Genitourinary Syndrome of Menopause (GSM)

What You Need to Know

Introduction

Menopause is a physiological phase in a woman's life, characterized by the decline in ovarian hormone production, particularly estrogen. This hormonal shift leads to numerous physical and psychological changes. A key clinical concern during this phase is the Genitourinary Syndrome of Menopause (GSM).
GSM describes the range of symptoms and clinical findings that result from estrogen deficiency in the genital and urinary tract. The terms vulvovaginal atrophy (VVA) or atrophic vaginitis are often used synonymously, but the term GSM provides a more comprehensive framework as it also encompasses urinary symptoms.

Prevalence

• GSM affects 27–84% of postmenopausal women.
• First symptoms already occur in about 15% of women during perimenopause.
• Other mucous membranes can also be affected, such as the conjunctiva, with approximately 72% of menopausal women reporting dryness of the eyes.
• Women spend, on average, more than one-third of their lives in a postmenopausal state, highlighting the importance of appropriate diagnosis and treatment of GSM.
• More than 75% of affected women report a negative impact on their sexual lives.

Causes

The decline in estrogen production from the ovaries leads to profound anatomical and functional changes in the genital and urinary tract:

• Thinning and loss of elasticity of the vaginal epithelium
• Reduced blood supply to the vulva, vagina, and urethra
• Decreased collagen and glycogen production
• Increased vaginal pH (above 5.5)
• Weakening of local immune defenses and changes in the vaginal microbiome

Estrogen receptors are densely present in the vulva, vagina, urethra, and vestibule. Therefore, the hormone deficiency affects not only the vaginal epithelium but the entire lower genital and urinary tract.

Symptoms

Vaginal Symptoms

• Vaginal dryness
• Itching, burning
• Painful intercourse (dyspareunia)
• Decreased elasticity of the vaginal wall
• Vaginal laxity and tendency toward prolapse
• Thinning and fragility of the epithelium
• Occasional mild vaginal discharge

Urinary Symptoms

• Dysuria (painful urination)
• Urge incontinence
• Frequent urination
• Nocturia (frequent nighttime urination)
• Recurrent urinary tract infections

Sexual Dysfunction

• Pain during intercourse
• Reduced lubrication
• Loss of libido
• Restrictions in sexual spontaneity and relationship problems

Psychosocial Impact

Surveys such as the REVIVE study (n = 3,046 women) show:

• 65% experience restrictions in sexual activity
• 62% feel limited in their intimacy
• 55% report relationship problems with their partner

Diagnosis

The diagnosis of GSM is based on:

• Medical History: Actively asking about symptoms is essential, as many women do not mention them voluntarily due to embarrassment.
• Gynecological Examination: Assessment of vaginal mucosal thickness, moisture, elasticity, and pH.
• pH Test: A vaginal pH greater than 5.5 indicates estrogen deficiency.
• Microscopy or Vaginal Swab: Optional for differential diagnosis or assessment of the vaginal microbiome.

Treatment

1. General Measures

• Healthy lifestyle (balanced diet, physical activity)
• Avoiding smoking and excessive alcohol consumption
• Regular sexual activity or masturbation to promote blood circulation
• Pelvic floor training / physiotherapy

2. Non-Hormonal Therapy

Vaginal Moisturizers and Lubricants

• Water-based, silicone-based, or oil-based (allergy considerations apply)
• Symptomatic relief, but no causal treatment

Hyaluronic Acid (gels or injections)

• Improves vaginal moisture and elasticity

Probiotics, Vitamin D, Vitamin E

• Theoretical beneficial effects on the microbiome, but limited scientific data

Vaginal Dilators

• Used in cases of vaginal stenosis or shortening due to estrogen deficiency

Ospemifene (SERM)

• Oral therapy with local estrogen-agonistic effects on the vaginal mucosa
• No stimulation of the endometrium or breast tissue
• Improves dyspareunia, lubrication, orgasm ability, and libido

Laser Therapy (CO₂ or Erbium-YAG Laser)

• Improves vaginal structure through collagen regeneration
• Long-lasting symptom relief (up to 24 months)
• No severe side effects reported in studies
• No official recommendation yet from ACOG

3. Hormonal Therapy

Local Estrogen Preparations

• Vaginal tablets
• Vaginal creams
• Vaginal rings

Advantages

• Rapid symptom improvement (1–3 months)
• Minimal systemic absorption
• No endometrial proliferation with correct use

Systemic Hormone Therapy (MHT)

• Indicated if additional climacteric symptoms are present
• Can improve GSM
• In isolated GSM, local therapy is preferred

DHEA (Dehydroepiandrosterone)

• Local application
• Conversion into estrogens and androgens at the site of action
• Improves dyspareunia, lubrication, and sexual function
• No stimulation of the endometrium
• Solid scientific evidence, FDA-approved for dyspareunia

Testosterone Cream

• In cases of combined GSM and decreased libido
• Limited data currently available

4. Innovative Procedures

Platelet-Rich Plasma (PRP)

• Experimental treatment for tissue regeneration

Threads, G-Shot, Botox

• Rejuvenation of the external genital area, limited evidence

Radiofrequency and High-Intensity Focused Electromagnetic Energy (HIFEM)

• Emerging therapeutic options, clinical data still evolving

Prevention

• Early education about GSM during perimenopause
• Healthy lifestyle
• Encouraging regular sexual activity
• Supplementation with micronutrients (Vitamin B2, Biotin, Niacin, Vitamin A, Zinc, Vitamin B12, Vitamin D, Folic Acid, Magnesium)

Conclusion

Genitourinary Syndrome of Menopause is a widespread, yet often underdiagnosed and undertreated condition. The symptoms can significantly impair quality of life. Due to the broad range of treatment options—from local hormonal therapy and non-hormonal alternatives to modern technologies such as laser therapy—an individualized and effective approach can be established for affected women. The prerequisite is open discussion of the topic in gynecological practice.