Genitourinary syndrome of menopause

Urogenital health is an essential component of wellbeing, underpinning comfort in daily activities, daily function, intimate relationships, and urinary function. Disruption to these domains can have a profound impact on quality of life, self-esteem, and psychosocial health.

Despite this, genitourinary symptoms in the perimenopausal period and beyond are often under-recognised, under-reported, and under-treated.   

GSM is the modern, more encompassing term for a condition previously described as vulvovaginal atrophy or atrophic vaginitis. The older terminology reflected the clinical observation of thinning, dryness, and inflammation of the vaginal epithelium due to oestrogen deficiency. However, these terms did not capture the breadth of symptoms or the involvement of the entire lower genitourinary tract. The introduction of GSM better represents the chronic, systemic effects of hypoestrogenism on the vulva, vagina, urethra, and bladder, as well as the associated sexual and urinary symptoms. 

GSM is a chronic, progressive condition because, unlike vasomotor symptoms that often resolve with time, the underlying oestrogen deficiency persists and typically worsens with age/duration post menopause. Without intervention, vaginal and urogenital tissues undergo continuing atrophy, reduced vascularity, and loss of elasticity, leading to increasing severity of symptoms. Studies suggest that over 50% of postmenopausal women develop clinically significant GSM, with some estimates reporting up to 85% experiencing at least one symptom during or after the menopausal transition^2,3. The incidence of GSM signs and symptoms is highest 5 - 10 years after menopause, consistent with the effects of longer duration post-menopause. 

Early diagnosis and management are crucial in preventing the cumulative impact on quality of life.  

Effective treatment can alleviate symptoms, maintain sexual function and intimacy, reduce urinary tract infections (UTIs), and protect against the long-term complications of untreated atrophy, such as painful intercourse (dyspareunia), recurrent cystitis, and progressive narrowing of the vaginal canal. Left unaddressed, these sequelae can lead to significant distress, avoidance of intimacy, and unnecessary morbidity, all of which are preventable with timely intervention. 

The most commonly reported symptoms include irritation of the vulva, inadequate vaginal lubrication, burning, dysuria, dyspareunia, and vaginal discharge¹. However, the clinical spectrum is often much broader. 

A frequent misconception is that vaginal dryness equates to an absence of discharge.  In fact, in marked cases of atrophic vaginitis, there may be an abnormal discharge, which can be copious or even blood-stained, reflecting mucosal fragility and inflammation¹. 

While GSM may cause bleeding, abnormal bleeding, or post-menopausal bleeding, it must be investigated to exclude other causes, including endometrial hyperplasia and malignancy (endometrial, vulval, cervical, anorectal, bladder).   

Genital

• ​​dryness, burning, pruritis, irritation,​ bleeding​​ 
• ​​​post menopausal bleeding – (other red flags must be excluded)  
• ​vaginal discharge - (other red flags must be excluded)​​ 
• ​​​prolapse​​ 
• ​​chronic pelvic pain​.

Sexual

• ​​Loss of lubrication, discomfort or pain (dyspareunia), ​inability to have penetrative intercourse, ​decreased libido, difficulty with arousal and orgasm, post coital bleeding and trauma to genital tissues​​​​​​.    ​​ 

Urinary

• ​​​Frequency, urgency, dysuria, recurrent UTIs.

​​​Psychological

• ​​​time off work​​ 
• ​​​relationship challenges​​ 
• ​​​discomfort wearing certain clothes​​ 
• ​​​bladder dysfunction may lead to activity avoidance, embarrassment, and significant distress​​.   ​​ 

A careful history and physical examination form the mainstay of assessment. 

• Evaluate 
  • impact of symptoms on the patient’s quality of life  
  • sexual function 
  • vulval hygiene practices and potential irritants, including douching, soaps, bath gels, powders, lubricants, condoms, panty liners, or sanitary pads that may contribute to symptoms 
  • ​​urinary symptoms, including urgency, frequency, dysuria, and bladder incontinence, particularly stress or urge incontinence, which may worsen postmenopausally and can contribute to local irritation 
  • ​​​pelvic symptoms eg pain and prolapse​​ 
  • ​​​bowel function 
  • ​medications; eg, antihistamines are drying.​​ 
• ​​Other systemic health conditions eg, skin, connective tissue disorders​. 
• Conduct a sexual history.

Infective causes 

• ​Sexually transmitted infections (chlamydia, gonorrhoea, trichomoniasis, HSV) 
• Recurrent candidiasis* 
• Bacterial vaginosis* 

​* Bacterial vaginosis and recurrent vulvovaginal candidiasis are more common in premenopausal women, though postmenopausal cases can occur in the presence of risk factors such as hormone therapy, diabetes, immunosuppression, or recent antibiotics. 

​Dermatological / inflammatory conditions 

• ​Lichen sclerosus 
• ​Lichen planus
• ​Psoriasis 
• ​Eczema/dermatitis 
• ​Contact/allergic vulvitis 

​Neoplastic / premalignant disease 

• ​Vulval intraepithelial neoplasia (VIN) 
• ​Vulval, cervical, endometrial, ovarian, bladder, or bowel malignancy 

​Systemic / other causes 

• ​Diabetes mellitus (predisposing to infection, vulval irritation) 
• ​Inflammatory bowel disease or fistulae 
• ​Pelvic organ prolapse (causing irritation, discharge, or bleeding) 
• ​Trauma/atrophy from pelvic radiotherapy or chemotherapy 

​​Consider that there may be multiple diagnoses. Particularly as poor skin health can exacerbate other dermatological conditions.​​​​ 

Signs of GSM include labial atrophy, vaginal dryness, introital stenosis, clitoral atrophy, and phimosis of the prepuce.  

Severe GSM can result in a vaginal surface that is friable and hypopigmented, with petechiae, ulcerations, and tears, as well as urethral findings such as caruncles, prolapse, or polyps.  

Bleeding may occur from minimal trauma, such as speculum insertion.  

• Abdominal examination​. 
• Assess external genitalia and anorectal skin:  
  • may show loss of clitoral hood, urethral caruncle, and labia minora atrophy 
  • evidence of excoriations or skin irritation due to atrophy or dryness. 
• Speculum examination: 
  • vaginal epithelium: thin, pale, less corrugated with loss of rugae 
  • skin appears thinner, with increased visibility of tiny blood vessels 
  • vaginal and vulval tissues are fragile and easily traumatised 
  • descent of anterior or posterior vaginal walls (cystocele, rectocele) 
  • vaginal shortening may be observed.

Atrophic Vulvitis

Urethral Caruncle

(With thanks to Associate Professor Amanda Oakley for use of images)

The Goodfellow short course: Vulval dermatology is a useful resource to help identify, assess, manage, and appropriately refer common vulval dermatological conditions.

Vaginal estrogens are the most effective treatment, and for the majority of individuals, it is not mandatory to trial the lifestyle and non-hormonal options prior.   

General management of GSM (non-hormonal options) 

• Non-hormonal measures are often first-line. 
• Lubricants for intercourse and moisturisers for ongoing symptoms are important. 
• Individualise product choice based on tolerance, compatibility (condoms/sex toys), and vaginal health (pH/osmolality).
• These approaches do not improve the histological change that is caused by low estrogen 

Lifestyle and self-care 

• Avoid tight clothing and irritants (scented soaps, bubble baths, douches). 
• General vulval skin care advice. 
• Advise gentle cleansing with emollient-based washes (e.g. Cetaphil). 

Lubricants (used at time of sexual activity) 

• First-line for reducing friction and discomfort during intercourse. 
• Encourage regular use by both partners. 
• Regular use has been associated with increase in pleasure and ease of orgasm. 
• Types: 
  • Water-based: widely available, can be drying with repeated use. 
  • Silicone-based: longer lasting, less drying; avoid with silicone sex toys or condoms. 
  • Oil-based lubricants are preferable as water-based products can be drying. Popular brands include Yes, Nu, and Natfem Balm. Coconut oil can also be used.   
  • Dr Jen Gunter highlights that vaginal products vary in pH and osmolality, which can impact vaginal health. Products with a pH close to physiological levels (≈4-5) and isoosmolar composition are least likely to disrupt the mucosa or microbiome, whereas hyperosmolar or alkaline products may irritate tissue or cause damage.  
  • If irritation occurs, trial a small skin patch test first; if intravaginal use still causes discomfort, switch to a propylene glycol-free, iso-osmolar, or silicone-based option. 

Moisturisers  

• Used 2 - 3 times weekly, irrespective of sexual activity 
• Provide baseline symptom relief, improve dryness, and facilitate comfortable sex. 
• Distinct from lubricants; not suitable for use during intercourse. 
• Hyaluronic acid (HA) is a naturally occurring glycosaminoglycan that promotes tissue hydration and epithelial repair, making it a promising non-hormonal option for postmenopausal vaginal atrophy. Clinical studies, including a randomised trial comparing HA vaginal gel with estriol cream, and a systematic review of nine studies, show that HA improves symptoms of vaginal dryness, itching, burning, and sexual discomfort^4,5. While effective for symptom relief, HA does not restore vaginal epithelial thickness or pH to the same extent as oestrogen therapy, so combination approaches may be needed in women with severe atrophy or additional urinary or sexual symptoms. 

Adjuncts 

• Pelvic floor physiotherapy: Useful for pain (particularly hypertonic pelvic floor), sexual dysfunction, and bladder symptoms, eg overactive bladder. Vaginal dilators or vibrators may improve blood flow, reduce pain, and provide psychological benefit. 
• Address contributing medications: Anticholinergics, antihistamines, and some antidepressants may exacerbate dryness. Fexofenadine is the least drying antihistamine. 
• Topical steroids may be required only if co-existing dermatitis or inflammatory vulval dermatoses are present. 
• Energy-based therapies (e.g. vaginal laser): Not routinely recommended; current evidence is limited and inconsistent. 

Vaginal oestrogens are the mainstay of treatment for moderate to severe symptoms of GSM. 

Vaginal estrogens help prevent and part-reverse atrophic changes by improving blood flow and promoting thickening of the vaginal epithelium. 

​​Systemic absorption is minimal. With low-dose vaginal oestrogen, serum estradiol levels generally remain within the normal postmenopausal range (typically ~3-10 pg/mL).  Transient increases may be detectable in the first weeks of use, especially when the vaginal epithelium is atrophic and more permeable. As the mucosa heals and thickens with treatment, systemic absorption decreases and levels stabilise back in the postmenopausal range¹.​ 

Vaginal oestrogens reduce the frequency of recurrent urinary tract infections in postmenopausal women (0.5 versus 5.9 episodes per year)⁶. 

The evidence in perimenopausal women with recurrent UTIs is less clear. However, if symptoms of GSM (eg. vaginal dryness, irritation) coexist with recurrent UTIs, a trial of topical oestrogen may be reasonable, guided by clinical judgement and individualised assessment. 
 

• Funded options in New Zealand: Estriol vaginal cream or pessaries are fully funded for postmenopausal women with GSM.
• Estriol 1 mg/g vaginal cream (Ovestin®): 
  • Initial dosing: Apply 0.5 g (0.5 ml) intravaginally at bedtime every night for 2 weeks. 
  • Maintenance dosing: Reduce to twice weekly once symptoms improve. 
  • Practical considerations: One applicator twice weekly corresponds roughly to one 15 g tube per month. 
  • Application tips: Some women may find the applicator uncomfortable particularly at first; the dose can be applied initially using a finger and gradually progressed to the applicator. Absorption occurs mainly through the anterior vaginal wall. For external GSM symptoms, including urethral or vulval irritation, cream may also be applied externally around the vulva and urethral meatus. 
• Set expectations: 
  • The first two weeks of daily therapy are intended to upregulate oestrogen receptors and restore the vaginal epithelium. 
  • Symptom improvement is usually noted within 2 - 4 weeks, but ongoing maintenance therapy is required to prevent recurrence. 
• Vaginal pessaries: 
  • Estriol pessaries are another funded option, providing similar efficacy to cream. 
  • Benefits include convenience, minimal mess, and precise dosing. 
  • Vagifem (estradiol 10 µg pessaries) may be used as an alternative for women who prefer estradiol; however, it is unapproved in NZ (Section 29) and not funded. 

Systemic 

• Minimal systemic absorption; serum oestradiol usually remains within the postmenopausal range. 
• Risks typically associated with systemic hormone therapy (eg, breast cancer, endometrial cancer, venous thromboembolism, cardiovascular disease) are not increased with low-dose vaginal oestrogen, based on clinical trials and large observational studies. 
• A progestogen is not required with low-dose vaginal oestrogen (there is no evidence of endometrial stimulation). 
• Package inserts still carry the boxed systemic hormone therapy warnings, which can cause confusion. 

Local 

• Vaginal discharge. 
• Vulvovaginal candidiasis. 
• Vaginal bleeding (usually dose-related, requires investigation) 
• Breast pain (uncommon). 
• Local irritation or sensitivity to cream base (rare). 

Pharmacokinetics and Safety 

• Systemic absorption is low. 
• Cohort studies have been reassuring, with no increased risk of CVD (myocardial infarction, stroke, pulmonary embolism/VTE, or cancer (total invasive breast, endometrial, ovarian, colorectal)  in post-menopausal women using vaginal oestogens^7,8.   
• In a 2019 meta-analysis use of vaginal estrogen was not found to be associated with risk of breast cancer⁹. 
• Data related to abnormal endometrial thickening and malignancy is reassuring.  A 2016 Cochrane review of RCTs reported no significant differences among vaginal estrogen formulations in terms of endometrial thickness, hyperplasia, or the proportion of women with adverse events (AEs). 
• The risk of venous thromboembolism (VTE) has not been found to be increased with vaginal oestrogen use.  However, prospective data for women at high risk of VTE is lacking. In large observational studies, neither vaginal estrogen nor systemic transdermal formulations of oestrogen have been associated with an increased risk of VTE¹. Therefore, low-dose vaginal oestrogen may be used, given minimal systemic absorption, the absence of a hepatic first-pass effect, and minimal, if any, effect on prothrombotic factors. 

Contraindications 

• Undiagnosed vaginal bleeding. 
• Active endometrial cancer. 
• Other active hormone-sensitive malignancy. 

Synthetic DHEA (dehydroepiandrosterone), a steroid precursor of oestrogens and androgens. Locally converted in vaginal tissues to oestrogen and testosterone, improving epithelial thickness, elasticity, and lubrication^11,12. 

6.5 mg vaginal pessary nightly at bedtime using the provided applicator. No predefined duration; continuous nightly use recommended for sustained symptom relief.   

Clinical evidence 

Improves vaginal epithelial maturation, lowers vaginal pH, and alleviates dryness, dyspareunia, and irritation.  May improve sexual function (desire, arousal), though effect sizes are variable.  Studies demonstrate efficacy comparable to that of low-dose local estrogen for symptom relief, although estrogen more effectively restores epithelial thickness¹². 

Side effects 

• Common: vaginal discharge, minor irritation. 
• Rare/serious: undiagnosed vaginal bleeding, local hypersensitivity. 

Cautions

• Not suitable for women with a history of oestrogen-sensitive cancers. 
• Minimal systemic absorption, but caution as per topical oestrogens if the patient has a breast or uterine cancer risk. 
• Individual response varies; it may take several weeks to notice improvement. 
• Does not restore vaginal pH or epithelial thickness to the same extent as topical oestrogen. 

Availability in New Zealand: Intrarosa (prasterone 6.5mg vaginal pessary) is available via named-patient import (Section 29) through selected pharmacies.  Contact pharmacy for supply and advice. 

Urogenital symptoms are common during and after breast cancer treatment, affecting approximately 75% of women. These symptoms significantly impact psychosocial wellbeing, sexual function, and relationships. 

A 2024 article in the Australian Journal of General Practice offers a tool for primary care clinicians to guide discussions, particularly considering breast cancer receptor subtype.  

• Use of topical oestrogen should be discussed with the treating specialist. 
• The mainstays of management are: 
• Genital skin care advice 
• Non-irritating vaginal moisturisers and lubricants 
• A patient-centred approach to shared decision-making 
• The Australian Menopause Society provides a helpful patient resource on this topic. 

This MedCase was created by Dr Danuta Amelung, BHB, MbChB, FRNZCGP, AFRACMA, Dip. Paed, PGCertWHlth, PGDipTrvMed with expert review by Dr Samantha Newman, FRCNZGP, MBChB, BSc (Hons), DipOMG.