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What is Genitourinary Syndrome of Menopause?

Genitourinary syndrome of menopause (GSM) describes a group of symptoms and physical changes that affect the genital, urinary, and sexual health of women during peri- and post-menopause. GSM is thought to affect over half of all women who are postmenopausal. However, it often goes underdiagnosed and undertreated. Women may find it difficult to discuss symptoms of GSM with their healthcare providers. To complicate matters, symptoms of GSM look like those of other genitourinary conditions which may lead to misdiagnoses and delays in treatment.

GSM is a chronic and progressive condition that affects the lower urinary tract, vagina, and vulva. During perimenopause and after menopause, there are declining levels of estrogen and androgen in the genitourinary tract. This hormonal shift leads to physical changes and atrophy of vaginal, valvular, bladder, and urethral tissues. Physical changes and symptoms often reduce quality of life. Symptoms of GSM are progressive and worsen if left untreated.

During menopause, the ovaries stop producing estradiol. This results in a 95% decline in estradiol, a form of estrogen. Estrogen plays a key role in maintaining the elasticity, moisture, and blood flow of the tissues of the vagina, vulva, bladder, and urethra. A decline in estrogen leads to vaginal and urogenital atrophy. Vaginal secretions and lubrication are also reduced leading to vulvovaginal dryness and painful intercourse.

Estrogen also maintains a healthy, balanced, vaginal flora. It supports the growth of lactobacilli, which creates an acidic environment that protects the vagina and urinary tract from infections. When estrogen levels fall, lactobacilli decrease, vaginal pH rises, and the risk of infection increases.

While GSM is often associated with natural menopause, it is important to note that other conditions can also lower estrogen levels. Surgical menopause or oophorectomy, chemotherapy, primary ovarian insufficiency, and hypothalamic amenorrhea can contribute to decreased hormone levels and onset of GSM symptoms.

Quality of Life

GSM does not just affect the body. It can take a toll on a person’s emotional, psychological, and social well-being. It can lead to depression, anxiety, lowered self-esteem, and negatively impact personal relationships. Often, patients don’t seek help because they think their symptoms are a natural part of aging or they feel too embarrassed to talk to their provider.

Sexual symptoms of GSM like dyspareunia (painful intercourse) and decreased libido (sexual desire) often cause people to avoid intimacy out of frustration or embarrassment. As a result, their partners can feel rejected or confused, putting strain on the relationship.

Physical changes to the genital area such as vaginal dryness or loss of elasticity, may result in women having a poor body image or lowered self-esteem. They may feel ashamed about their body or feel they are losing their womanhood.

Urinary symptoms may cause emotional and social distress. Urgency or incontinence in public can lead to embarrassment or avoidance of social situations. Women may avoid exercise for fear of leakage.

2025 Guidelines

The term genitourinary syndrome of menopause was first used in 2014. However, since that time, there has been little guidance on how to define or diagnose it. In 2025, the American Urological Association released formal GSM guidelines titled Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline (2025). These guidelines aim to improve quality of life for patients with GSM while optimizing symptom control. The guidelines provide information to healthcare providers on the identification and diagnosis of GSM. The guidelines also discuss how to counsel patients and provide treatment options for GSM.

“One of the most rewarding parts of my clinical practice has been helping patients improve their quality of life by addressing symptoms of GSM. Through scientific evidence and the application of shared decision making, this AUA guideline will help clinicians educate, empower, and treat patients with GSM.”

– Dr. Una Lee, vice-chair of the GSM guidelines

The guidelines emphasize a patient-centered approach to treating GSM that focuses on shared decision-making between patient and provider. Providers should understand the patient’s treatment goals and preferences. Education on symptoms, diagnosis, and treatment options is paramount.

Diagnosis

Diagnosis of GSM encompasses a physical examination, collecting a thorough patient history, and a careful review of symptoms.

Patients should be screened for GSM symptoms. It is important for providers to lead the patient through a thorough screening of symptoms because patients may be reluctant to discuss symptoms or bring up symptoms on their own. Providers should reassure patients that symptoms are common. Providers should understand which symptoms are most bothersome to the patient.

A focused history of GSM symptoms should be collected. It is important to understand when symptoms started, the severity of symptoms, and whether the symptoms affect the patient’s quality of life.

A pelvic exam helps confirm signs of GSM, such as tissue atrophy or physical changes. The physical exam should look for the presence of other conditions to ensure differential diagnoses are treated appropriately.

Treatment

Treatment for GSM should be tailored to the goals and preferences of individual patients. When discussing treatment options, providers should clearly explain both risks and benefits.

In the treatment of GSM, the use of natural or herbal supplements is not recommended. The FDA does not regulate these supplements. Their quality and formulations may be variable, making their effects and risks not generally predictable. In addition, there is little scientific data available to support the use of supplements.

Patients should be advised to avoid the use of soap or cleansers that may cause irritation and increase the symptoms of GSM.

Follow-up is essential. Providers should check in regularly to assess whether the treatment is working or if adjustments are needed. Since GSM is progressive, treatment may need to be modified over time.

Conclusion

Genitourinary syndrome of menopause is common, often distressing, and frequently underdiagnosed. By raising awareness and educating patients, providers can create a safe space for open discussion. This can lead to timely diagnosis, effective treatment, and an overall improvement in quality of life.

Terese H., APPE Student

Resources

1. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 0(0). doi:10.1097/JU.0000000000004589. https://www.auajournals.org/doi/10.1097/JU.0000000000004589
2. American Urological Association. American Urological Association Releases New Guideline on Genitourinary Syndrome of Menopause. 28 Apr. 2025, American Urological Association, www.auanet.org/about-us/media-center/press-center/american-urological-association-releases-new-guideline-on-genitourinary-syndrome-of-menopause. Accessed 27 Aug. 2025.
3. Carlson K, Nguyen H. Genitourinary Syndrome of Menopause. [Updated 2024 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559297/