM) is the current internationally accepted term for the changes that happen in the vagina, vulva, bladder and urethra when oestrogen levels fall in perimenopause and menopause. It replaces older terms you may have heard:

• Vulvovaginal atrophy.
• Atrophic vaginitis.
• Urogenital atrophy.

The new term, adopted in 2014 by the International Society for the Study of Women's Sexual Health and the North American Menopause Society, was introduced for two reasons: the older terms did not capture the urinary symptoms, which are a major part of the picture, and "atrophy" sounded both clinical and demoralising to many women. The 2024 update to UK NICE menopause guidance now also uses this framing.

The symptoms

GSM is a wide spectrum of related symptoms. You may have only some of these; many women and those assigned female at birth have several.

How common is GSM?

GSM is extremely common, and the figures depend on how strictly you define it. Up to 87% of women over 40 are thought to be affected by some form of GSM, with around half of postmenopausal women reporting bothersome symptoms. Despite this:

• Only around 1 in 4 women volunteer GSM symptoms to their healthcare team.
• Only between 4 and 35% of affected women use any treatment.
• Women in the UK are less likely than women in other European countries to seek advice for GSM symptoms.

The British Menopause Society describes GSM as a "silent epidemic": a condition that is common, treatable, and yet routinely undiagnosed and untreated. Part of the reason is embarrassment; part is the assumption that this is just how things are now; part is that many clinicians do not ask.

Why GSM happens

The tissues of the vulva, vagina, urethra and bladder all depend on oestrogen to stay healthy. Specifically, oestrogen:

• Maintains the thickness, elasticity and lubrication of the vaginal walls.
• Keeps the vaginal pH slightly acidic, which protects against infection.
• Supports the lining of the urethra and bladder.
• Maintains healthy blood flow to all of these tissues.

When oestrogen levels fall in perimenopause and menopause, these tissues become thinner, drier, less elastic and more fragile. The pH rises, which makes UTIs more likely. The result is the constellation of symptoms we call GSM.

GSM can also occur in women who are not in natural menopause, including those experiencing surgical menopause, treatment-induced menopause, premature ovarian insufficiency, early menopause, and those on certain breast cancer treatments such as aromatase inhibitors. It can temporarily occur in breastfeeding mothers too, as this may cause lowered oestrogen.

The recurrent UTI connection

This connection is so often missed. Recurrent UTIs in perimenopausal and postmenopausal people are frequently a symptom of GSM rather than a separate problem. The thinning urethral and bladder tissue, and the changed vaginal pH, make UTIs much more likely.

Vaginal oestrogen treats GSM and substantially reduces the frequency of recurrent UTIs, which has a strong evidence base and is one of the most important things many women learn too late. If you have been put on rotating courses of antibiotics for repeated UTIs and vaginal oestrogen has not been discussed, this is a conversation to have with your GP.

The emotional and intimate impact

GSM is not just a physical issue. Many women describe:

• Loss of interest in, or anxiety around, sex.
• A sense of grief for the body and intimacy life they had before.
• Strain in intimate relationships, including unspoken tension and misunderstanding.
• Loss of dignity around urinary symptoms or recurrent UTIs.
• A sense of being old before their time.
• Shame, silence, or the feeling that this is too embarrassing to raise.
• Frustration at not having been told this would happen, or what could help.

None of these are unusual. They are the lived reality of a condition that has been quietly affecting women's bodies, relationships and confidence, often for years. Naming it, and treating it, can change a great deal.

What helps: the treatments

Treatment for GSM is layered, and the right combination depends on the symptoms, severity and your other circumstances. UK guidance includes:

Vaginal oestrogen: what the evidence really shows

Vaginal oestrogen is one of the most consistently misunderstood treatments in women's health. The evidence is now very clear:

• It is highly effective for GSM, including vaginal dryness, painful sex, recurrent UTIs, urinary urgency and frequency.
• It has minimal absorption into the rest of the body. Blood oestrogen levels stay within the postmenopausal range.
• It does not increase the risk of breast cancer at standard doses in current evidence.
• It is generally considered safe for most women with a history of hormone-sensitive cancers, including many breast cancer survivors, though decisions should always be made with your oncology and menopause teams together.
• It can be used long-term, often lifelong, because the symptoms are progressive without treatment.
• It does not require a break, an annual stopping period, or progestogen "opposition" in the way systemic HRT does.

If you have been told vaginal oestrogen is risky, or that you should only use it briefly, this may not reflect current evidence. A BMS-registered menopause specialist can advise.

If you have a history of cancer

GSM after cancer treatment can be particularly difficult and is often overlooked in oncology follow-up:

Whatever your cancer history, GSM is not something you have to live with. Specialist menopause input alongside your oncology team can change this picture significantly.

When to seek help

You do not need to wait for things to be unbearable, and you do not need to wait for sex to be affected. Reasons to reach out include:

• Vaginal dryness, burning, soreness or itching.
• Pain or discomfort during sex.
• Recurrent UTIs.
• Urinary urgency, frequency, or burning when there is not a UTI.
• A feeling that something has changed and you do not know what.
• Difficulty raising it with your GP.
• Worry about HRT in cancer follow-up, where you would benefit from a joint conversation with menopause and oncology teams.

If your GP is not familiar with GSM, you are entitled to ask for a referral to a menopause specialist within the practice or a referral to a BMS-registered specialist.

Trusted UK resources

Frequently asked questions

Is GSM the same as vaginal atrophy?

GSM is the current term for what used to be called vaginal atrophy, vulvovaginal atrophy or urogenital atrophy. It is a wider term that includes the urinary symptoms, such as urgency, frequency and recurrent UTIs, that the older terms did not capture. The condition itself is the same.

Will GSM go away on its own?

No. Unlike hot flushes, which often settle over time, GSM is progressive without treatment. The good news is that it responds very well to treatment, particularly vaginal oestrogen, and treatment can be continued long-term.

Is vaginal oestrogen safe?

For most women, yes. Vaginal oestrogen acts locally on the urogenital tissues, with minimal absorption into the rest of the body. Current evidence does not show an increased risk of breast cancer at standard doses. It is generally considered safe for many women with a history of hormone-sensitive cancers, but in that case the decision is best made with your oncology and menopause teams together.

Can I buy vaginal oestrogen without a prescription in the UK?

Yes. Since 2022, low-dose vaginal oestradiol, sold as Gina, has been available over the counter from UK pharmacies for postmenopausal women aged 50 and over who are at least 12 months past their last period. Other vaginal oestrogen preparations remain prescription only.

Does HRT treat GSM?

Systemic HRT, such as patches, gels or tablets, helps GSM for some women, but often does not fully resolve it. Vaginal oestrogen is frequently added alongside systemic HRT for women who continue to have genitourinary symptoms. The two are different things and can be used together.

Will lubricants and moisturisers be enough?

For mild GSM, yes: regular use of a vaginal moisturiser, not just lubricant for sex, can help significantly. For moderate to severe GSM, or where urinary symptoms are present, vaginal oestrogen or another medical treatment is usually needed alongside, because it treats the underlying tissue changes rather than just adding moisture.

I have not had sex in years. Do I still need to bother with treatment?

Yes. GSM affects urinary health, comfort in daily life, infection risk, and the long-term health of vaginal and urethral tissue, whether or not you are sexually active. Treatment is about your body, not just about sex.

Take what is useful. Leave what is not. Go gently with yourself. GSM is common, real, and very treatable. You do not have to live with it.