Genitourinary syndrome of menopause
What GSM is, how it can show up, and how vaginal estrogen can help.
What GSM is
Genitourinary syndrome of menopause, or GSM, is a common group of changes involving the vulva, vagina, urethra, and bladder that can begin during perimenopause and often becomes more noticeable after menopause.
As estrogen levels fluctuate and decline, the tissues of the vagina and urinary tract can become thinner, drier, less elastic, and more sensitive. GSM is not “just part of getting older” that you have to live with. It is common, treatable, and worth discussing.
Vaginal and vulvar symptoms
You may notice symptoms such as:
- Vaginal dryness or a feeling of tightness
- Burning, itching, irritation, or soreness around the vaginal opening or vulva
- Less natural lubrication with sexual activity
- Discomfort with sitting, exercise, tight clothing, or wiping
- Light bleeding, tearing, or burning after sex
- Pain with penetration, including intercourse, tampons, fingers, or pelvic exams
- A feeling that the vaginal opening has become narrower or less flexible
- Changes in vaginal discharge or odor related to changes in vaginal pH
Urinary and bladder symptoms
You may notice symptoms such as:
- Urinary urgency, including a sudden “have to go now” feeling
- Going to the bathroom more often, including overnight
- Burning with urination even when urine testing does not show an infection
- Leakage of urine with coughing, laughing, sneezing, lifting, exercise, or on the way to the bathroom
- Feeling that the bladder is more easily irritated
- More frequent urinary tract infections (UTIs)
Urinary leakage can have more than one cause, including pelvic-floor changes, prior pregnancy or childbirth, aging, bladder overactivity, and GSM. Treating GSM can improve some urinary symptoms, but additional treatment, such as pelvic-floor physical therapy or bladder-focused care, may also be helpful.
How GSM can affect sexual function
GSM can affect sexual comfort, confidence, and desire. When sex is painful or the vagina is dry, the body may naturally become less responsive to touch or penetration.
You may experience:
- Less lubrication or a longer time to become lubricated
- Pain, burning, friction, or tearing during or after sex
- Avoiding intimacy because it is uncomfortable or you are worried it will hurt
- Less arousal or genital sensation
- Difficulty reaching orgasm
- Orgasms that feel weaker, less intense, delayed, or different than before
- Lower sexual desire, especially when pain, sleep disruption, stress, relationship concerns, or other menopause symptoms are also present
These concerns are real and common. A weak or less satisfying orgasm is not necessarily “all in your head.” Reduced blood flow, tissue sensitivity, comfort, lubrication, and pelvic-floor function can all contribute. Vaginal estrogen can help restore healthier vaginal tissue and improve comfort and lubrication. For many women, this can make sexual activity more enjoyable and may support improved arousal and orgasmic response. However, orgasm and desire are influenced by many physical, emotional, relationship, and hormonal factors, so some people benefit from additional therapies.
How vaginal estrogen can help
Vaginal estrogen is a local treatment that delivers a low dose of estrogen directly to vaginal and nearby urinary tissues. It helps rebuild and maintain healthier, more flexible, better-lubricated tissue.
Vaginal estrogen can help with:
- Vaginal dryness, burning, itching, and irritation
- Pain with sex and other vaginal penetration
- Natural lubrication and comfort during intimacy
- Vaginal elasticity and tissue resilience
- Urinary urgency, frequency, and nighttime urination for some women
- Certain types of urinary leakage, especially urgency-related leakage
- Recurrent UTIs
- Overall vaginal and urinary comfort
Forms and what to expect
Vaginal estrogen is available as a cream, tablet or insert, or vaginal ring. The best option is the one that fits your symptoms, preferences, medical history, and insurance coverage. Improvement often begins over several weeks, with fuller benefit commonly taking about 1–3 months. GSM symptoms can return if treatment is stopped, so ongoing treatment is often appropriate when it continues to be helpful.
Local, not systemic
Low-dose vaginal estrogen is different from systemic hormone therapy taken by pill, patch, or spray. It is designed to act primarily in the vaginal tissues, with minimal absorption into the bloodstream.
If you have a history of breast cancer
Low-dose vaginal estrogen is a safe option for women with a history of breast cancer. Large studies following tens of thousands of breast cancer survivors have found no increase in breast cancer recurrence, breast cancer deaths, or overall deaths among women who used vaginal estrogen. If you are currently taking an aromatase inhibitor (such as anastrozole, letrozole, or exemestane), we make this decision together with your oncologist, since that combination has been studied less.
As with any treatment, your plan is individualized, especially if you have unexplained vaginal bleeding or another estrogen-sensitive cancer.
Your vaginal estrogen care guides
If vaginal estrogen is part of your plan, our care guides cover your specific medication — how to use it, your schedule, and what to expect:
- Vaginal Estradiol — what it treats and how to use it correctly
- Vaginal Estradiol — step-by-step visual walkthrough
- Vagifem — the low-dose estradiol insert placed with an applicator
- Imvexxy — the applicator-free estradiol softgel
- Estring — the low-dose vaginal ring, one ring every three months
Research
- Portman DJ, Gass MLS. Genitourinary Syndrome of Menopause: New Terminology for Vulvovaginal Atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society. Menopause. 2014.
- The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 Genitourinary Syndrome of Menopause Position Statement of The North American Menopause Society. Menopause. 2020.
- Kaufman MR, Ackerman AL, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 2025.
- Danan ER, Sowerby C, Ullman KE, et al. Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause: A Systematic Review. Ann Intern Med. 2024.
- Perrotta C, Aznar M, Mejia R, et al. Oestrogens for Preventing Recurrent Urinary Tract Infection in Postmenopausal Women. Cochrane Database Syst Rev. 2008.
- Cody JD, Jacobs ML, Richardson K, et al. Oestrogen Therapy for Urinary Incontinence in Post-Menopausal Women. Cochrane Database Syst Rev. 2012.
- Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Vaginal Estrogen Use and Chronic Disease Risk in the Nurses' Health Study. Menopause. 2019.
- American College of Obstetricians and Gynecologists. Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer: Clinical Consensus No. 2. Obstet Gynecol. 2021.
- Beste ME, Kaunitz AM, McKinney JA, Sanchez-Ramos L. Vaginal Estrogen Use in Breast Cancer Survivors: A Systematic Review and Meta-Analysis of Recurrence and Mortality Risks. Am J Obstet Gynecol. 2025.
- McVicker L, Labeit AM, Coupland CAC, et al. Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer. JAMA Oncol. 2024.
- Agrawal P, Singh SM, Able C, et al. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023.
- Cold S, Cold F, Jensen MB, et al. Systemic or Vaginal Hormone Therapy After Early Breast Cancer: A Danish Observational Cohort Study. J Natl Cancer Inst. 2022.