Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause, usually shortened to GSM, describes a collection of symptoms and physical changes affecting the vagina, vulva and lower urinary tract. The lower urinary tract includes the urethra, which carries urine out of the body, and the bladder.

The term recognises that symptoms which may seem separate can share the same underlying hormonal changes. Vaginal dryness, soreness during sex, urinary urgency and recurrent UTI-type symptoms may therefore be part of one connected picture.

Older terms include vaginal atrophy, atrophic vaginitis, vulvovaginal atrophy and urogenital atrophy. These descriptions may still appear in medical records, medicine leaflets and online searches. GSM is now generally preferred because it includes the vulval, sexual and urinary effects as well as changes inside the vagina.

Yes. Although GSM is often discussed as a postmenopausal condition, symptoms can begin during perimenopause as oestrogen levels fluctuate and gradually become lower. They may initially come and go or be more noticeable at certain points in the menstrual cycle.

Some people first notice that familiar products begin to sting, tampons feel less comfortable, more lubricant is needed during sex or urinary urgency appears unexpectedly. Others do not develop noticeable symptoms until several years after their final period.

Similar symptoms can also occur when oestrogen levels are lower for other reasons, including breastfeeding, surgical removal of the ovaries, some cancer treatments and certain medicines. This is one reason an individual assessment matters.

Oestrogen helps maintain the structure, moisture, blood supply and natural balance of tissues throughout the vagina, vulva, bladder and urethra. When oestrogen fluctuates or falls, several connected changes can occur.

GSM can affect both the inside of the vagina and the external vulval area, including the labia and vaginal opening. Symptoms vary in combination and severity.

• vaginal dryness or reduced moisture;
• vulval or vaginal burning;
• soreness, tenderness or a raw sensation;
• itching or persistent irritation;
• a feeling of tightness at the vaginal opening;
• fragile tissue that splits or cracks easily;
• stinging when urine touches the vulval skin;
• spotting after penetration or an examination;
• discomfort from underwear or fitted clothing;
• irritation when sitting, walking, running or cycling.

The tissues may appear paler, thinner, redder or more inflamed. However, persistent itching, white patches, thickened skin, ulcers, sores, lumps or changes in the shape of the vulva should be examined rather than assumed to be GSM.

Painful or uncomfortable sex is a common feature of GSM, but dryness is not the only possible cause. Thinner tissue, reduced elasticity, lower lubrication and increased sensitivity can all contribute.

• pain, stinging or burning at the vaginal opening;
• a feeling that the opening is too tight;
• friction or dragging during penetration;
• deeper discomfort during sex;
• soreness or burning that continues afterwards;
• minor splitting or spotting after penetration;
• reduced desire because sex has become associated with pain.

Pain may also cause the pelvic-floor muscles to tighten automatically. This is a protective response rather than something you are choosing to do. If the body begins to expect penetration to hurt, muscle tightening can make penetration more difficult and reinforce a cycle of pain, anxiety and further tension.

GSM can affect much more than physical comfort. Persistent soreness, urinary urgency or fear of pain during sex can influence confidence, sleep, exercise, relationships and intimacy. Some people begin avoiding cervical screening, examinations or sexual contact because they expect discomfort. These effects are important and deserve the same attention as the physical symptoms.

GSM can affect daily comfort as well as sexual activity. Reduced moisture, fragile tissue and protective pelvic-floor tightening may make ordinary activities uncomfortable.

• walking, sitting or exercising;
• cycling or wearing fitted clothing;
• inserting a tampon;
• inserting a vaginal tablet, pessary or applicator;
• having cervical screening or a vaginal examination;
• passing urine when the skin is sore.

Some people also notice urinary leakage, pelvic pressure, heaviness or a sensation that something is coming down into the vagina. These symptoms may indicate pelvic-floor weakness or pelvic-organ prolapse rather than GSM alone, although the conditions can occur together.

Pelvic-floor problems are not always caused by weakness. Muscles can become overactive or remain tightly braced in response to pain. Pelvic-health physiotherapy may help when there is persistent pain with penetration, difficulty relaxing the pelvic floor, pain with tampons or examinations, urinary leakage, pelvic heaviness or continuing discomfort after the vaginal tissues have been treated.

Physiotherapy may include assessment of strength and tension, relaxation work, breathing techniques, gradual desensitisation and advice on returning to comfortable activity. Pelvic-floor exercises should be individualised because repeatedly tightening already overactive muscles may worsen some pain.

Yes. Natural discharge may reduce as vaginal moisture and lubrication decrease. You may notice less moisture throughout the day or during sexual arousal.

Changes in vaginal pH and the local microbiome may sometimes cause a different or increased discharge. Vaginal moisturisers and locally applied treatments can also leave residue or temporarily increase discharge as the product dissolves or leaves the vagina.

Discharge should be assessed if it has an unusual colour, an offensive smell, contains blood or is accompanied by pelvic pain, fever, marked itching, swelling or feeling unwell. Bleeding after sex, bleeding between periods or any unexplained bleeding after menopause should also be discussed with a clinician.

The bladder and urethra are also sensitive to oestrogen. Changes in these tissues may contribute to urinary symptoms that seem separate from vaginal dryness.

• needing to urinate more frequently;
• a sudden or difficult-to-control urge to urinate;
• waking during the night to pass urine, known as nocturia;
• burning or stinging when urinating;
• urinary leakage;
• recurrent UTI-type symptoms;
• repeated confirmed urinary tract infections.

Burning does not always mean a bacterial infection is present. In GSM, urine touching thin or irritated tissue around the vaginal opening can cause stinging. A urine test may still be needed, especially when symptoms are new, severe or accompanied by blood in the urine, fever, back pain or feeling unwell.

For a fuller explanation, read Why Do UTIs Become More Common During Perimenopause and Menopause? Bladder Symptoms and Low Oestrogen Explained.

There is no single blood test that confirms GSM. Assessment usually starts with the pattern, timing and impact of your symptoms, together with your menopause stage, medical history, medicines and any previous treatments.

A clinician may recommend examining the vulva and vagina, particularly when symptoms are persistent, severe, one-sided or associated with bleeding or visible skin changes. A urine test, vaginal swab or further investigation may be appropriate when infection, a vulval skin condition, prolapse or another cause is suspected. An examination is not always necessary before initial advice, but it should not be repeatedly avoided when symptoms are unexplained or not improving.

GSM can resemble thrush, bacterial vaginosis, a urinary infection or a vulval skin condition. It is also possible to have GSM and an infection at the same time.

Repeatedly using over-the-counter thrush products without a clear diagnosis may further irritate sensitive tissue. Assessment may involve discussing the pattern of symptoms, examining the vulva and vagina, checking a urine sample or taking a vaginal swab when appropriate.

Although GSM is common, similar symptoms can result from another condition or from several factors occurring together.

• sexually transmitted infections, where relevant to symptoms and sexual history;
• lichen sclerosus, lichen planus and other vulval skin conditions;
• eczema, psoriasis, dermatitis or irritant reactions;
• pelvic-floor tension or poor muscle coordination;
• pelvic-organ prolapse;
• endometriosis and other causes of deeper or cyclical pelvic pain;
• less commonly, precancerous changes or vulval or vaginal cancer.

Lichen sclerosus can cause persistent itching, soreness, pale or white skin, splitting and changes to vulval anatomy. It requires medical diagnosis and treatment. A non-healing sore, new lump or unexplained skin change should always be examined.

GSM differs from some menopause symptoms that may naturally become less troublesome over time. Without targeted management, genital and urinary tissue changes may persist and can gradually progress.

Some people with mild symptoms improve by avoiding irritants and using suitable non-hormonal products. Others need treatment directed at the underlying tissue changes or additional pelvic-floor support.

• avoiding perfumed or irritating vulval products;
• using a lubricant during sexual activity;
• using a vaginal moisturiser regularly;
• vaginal oestrogen where clinically appropriate;
• vaginal prasterone where clinically appropriate;
• pelvic-health physiotherapy or other pelvic-floor support.
• connect vaginal, vulval, sexual and urinary symptoms;
• consider whether infection, skin disease or pelvic-floor problems may also be present;
• identify symptoms that require examination or testing;
• discuss appropriate treatment categories without assuming one option suits everyone;
• plan review or referral where symptoms are complex or persistent.

This article does not compare these options in detail. Read Vaginal Treatments Compared: Moisturisers, Lubricants, Vaginal Oestrogen and Intrarosa. For safety questions, read Is Vaginal Oestrogen Safe? Long-Term Use, HRT and Breast Cancer Explained.

• symptoms are persistent, worsening or affecting daily life;
• sex has become newly or repeatedly painful;
• you have recurrent UTI-type symptoms;
• you are unsure whether symptoms are GSM, infection or a skin condition;
• you have bleeding after sex, bleeding between periods or bleeding after menopause;
• you see blood in your urine;
• discharge is offensive, bloodstained or accompanied by pelvic pain;
• you have severe vaginal, vulval or pelvic pain;
• itching is persistent or associated with visible skin changes;
• a lump, ulcer or sore does not heal;
• you have fever, back pain, difficulty passing urine or feel generally unwell;
• symptoms do not improve as expected.

Is vaginal dryness normal during menopause?

Vaginal dryness is common during perimenopause and after menopause, but it does not have to be accepted or left untreated. It can be part of GSM and may occur alongside soreness, painful sex or urinary symptoms. Seek advice if dryness is persistent, painful, associated with bleeding, unusual discharge or visible skin changes, or is affecting daily life.

What does genitourinary syndrome of menopause mean?

GSM is the term for vaginal, vulval, sexual and lower urinary symptoms linked with changing or lower oestrogen levels. It includes vaginal dryness but also covers soreness, painful sex, urinary urgency, frequency and recurrent UTI-type symptoms.

Is GSM the same as vaginal atrophy?

Vaginal atrophy is an older term describing thinning and drying of vaginal tissues. GSM is broader because it also includes vulval, sexual, bladder and urethral symptoms.

Can GSM start before my periods stop?

Yes. Symptoms can begin during perimenopause while oestrogen levels are fluctuating. They may initially be mild or intermittent.

Why does sex hurt during menopause?

Lower moisture, thinner tissue and reduced elasticity can increase friction and pain. The pelvic-floor muscles may also tighten in response to anticipated pain. Dryness is not the only possible cause, so persistent pain should be assessed.

Can GSM make walking or sitting uncomfortable?

Yes. Fragile or irritated vulval tissue can feel sore during walking, sitting, exercise, cycling or when clothing rubs against the area.

Can GSM feel like thrush or a UTI?

Yes. GSM can cause itching, burning, urinary urgency, frequency and stinging. Tests or an examination may be needed to distinguish GSM from infection or a vulval skin condition.

Can GSM change vaginal discharge?

Natural discharge may reduce as lubrication falls. Vaginal products can cause residue or increased discharge. Unusual colour, offensive smell, blood or associated pelvic pain requires assessment.

Does GSM go away on its own?

Symptoms often persist and may progress without targeted management. Appropriate treatment and avoidance of irritants can improve symptoms.

When should I be worried about vulval itching?

Persistent itching, especially with white, red, darkened or thickened skin, splitting, a lump, ulcer or a sore that does not heal, should be examined.

How is GSM diagnosed?

GSM is usually identified from your symptoms and medical history. A clinician may also examine the vulva and vagina or arrange urine testing, a vaginal swab or further assessment when infection, a skin condition, prolapse or another cause is possible.

Can pelvic-health physiotherapy help?

It may help when pain has led to pelvic-floor tightening, when penetration or examinations are difficult, or when urinary leakage, pelvic heaviness or prolapse symptoms are present.