Genitourinary Syndrome of Menopause (GSM): Why Vaginal Dryness Gets Worse — and What Helps
If you’ve noticed vaginal dryness, irritation, pain with sex, urinary symptoms, or a feeling that things just don’t feel the same anymore — you’re not imagining it, and you’re not alone.
These changes are very common during perimenopause and menopause. They have a name: Genitourinary Syndrome of Menopause (GSM).
Unlike many menopausal symptoms that often improve over time — such as hot flashes or brain fog — GSM tends to worsen over time if left untreated.
The good news is that GSM is very treatable.
What is GSM?
GSM refers to changes in the vaginal and urinary tissues caused by declining estrogen levels during perimenopause and menopause.
Estrogen plays an important role in maintaining tissue thickness, elasticity, blood flow, and natural moisture. As estrogen levels fall, these tissues can become thinner, drier, and more fragile. Without treatment, symptoms often progress gradually rather than stabilizing on their own.
How common is GSM?
GSM is extremely common:
It affects a majority of women in midlife
It can begin during perimenopause, not just after menopause
It is frequently underdiagnosed and undertreated
Many women experience GSM symptoms without ever being told what they are — or that effective treatment exists.
Common symptoms
GSM can affect genital, sexual, and urinary health. Symptoms may include:
Vaginal dryness, burning, or irritation
Pain with penetration
Itching or recurrent discomfort
Recurrent urinary tract infections
Urinary urgency, frequency, or leakage
Bleeding, tearing, or soreness with sex
These symptoms are often minimized, but they are not trivial — and they are not something you have to “just live with.”
Where lubricants help — and where they don’t
Lubricants can be helpful for comfort during sexual activity.
Not all lubricants are the same:
Some water-based lubricants dry quickly or pull moisture from tissue
Silicone-based lubricants tend to last longer and reduce friction
Lubricants help with symptoms, but they do not reverse the underlying tissue changes caused by estrogen decline.
If symptoms are persistent, progressive, or affecting quality of life, medical treatment is often appropriate.
Medical treatment options for GSM
Treatment is individualized and may include:
Low-dose vaginal estrogen (cream, tablet, or ring)
Vaginal DHEA
Non-hormonal prescription options
Pelvic floor physical therapy
Addressing contributing factors such as inflammation or skin conditions
Low-dose vaginal estrogen is considered safe for the vast majority of women.
Systemic absorption is extremely small, and blood estrogen levels remain very low.
If you have been told you are “not a candidate” for vaginal estrogen, get another opinion — ideally from a clinician who specializes in menopause care.
If you have been told you are “not a candidate” for vaginal estrogen, this is often incorrect — and it is reasonable to seek another opinion. Vaginal estrogen is not the same as systemic hormone therapy and is safe in essentially all clinical situations when used appropriately. It is well studied, highly effective, and often life-changing for GSM symptoms.
Many women are surprised to learn that systemic menopausal hormone therapy (MHT) does not always fully treat GSM.
Even among women taking systemic estrogen, up to 30–40% continue to have persistent vaginal or urinary GSM symptoms and benefit from additional local (vaginal) therapy. Systemic estrogen levels that are appropriate for hot flashes, sleep, or mood are often not sufficient to fully restore vaginal tissue health.
If you are already on systemic MHT and still experiencing GSM symptoms, adding vaginal estrogen is often more effective than increasing your systemic dose.
Why GSM is often missed
GSM is frequently overlooked because:
Many women don’t bring it up
Symptoms feel personal or embarrassing
There is a misconception that nothing can be done
At the same time, many clinicians receive limited training in midlife sexual health. Reassurance is often offered when treatment would be more appropriate.
GSM deserves the same thoughtful, evidence-based care as any other medical condition.
When to seek care
Now.
If you are experiencing any symptoms of GSM, there is no need to wait for things to get “bad enough.”
Early treatment matters — especially when pain is involved.
As someone who spends much of my time helping midlife women navigate low libido, I see this pattern frequently: once pain enters the equation, treating libido becomes significantly more difficult — even after the tissue has healed.
Our brains remember pain.
So do our partners.
When discomfort or pain leads to avoidance — by you, your partner, or both — a cycle can develop:
Pain → avoidance
Fear of pain → further avoidance
Loss of confidence, intimacy, and desire
Addressing GSM before pain becomes established can help prevent this cycle from forming in the first place.
There is no benefit to waiting.
A note on collaborative care
Pelvic floor physical therapy can be an important part of GSM treatment, particularly when pain, muscle tension, or urinary symptoms are present. A collaborative, multidisciplinary approach often leads to the best outcomes.
Final thought
GSM is common, progressive if untreated, and very treatable.
You do not need to live with dryness, discomfort, pain, or urinary symptoms — and you do not need to wait.
If you want evidence-based, individualized menopause care, help is available.
→ Schedule a menopause consultation
Educational content only. Not a substitute for personalized medical advice.
