Vaginal and Urinary Health After 40: GSM Explained

By Menopause Reviewed Editorial Team | Last reviewed: May 2026

For decades, the medical shorthand for vaginal changes during and after menopause was "vaginal atrophy." The term captured something real, but it missed most of the picture. In 2014, the International Society for the Study of Women's Sexual Health (ISSWSH) and the North American Menopause Society (NAMS) formally replaced it with genitourinary syndrome of menopause, or GSM.

The change was not semantic housekeeping. The 2014 consensus paper by Portman and Gass, published in Menopause and the Journal of Sexual Medicine, defined GSM as "a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder." The definition covers genital symptoms (dryness, burning, irritation), sexual symptoms (dyspareunia, impaired lubrication), and urinary symptoms (urgency, dysuria, recurrent UTIs). Naming the urinary dimension gave clinicians and patients language for a connected set of problems that had long been managed in isolation — or ignored entirely.

GSM is chronic and progressive. Unlike vasomotor symptoms, which often diminish without treatment, GSM typically worsens as estrogen deficiency continues. Many women and their providers assume tolerance is the only option. The evidence disagrees.

Prevalence and the Underreporting Problem

GSM affects an estimated 50–70 percent of postmenopausal women. The GENISSE study, a multicenter cross-sectional study published in Climacteric in 2018, found GSM in 70 percent of postmenopausal women presenting to gynecology clinics — and 60 percent of those women had no prior diagnosis. The REVIVE (Real Women's Views of Treatment Options for Menopausal Vaginal Changes) survey series documented the treatment gap across multiple countries: European data published in Maturitas in 2016 showed that only a minority of affected women were receiving treatment, and discussions were far more often patient-initiated than clinician-initiated. The Pan-Asian REVIVE survey, published in Climacteric in 2017, found that among 638 postmenopausal women with GSM symptoms, only 25 percent had discussed them with a healthcare provider.

The barriers are layered: women attribute symptoms to normal aging, clinicians facing time constraints may not ask, and cultural reluctance to discuss pelvic health creates silence on both sides. Fewer than 25 percent of symptomatic women seek care.

The Biology: Estrogen Receptors and What Happens Without Estrogen

Estrogen receptors are distributed throughout the genitourinary tract: vaginal epithelium, vulvar tissue, urethra, and bladder trigone. As ovarian estrogen production declines — beginning in perimenopause and accelerating after the final menstrual period — all of these tissues undergo measurable change.

In the vagina, estrogen supports epithelial thickness, glycogen content, and connective tissue elasticity. Glycogen feeds Lactobacillus species, which produce lactic acid and maintain a protective pH below 4.5. When estrogen falls, the epithelium thins and Lactobacillus populations decline. Vaginal pH rises to 5.0 or above, creating conditions more hospitable to Enterobacteriaceae — the bacterial family that includes E. coli. A 2024 study in Frontiers in Microbiology confirmed that vaginal estrogen shifts the microbiome back toward Lactobacillus-dominant states, with the greatest response in women who were most dysbiotic at baseline.

In the urethra and bladder trigone, estrogen supports mucosal integrity and closure pressure; its deficiency contributes to urethral thinning, urgency, and infection susceptibility. The same process drives both the vaginal and urinary components of GSM — which is precisely why the 2014 term replaced one that named only half the condition.

The Symptom Spectrum

GSM symptoms span a range that women may not connect to a single cause:

• Vaginal dryness — the most commonly reported symptom; affecting up to 93 percent of women with GSM in the GENISSE cohort
• Dyspareunia — pain with intercourse, often burning or tearing; present in 81.6 percent of GENISSE cases
• Recurrent urinary tract infections — a frequently overlooked GSM manifestation
• Urinary urgency and dysuria — reflecting bladder trigone changes
• Postcoital spotting — from fragile, thinned vaginal epithelium

The urinary symptoms deserve emphasis: they are routinely managed as isolated infectious disease problems without recognition of the hormonal mechanism. A woman treated for her fourth UTI in a year may never have been told that recurrences are a direct consequence of estrogen-deficient tissue.

Treatment Evidence

Vaginal Estrogen: The Benchmark Treatment

Vaginal estrogen — available as cream, tablet/insert, and ring — is the most extensively studied GSM treatment and produces consistent improvements across the full symptom spectrum. At low doses, it achieves local tissue effects without clinically meaningful systemic absorption. A 2020 literature review published in Menopause by Simon et al. confirmed that serum estradiol with low-dose and ultralow-dose vaginal formulations remains at or near postmenopausal baseline after the initial absorption period, with longer-term use (12+ weeks) producing levels equivalent to placebo.

The safety picture has clarified. For years, vaginal estrogen carried the same FDA boxed warning as systemic hormone therapy — a conflation professional societies argued was unsupported for locally administered, low-dose products. The FDA has since removed the breast cancer boxed warning from low-dose vaginal estrogen labeling. ACOG's 2021 Clinical Consensus (updated 2023) concluded that low-dose vaginal estrogen is safe for breast cancer survivors at low recurrence risk and should be offered when nonhormonal options are insufficient, under oncology supervision. At low doses it does not require progestin co-administration, does not substantially raise circulating estrogen, and is appropriate for the vast majority of postmenopausal women.

Vaginal DHEA (Prasterone/Intrarosa)

Prasterone (DHEA in vaginal suppository form) was FDA-approved in 2016 as Intrarosa. Its mechanism is distinct: DHEA is converted locally within vaginal cells into both estrogens and androgens without substantial systemic hormone elevation. Approval rested on trials ERC-231 and ERC-238, showing significant improvements over placebo in vaginal maturation index, pH, and dyspareunia severity at 12 weeks. A 2024 review in Australian Prescriber summarizing all three randomized trials (436 active, 260 placebo) confirmed clinically meaningful dyspareunia improvement; the most common adverse effect was vaginal discharge (8.3% vs. 3.4% on placebo). Prasterone is a relevant option for women on aromatase inhibitors or with concerns about any estrogen exposure.

Ospemifene (Osphena)

Ospemifene is an oral SERM approved for dyspareunia and vaginal dryness. Unlike raloxifene, it exerts a near-full estrogen agonist effect on vaginal epithelium. Phase III trials showed significant improvements in parabasal cells, superficial cells, vaginal pH, and dyspareunia at 60 mg over 12 weeks — reviewed in Clinical Interventions in Aging in 2014 and confirmed in Menopause in 2019. The once-daily oral route suits women who prefer not to use intravaginal preparations. It is not recommended for women with breast cancer history or elevated thromboembolic risk.

Non-Hormonal Options: Moisturizers and Lubricants

Moisturizers and lubricants are distinct. Moisturizers (including Replens and hyaluronic acid preparations such as Hyalo Gyn) are applied 2–3 times per week to maintain tissue hydration. Lubricants are used at the time of sexual activity to reduce friction acutely. Neither addresses underlying tissue atrophy the way hormonal therapies do, but both provide symptom relief.

Hyaluronic acid has the strongest non-hormonal evidence base. A 2023 systematic review in Cureus found HA inferior to vaginal estrogen on objective tissue measures but comparable for dryness and dyspareunia symptoms in several studies. A 2024 randomized pilot trial in Menopause found significant symptom improvement in both the vaginal estrogen and HA groups at 12 weeks, with no significant between-group difference — though the study was underpowered for definitive conclusions. For mild symptoms or women who decline hormonal options, HA moisturizers are the best-supported alternative.

CO2 Laser (MonaLisa Touch): Mixed RCT Evidence

Fractional CO2 laser generated early enthusiasm from observational data suggesting histologic and symptomatic improvement through fibroblast stimulation and collagen remodeling. In July 2018, the FDA issued warning letters to multiple device manufacturers — including Cynosure (MonaLisa Touch) — noting that the devices had not received clearance for vaginal rejuvenation indications and that adverse event reports had been filed, including burns, dyspareunia, and pain.

Subsequent RCTs have not been favorable. A trial published in JAMA Network Open in February 2023 randomized women with GSM to fractional CO2 laser or sham; both groups improved at 6 months with no significant difference between them. The authors concluded laser efficacy "remains to be demonstrated." A December 2023 systematic review in the Journal of Personalized Medicine offered a more positive interpretation of pooled data but acknowledged substantial heterogeneity. CO2 laser has a plausible mechanism and an acceptable safety profile with cleared devices — but superiority over placebo is unconfirmed. Given out-of-pocket costs of $1,500–$3,000 per series, the evidence-to-cost ratio compares poorly against vaginal estrogen.

The Recurrent UTI Connection

Recurrent UTIs in postmenopausal women are frequently managed as isolated infectious disease problems without recognition of the hormonal mechanism. The landmark study is Raz and Stamm, published in the New England Journal of Medicine in 1993: a randomized, placebo-controlled trial in 93 postmenopausal women with recurrent UTIs. The intravaginal estriol group experienced 0.5 UTI episodes per patient-year versus 5.9 in the placebo group — roughly a 90 percent reduction. Enterobacteriaceae vaginal colonization fell from 67 to 31 percent with estriol, and was essentially unchanged (67 to 63 percent) with placebo.

The finding has held up. The 2008 Cochrane review by Perrotta et al. (9 studies, 3,345 women) confirmed that vaginal estrogens — but not oral estrogens — reduced UTI recurrence versus placebo. A meta-analysis of 8 RCTs found vaginal estrogen reduced recurrent UTI risk by 58 percent (RR 0.42; 95% CI 0.30–0.59). Both the American Urological Association and the European Association of Urology guidelines now recommend vaginal estrogen for UTI prophylaxis in postmenopausal women. Any woman being treated for repeated UTIs after menopause should have a conversation about whether GSM is the underlying driver.

Bottom Line

GSM affects 50–70 percent of postmenopausal women, worsens without treatment, and is among the most undertreated conditions in women's health. The 2014 ISSWSH/NAMS terminology change was intended to make the syndrome easier to discuss and harder to ignore. A decade later, fewer than 25 percent of symptomatic women seek care.

The barriers are well-documented. The 2013 REVIVE-US survey by Kingsberg et al., published in the Journal of Sexual Medicine, found that patients normalize symptoms as aging, clinicians conflate local vaginal estrogen with systemic hormone therapy, and sexual health rarely gets adequate time in visits — patterns that had persisted despite available, effective treatments.

Vaginal estrogen is the first-line recommendation: safe, inexpensive, highly effective, and now endorsed by ACOG and the FDA for use even in breast cancer survivors at low recurrence risk. Prasterone (Intrarosa) and ospemifene (Osphena) provide validated alternatives. Hyaluronic acid moisturizers are the best-supported non-hormonal option. CO2 laser should be considered investigational pending more consistent RCT data. And for the many postmenopausal women with recurrent UTIs, treating GSM is treating the cause — a connection the evidence established 30 years ago that still too often goes unmade.

References

1. 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;21(10):1063–1068. https://pubmed.ncbi.nlm.nih.gov/25155380/

1. Portman DJ, Gass MLS. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy. Journal of Sexual Medicine. 2014;11(12):2865–2872. https://pubmed.ncbi.nlm.nih.gov/25179577/

1. Pérez-López FR, Vieira-Baptista P, et al. Genitourinary syndrome of menopause. Prevalence and quality of life in a cohort of Spanish postmenopausal women (GENISSE study). Climacteric. 2018;21(2):171–178. https://pubmed.ncbi.nlm.nih.gov/29411644/

1. Nappi RE, Palacios S, Particco M, Panay N. The REVIVE survey in Europe: women's views of treatment options for menopausal vaginal changes. Maturitas. 2016;91:85–92. https://pubmed.ncbi.nlm.nih.gov/27451325/

1. Huang KE, Baber R, Asia Pacific Menopause Federation. Pan-Asian REVIVE survey: women's experience of genitourinary syndrome of menopause. Climacteric. 2017;20(4):373–380. https://pubmed.ncbi.nlm.nih.gov/28453308/

1. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. New England Journal of Medicine. 1993;329(11):753–756. https://pubmed.ncbi.nlm.nih.gov/8350884/

1. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database of Systematic Reviews. 2008;(2):CD005131. https://pubmed.ncbi.nlm.nih.gov/18425910/

1. Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE survey. Journal of Sexual Medicine. 2013;10(7):1790–1799. https://pubmed.ncbi.nlm.nih.gov/23679050/

1. Simon JA, et al. Systemic estradiol levels with low-dose vaginal estrogens: a review of the literature. Menopause. 2020;27(3):361–370. https://pmc.ncbi.nlm.nih.gov/articles/PMC7050796/

1. ACOG Clinical Consensus. Treatment of urogenital symptoms in individuals with a history of estrogen-dependent breast cancer. American College of Obstetricians and Gynecologists. 2021 (updated 2023). https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2021/12/treatment-of-urogenital-symptoms-in-individuals-with-a-history-of-estrogen-dependent-breast-cancer

1. Archer DF, et al. Efficacy and safety of ospemifene in postmenopausal women with moderate-to-severe vaginal dryness: a randomized, double-blind, placebo-controlled phase 3 study. Menopause. 2019;26(6):611–621. https://pmc.ncbi.nlm.nih.gov/articles/PMC6553508/

1. Bachmann G, et al. Safety and efficacy of ospemifene for the treatment of dyspareunia. Clinical Interventions in Aging. 2014;9:1939–1950. https://pmc.ncbi.nlm.nih.gov/articles/PMC4235480/

1. Labrie F, et al. FDA approval of intravaginal prasterone (DHEA, Intrarosa) for dyspareunia due to menopause. FDA NDA 208470. 2016. https://www.accessdata.fda.gov/drugsatfda_docs/nda/2016/208470Orig1s000SumR.pdf

1. Prasterone for vulvar and vaginal atrophy in postmenopausal women. Australian Prescriber. 2024;47(5). https://pmc.ncbi.nlm.nih.gov/articles/PMC11540908/

1. Casarini M, et al. Comparison of the efficacy of vaginal hyaluronic acid to vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Cureus. 2023;15(8):e44135. https://pmc.ncbi.nlm.nih.gov/articles/PMC10520994/

1. Tadir Y, et al. A randomized, pilot trial comparing vaginal hyaluronic acid to vaginal estrogen for genitourinary syndrome of menopause. Menopause. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11469619/

1. Paraiso MFR, et al. Effect of fractional carbon dioxide vs sham laser treatment on genitourinary syndrome of menopause: a randomized clinical trial. JAMA Network Open. 2023;6(2):e2251308. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2801236

1. FDA Safety Communication: Cynosure MonaLisa Touch warning letter. U.S. Food & Drug Administration. July 24, 2018. https://www.fda.gov/files/medical%20devices/published/Cynosure--Inc.-Letter---July-24--2018.pdf

1. Arabzadeh S, et al. CO2 laser versus sham control for the management of symptoms of GSM. Journal of Personalized Medicine. 2023;13(12). https://pmc.ncbi.nlm.nih.gov/articles/PMC10744987/

1. Geng M, et al. Change in microbiota profile after vaginal estriol cream application in postmenopausal women with stress urinary incontinence. Frontiers in Microbiology. 2024;15:1302819. https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2024.1302819/full