Genitourinary Syndrome of Menopause (GSM)

There is a part of menopause that very few people talk about, and it is one I hear about often in my consults. Genitourinary syndrome of menopause, or GSM, is a common condition caused by the lower hormone levels that come around and after menopause.

It can affect the vulva, vagina, urethra, and bladder, and it shows up in all sorts of ways: dryness, burning, irritation, pain with sex, urinary urgency or frequency, leakage, and recurrent urinary tract infections (UTIs). Here is the part I really want you to know. Unlike many other menopause symptoms, GSM usually does not settle on its own, and it can quietly worsen over time if it is left untreated. The good news is that it is very treatable, and you do not have to put up with it.

Just how common is it?

More common than you might think. GSM affects somewhere between 27 and 84% of women, that is more than 1 in 2 of us experiencing bothersome genitourinary symptoms of menopause. So if this is you, please know you are in very good company.

The symptoms you might notice

‍ ‍GSM can show up in a few different ways, and it looks a little different for everyone. You might notice:

• Sexual symptoms: pain with intercourse, tightness, loss of pleasure, reduced libido, and reduced ability to climax.

• Vaginal or vulval symptoms: dryness, burning, itching, irritation, soreness, reduced lubrication, and vaginal discharge.

• Urinary symptoms: burning when you pass urine, needing to go more often, urgency, leakage, waking several times overnight to pass urine, and recurrent UTIs.

So why does it happen?

It comes down to oestrogen. After menopause, lower oestrogen causes the tissues of the vagina, vulva, bladder, and urethra to become thinner, drier, less elastic, and a little more fragile. The vaginal environment changes too, including its moisture, pH, and microbiome, and that can add to the irritation and urinary symptoms.

You do not have to just put up with it.

When symptoms can be more intense

For some women, symptoms hit harder than for others. That tends to be the case if you have had:

• surgical menopause

• chemotherapy or pelvic radiation

• breast cancer treatment such as aromatase inhibitors

• early menopause

What can actually help

Here is the reassuring part: there is a lot we can do. The right approach depends on your symptoms, your preferences, and your medical history, and it is something we work out together. Let me walk you through the main options.

1. Moisturisers, barrier creams, and lubricants

For a lot of women, this is a good first step for vulval and vaginal irritation.

• Moisturisers are the ones you use regularly to help with ongoing dryness.

• Barrier creams and balms are the thicker, greasier products. They moisturise and form a protective barrier, which helps with dryness and itching of the vulva. And in case you are wondering: no, they cannot double as lube.

One important thing: choose products without fragrances or harsh chemicals. Those ingredients can do more harm than good, and often lead to more irritation and itching.

A few easy options I often suggest:

• Bepanthen nappy rash ointment: a gentle, soothing barrier cream that helps protect the vulval skin from moisture. Cheap and cheerful. It is for external use only though, so do not put it inside your vagina, and do not use it as lube.

• Sudocrem: a common, thick, zinc-based cream that protects against moisture, acts as a barrier against urine, and helps with chafing. It is particularly good for irritated skin. Some people swear by it, though I will be honest, it is not my personal favourite. It is usually soothing, but zinc-based creams like Sudocrem can sometimes cause irritation, especially if the skin is already broken, because it contains benzyl alcohol.

• White petroleum jelly: yes, good old Vaseline. It is another readily available barrier ointment that can help with external irritation, and it is actually less likely to cause irritation or hypersensitivity than Bepanthen or Sudocrem, because it is just plain petroleum jelly. It is not a great moisturiser as such, but it is a powerhouse for barrier protection against moisture like sweat and urine, and against chafing.

• Vulva balms: personally, I am a big fan of Serenity pH's V Balm (I even use it as a cuticle and nail balm). Have a look at their webpage, they have a lovely range of vaginal and sexual health products, and both Sharon and Natalie share a wealth of knowledge on all things vaginal health in their blogs: serenityph.com.au/about-us.

• ‍And lubricants are the ones to reach for during sex, to reduce friction and discomfort.

2. Vaginal oestrogen

This is one of the most effective treatments we have for GSM, and it works well for a lot of women. Low-dose vaginal oestrogen helps with dryness, discomfort, painful sex, and some of the urinary symptoms too. It actually has the strongest evidence base of all the GSM treatments. Because so little of it is absorbed into the bloodstream, it is safe for nearly all women to use.

Is it safe? For most women, yes. Low-dose vaginal oestrogen is considered a useful and effective treatment, with very little absorption into the rest of the body.

3. Other prescription options

Depending on your situation, we might talk about other therapies, including other prescription options. There is not enough evidence to say one hormonal option is best for everyone, so this is something we tailor to you.

4. Pelvic floor physiotherapy

If you also have pelvic floor pain, tightness, pain with penetration, or some bladder symptoms, pelvic floor physiotherapy can be really helpful.

What you can do at home

Alongside any treatment, a few simple things can make a real difference:

• steer clear of irritants like harsh soaps, bubble baths, or fragranced products around the vulva

• use a vaginal moisturiser regularly if dryness is ongoing

• use lubricant for sex

• and keep talking to your doctor if symptoms continue, because there is effective treatment available

If you would like some further reading, Jean Hailes has a lovely guide on caring for your vulva and vagina: jeanhailes.org.au

When to see your doctor sooner

Most of the time GSM is uncomfortable rather than urgent, but please book in promptly if you notice:

• bleeding after menopause

• blood in your urine

• new or severe pelvic pain

• symptoms that just are not improving

• repeated UTIs

• any vulval skin changes, ulcers, or a lump that does not go away

If you take one thing from this

Let it be this: GSM is common (somewhere between 27 and 85% of women will experience it), it is very treatable, and it is absolutely worth talking about. You do not need to just put up with it. If it is affecting your comfort, your bladder, your sleep, or your sex life, please come and have a chat with your doctor.