What is genitourinary syndrome of menopause (SGS)?


Menopausal genitourinary syndrome (SGS) is a chronic disease that can affect the genitals and urinary tract in women. It usually results from hormonal changes during menopause, although there can be other causes.

Earlier names for GSM were vulvovaginal atrophy, atrophic vaginitis, and urogenital atrophy. But in 2014, the International Society for the Study of Women’s Sexual Health and the North American Menopause Society renamed the disease to better reflect the spectrum of its symptoms.

GSM can have a significant effect on quality of life, but due to a lack of awareness and screening, the syndrome is often underdiagnosed. However, several effective treatments exist.

This article explores the symptoms, causes, treatments for GSM, as well as associated conditions.

Hormonal changes cause GSM. Levels of female sex hormones drop before menopause, a period called perimenopause, which can affect the genitals and urinary tract.

For example, the hormone estrogen helps lubricate the vagina, and reduced levels of estrogen can cause the vagina to dry, itch, and tighten.

After menopause, estrogen levels remain very low. GSM affects 27 to 84% people who have experienced natural menopause.

GSM can also occur for other reasons, such as:

  • primary ovarian failure, which causes the ovaries to stop working as they normally do before the age of 40
  • surgically induced menopause, which involves removing the ovaries during a procedure known as an oophorectomy
  • hormonal imbalances related to postpartum and breastfeeding
  • treatment for cancer, which can affect the function of the ovaries or cause sudden hormonal changes
  • medicines, such as gonadotropin releasing hormone agonists or aromatase inhibitors

According to a 2019 review, the majority of women with GSM report symptoms during perimenopause and the early postmenopausal period. Vaginal dryness is one of the most common symptoms, and others include:

  • vaginal burning
  • vaginal itching or irritation
  • reduced vaginal lubrication
  • decreased elasticity of the vagina
  • impaired sexual function
  • pain during sex with penetration
  • pain during urination
  • greater sense of urgency and frequency of urination
  • increased risk of vaginal, urinary tract and bladder infections

A person does not need to have all of these symptoms to meet the criteria for a GSM diagnosis.

A doctor first has a conversation with a person about their symptoms and medical history. Then they can do a pelvic exam.

The doctor may also order lab tests to assess vaginal pH, which tells them how acidic the vagina is, or to assess vaginal maturation.

The Vaginal Maturation Index is a way to measure how estrogen levels affect the vagina, based on the idea that estrogen helps cells in the area mature completely. If there is a high number of immature cells, it may indicate that there is not enough estrogen in the vagina.

There is no permanent cure for GSM, but various hormonal and non-hormonal treatments can reduce symptoms.

Topical treatments

For milder symptoms, a doctor may recommend a non-hormonal vaginal lubricant to use during sex or a long-acting moisturizer to reduce discomfort more generally. Clinicians generally recommend using these moisturizers several times a week.

Some doctors may suggest hyaluronic acid to treat vaginal dryness. This acid is present in many skin care products because it attracts moisture to the skin. But to date, there is no clear evidence that hyaluronic acid-based lubricants work better than other lubricants or moisturizers.

Hormone therapy

For more disruptive symptoms, doctors often recommend hormone therapy. This replaces estrogen that the body no longer produces.

Guidelines from 2020 report that hormone replacement therapy is the most effective way to treat symptoms of GSM. Some options include:

  • low dose intravaginal estradiol tablets
  • low dose estrogen vaginal inserts
  • intravaginal dehydroepiandrosterone (DHEA) or prasterone
  • DHEA vaginal inserts
  • oral ospemifene, a selective estrogen receptor modulator

Some people worry that estrogen replacement therapy is dangerous and increases the risk of certain cancers. However, local estrogen therapy is well documented and safe for most people.

Anyone with concerns and anyone who has had some form of hormone-sensitive cancer should discuss them with their doctor.

Pelvic floor physiotherapy

Some people with GSM may benefit from it, in addition to other treatments. Pelvic floor physiotherapy, sometimes called PFPT, can help strengthen the muscles of the pelvic floor.

It can prevent incontinence or urine leakage and improve sexual function in people with GSM.

Dilation therapy

People with GSM who experience tightness or pain during sex may benefit from dilation therapy. This involves the use of dilators to gradually train the pelvic floor muscles to relax and therefore increase the capacity of the vagina.

Laser technology

In recent years, some GSM treatments have made use of laser technologies, such as microablative fractional CO.2 and non-ablative vaginal therapy with erbium YAG laser.

Preliminary research suggests that CO2 laser therapy can improve sexual function, quality of life, and urinary symptoms in people with GSM.

However, the Food and Drug Administration (FDA) warned against the use of CO2 laser treatment, especially for breast cancer survivors, until more studies show it to be safe.

In addition to receiving medical treatment, people with GSM can benefit from:

  • Avoid aggressive products: The vagina is self-cleaning, so soaps and douches are not necessary for hygiene. Douching, in particular, can drier the fragile tissue around the vulva and vagina, which can make symptoms of GSM worse. It also increases the risk of infections. Instead, wash the outside of the vagina only with lukewarm water.
  • Stop smoking: Smoking is linked to a faster start symptoms of GSM. Healthcare professionals can help people quit smoking, and anyone in the United States can also call 1-800-QUIT-NOW for free information and references to local resources.
  • Changing approaches to sex: Menopause and GSM can mean arousal is taking over longer, and being aroused reduces the risk of dryness and pain during sex. Beyond using lubricants and moisturizers, people might benefit from spending more time on foreplay, slowing things down, and focusing on the types of sex that aren’t penetrating. A sexual health professional can provide additional advice on how to cope with these changes.

Learn more about sex after menopause here.

Not all people with dryness, itching and pain during sex have a GSM. Other factors that can lead to these symptoms include:

Anyone who has these symptoms should talk to a doctor. It is important to do this before making any changes to any prescribed treatment plan.

GSM is a common condition in postmenopausal people. It can also result from low estrogen levels caused by other factors, such as surgery to remove the ovaries or certain cancer treatments.

GSM can cause vaginal dryness, itching, and pain during sex, among other symptoms. A variety of treatments and home care strategies can help.

However, GSM is often underdiagnosed because many people consider symptoms to be a natural part of aging or are uncomfortable discussing them with their doctor.

Effective and safe treatments are available. If possible, try talking to a doctor who is familiar with menopause issues.


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