As women approach menopause, many changes occur in the body due to declining estrogen1 levels. One condition that often goes unrecognized or under-discussed is genitourinary syndrome of menopause (or GSM).
This condition, which affects the vaginal and urinary tract tissues, can lead to discomfort and impact quality of life. If you’ve been experiencing changes in vaginal health, bladder function, or sexual discomfort that point to GSM, below you'll learn how to help manage the condition, such as supplements including probiotics, pelvic floor exercises, and changes to your lifestyle.
In this article:
What Is Genitourinary Syndrome of Menopause?
Genitourinary syndrome of menopause (GSM), previously known as genitourinary atrophy or atrophic vaginitis2, refers to a collection of symptoms caused by estrogen deficiency3 that affects the vagina, vulva, and lower urinary tract.
Among estrogen's many jobs is helping to maintain the elasticity, thickness, and moisture of vaginal and urethral tissues. Therefore, when estrogen levels drop during menopause, these tissues typically become thinner, drier, and more fragile, leading to a range of uncomfortable symptoms.
GSM is very common, affecting an estimated 50-70% of postmenopausal women4. GSM-like symptoms are also present in about 15% of premenopausal women due to the hypoestrogenic state (reduced estrogen).
This condition can develop in premenopausal women5 who have low estrogen, such as those experiencing early menopause, those in the postpartum period, those who are breastfeeding, or due to hypothalamic amenorrhea or antiestrogenic drugs.
Unfortunately, unlike menopause symptoms like hot flashes, which often improve over time, GSM symptoms tend to persist and worsen without treatment. Despite its prevalence, many women don’t seek for genitourinary syndrome of menopause due to embarrassment or a lack of awareness that treatments are available.
Symptoms of Genitourinary Syndrome of Menopause
Common genitourinary syndrome symptoms6 include:
- Vaginal dryness and irritation: a persistent dry or itchy sensation in the vaginal area. This is the most common GSM symptom, affecting more than 90% of women7 with this condition.
- Painful sex (dyspareunia): discomfort or burning during sexual activity, as well as reduced libido and decreased sexual satisfaction, often due to pain (these symptoms affect as many as 80% of women with GSM)
- Vaginal burning or discomfort: a feeling of heat or rawness
- Urinary urgency or frequency: a sudden, intense need to urinate more often
- Urinary incontinence: leakage or difficulty controlling urination
- Recurrent urinary tract infections (UTIs): increased risk of infections due to a less protective vaginal environment and changes in bacterial flora
GSM symptoms can vary in severity but they often get worse if left untreated. These symptoms often impact sexual health, bladder function, and overall well-being, including increasing susceptibility to infections such as UTIs. Some women can experience genitourinary system disease symptoms, which include discomfort during urination and more frequent infections.
What Causes GSM?
GSM is primarily caused by estrogen decline, which occurs during perimenopause, menopause, and postmenopause. Estrogen is connected to vaginal and urinary tract health because it helps support:
- Collagen production, which keeps tissues elastic and resilient
- Blood flow, which ensures oxygen and nutrient delivery to vaginal and urethral tissues
- Glycogen production, which provides fuel for beneficial vaginal bacteria and supports a balanced vaginal microbiome
Aside from menopause leading to low estrogen, studies suggest8 that other risk factors for GSM include:
- Absence of vaginal childbirth
- Missing periods
- Alcohol abuse
- Bilateral oophorectomy (removal of both ovaries)
- Decreased frequency of sexual activity or sexual abstinence (including having few orgasms)
- Cigarette smoking
- Non-menopausal hypoestrogenism
- Lack of exercise
- (Premature) ovarian failure
- Cancer treatments (pelvic irradiation, chemotherapy, endocrinal agents)
- Having other chronic diseases (mostly urogynecological conditions, like interstitial cystitis)
The Connection Between GSM and Infections:
When estrogen declines, so does tissue glycogen production, leading to a reduction in lactobacillus9, the dominant and beneficial bacteria that help maintain a healthy vaginal pH.
Lactobacillus bacteria help maintain an acidic vaginal pH, typically around 3.8 to 4.5, which acts as a natural defense against harmful microbes. As the presence of protective lactobacillus decreases, vaginal pH rises, creating an environment that's more susceptible to irritation, infections, and dryness.
Having a higher vaginal pH allows opportunistic bacteria and yeast to thrive. This shift can lead to an increased risk of bacterial vaginosis (BV), yeast infections, and recurrent urinary tract infections.
Without sufficient lactobacillus to outcompete harmful organisms, the vaginal ecosystem becomes more vulnerable, contributing to ongoing irritation, discomfort, and recurrent infections. Addressing this imbalance through targeted treatments, such as probiotics, vaginal estrogen therapy, and pH-balancing strategies, can help restore vaginal health and reduce infection risk.
Genitourinary Syndrome of Menopause Treatment Options
Although GSM is considered a chronic condition10, it's still highly treatable with the right approach, especially when treatments are used long-term and consistently. Here's an overview of different treatment options, which include the use of medications, supplements, exercises11, and other therapies:
1. Topical Estrogen Therapy
Low-dose estrogen creams, vaginal rings, or suppositories can help to restore vaginal tissue health12 and alleviate dryness, irritation, and pain.
These treatments work by delivering small amounts of estrogen directly to the vaginal tissues, helping to improve elasticity, increase blood flow, and restore moisture.
Topical estrogen is considered one of the most effective treatments for GSM, with minimal systemic absorption, making it a safer option for many women.
2. Non-hormonal Vaginal Moisturizers and Lubricants
These over-the-counter remedies can help provide relief for mild symptoms13, although they don’t address the underlying cause of GSM.
Vaginal moisturizers help hydrate and replenish vaginal tissues, while lubricants reduce friction during intercourse, making sexual activity more comfortable. For the best results, moisturizers should be used regularly, while lubricants are applied as needed before sex.
3. Pelvic Floor Therapy
Strengthening pelvic muscles can improve bladder control and reduce urinary symptoms. For example, a trained pelvic floor therapist can guide women through exercises such as kegel exercises and biofeedback therapy, which help strengthen the muscles that support the bladder and vaginal walls.
Improving pelvic floor strength can also help enhance urinary continence in some cases.
4. Oral Medications
Certain medications, like selective estrogen receptor modulators (SERMs), may help improve vaginal and urinary symptoms14. SERMs, such as ospemifene, work by mimicking the effects of estrogen in vaginal tissues without affecting other estrogen-sensitive organs. These medications can be an option for women who cannot use topical estrogen.
5. Laser Therapy
Vaginal laser treatments, such as co2 laser, Vaginal Laser Ablation (VLA), or radiofrequency therapy, can help stimulate collagen production and improve tissue health.
Laser therapies help promote the regeneration of vaginal tissue by enhancing blood flow and encouraging the growth of new, healthy cells. For instance, VLA uses lasers to make micro-abrasions15 or tiny scratches in the vaginal wall, which stimulate the growth of new blood vessels causing a “remodeling” of the vaginal mucosa. Women who opt for laser therapy often report improvements in vaginal moisture, elasticity, and overall comfort.
One systematic review and meta-analysis16 of 270 women from six randomized clinical trials found that vaginal laser therapy, compared with vaginal estrogen, was associated with similar improvement in GSM symptoms, including improvements in vaginal health, urinary symptoms, and sexual function.
In this study, side effects of vaginal estrogen were minimal, including breast tenderness, migraines, abdominal cramping, and vaginal bleeding, but no serious adverse events were reported in the laser therapy studies.
Note: combining different approaches, such as topical estrogen with pelvic floor therapy or probiotics with non-hormonal moisturizers, can often provide a more comprehensive treatment plan that's more individualized and more effective.
The Role of Probiotics in GSM
One often-overlooked aspect of GSM menopause management is the role of gut and vaginal microbiomes.
As mentioned above, decreased estrogen can lead to lower vaginal lactobacillus levels, leading to an elevated pH that contributes to irritation, infections, and discomfort. Since the gut acts as a reservoir for vaginal bacteria, taking oral probiotics containing lactobacillus strains can help restore vaginal microbiome balance17 and support urinary tract health.
Here's why probiotics can help manage GSM:
- They help repopulate beneficial bacteria: certain probiotic strains, like lactobacillus crispatus and lactobacillus rhamnosus, help restore a healthy vaginal microbiome.
- They help lower vaginal pH: maintaining an optimal pH reduces the risk of infections and irritation.
- They support bladder health: lactobacillus probiotics can help prevent UTIs and reduce urinary symptoms.
- They help enhance estrogen metabolism: gut bacteria play a role in how the body processes and utilizes estrogen, indirectly supporting vaginal tissue health.
In addition to supplementing with probiotics, such as my Women's Probiotic formula—which contains a powerful blend of probiotics, prebiotics, and antioxidants designed to specifically support healthy hormones and a balanced vaginal microbiome—incorporating probiotic-rich foods into your diet is also helpful. Probiotic foods include:
- Yogurt
- Kefir
- Fermented vegetables like sauerkraut and kimchi
- Kombucha
- Miso
To get you started, I've created a free Hormone Balancing Starter Kit packed with nutrition and lifestyle tips for healthy hormone balance (including a 7-day meal plan with recipes.
Key Takeaways on
- GSM is a common but treatable condition that affects the vaginal and urinary health of menopausal women.
- Symptoms like vaginal dryness, urinary discomfort, and painful intercourse result from declining estrogen levels, but multiple treatment options—including topical estrogen, pelvic therapy, and probiotics—can help restore comfort and improve quality of life.
- If you’re experiencing symptoms of genitourinary atrophy or related genito urinary diseases, seeking medical advice and exploring treatment options can make a significant difference in your quality of life.
References
- https://pmc.ncbi.nlm.nih.gov/articles/PMC7212735/ ↩︎
- https://journals.lww.com/menopausejournal/abstract/2014/10000/genitourinary_syndrome_of_menopause__new.6.aspx ↩︎
- https://pubmed.ncbi.nlm.nih.gov/25155380/ ↩︎
- https://pmc.ncbi.nlm.nih.gov/articles/PMC7212735/ ↩︎
- https://www.uptodate.com/contents/genitourinary-syndrome-of-menopause-vulvovaginal-atrophy-clinical-manifestations-and-diagnosis ↩︎
- https://www.mayoclinicproceedings.org/article/S0025-6196(17)30639-0/fulltext ↩︎
- https://pmc.ncbi.nlm.nih.gov/articles/PMC7212735/ ↩︎
- https://pmc.ncbi.nlm.nih.gov/articles/PMC7212735/ ↩︎
- https://pubmed.ncbi.nlm.nih.gov/37366082/ ↩︎
- https://www.uptodate.com/contents/genitourinary-syndrome-of-menopause-vulvovaginal-atrophy-clinical-manifestations-and-diagnosis ↩︎
- https://www.uptodate.com/contents/genitourinary-syndrome-of-menopause-vulvovaginal-atrophy-treatment ↩︎
- https://linkinghub.elsevier.com/retrieve/pii/S0025-6196(17)30639-0 ↩︎
- https://www.jogc.com/article/S1701-2163(21)00689-7/abstract ↩︎
- https://www.jogc.com/article/S1701-2163(21)00689-7/abstract ↩︎
- https://www.hopkinsmedicine.org/health/conditions-and-diseases/genitourinary-syndrome-of-menopause ↩︎
- https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796567 ↩︎
- https://pmc.ncbi.nlm.nih.gov/articles/PMC9366906/ ↩︎
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