Detailed definition
Genitourinary syndrome of menopause (GSM) was named in 2014 by the North American Menopause Society (NAMS) and the International Society for the Study of Women's Sexual Health (ISSWSH) to replace the older terms vulvovaginal atrophy, atrophic vaginitis, and urogenital atrophy. The new name was chosen for two reasons: (1) it captures the lower-urinary-tract component, which the older terms ignored, and (2) the word "atrophy" is clinically loaded and discouraged some women from seeking care. GSM is the umbrella diagnosis used in NAMS, ACOG, and Endocrine Society guidance.
The genital component includes vaginal dryness, burning, irritation, decreased lubrication, dyspareunia (painful intercourse), and post-coital bleeding. The urinary component includes urgency, dysuria, and recurrent urinary tract infections. The underlying mechanism is estrogen withdrawal: vaginal epithelium thins and loses glycogen, lactobacilli decline, vaginal pH rises (from ~4.0 toward ~6.0), and the urethra and bladder trigone — which are densely populated with estrogen receptors — also atrophy. Approximately 50–70% of postmenopausal women have GSM, and unlike vasomotor symptoms (hot flashes, night sweats) it is progressive and does not improve without treatment.
Why it matters in menopause
GSM is among the most undertreated conditions in women's health. Survey data from NAMS and ISSWSH consistently shows that women feel embarrassed to bring it up, clinicians often don't ask, and many women don't realize that vaginal dryness and recurrent UTIs are linked to a treatable hormonal cause. Vaginal estrogen, at the doses used in modern practice, raises serum estrogen levels by a tiny fraction of systemic HRT. The 2024 ACOG Practice Bulletin and the 2020 NAMS Position Statement both emphasize that low-dose vaginal estrogen is considered safe even for many breast-cancer survivors with their oncologist's coordination.
Treatment options
Treatment options span a tiered approach. For mild cases, vaginal moisturizers (Replens, Hyalo Gyn) and lubricants are first line. For moderate-to-severe symptoms, vaginal estrogen — cream (Estrace, Premarin), tablet (Vagifem), insert (Imvexxy), or ring (Estring) — reverses the underlying tissue change directly and is the gold standard. Compounded estrogen + progesterone vaginal cream is a common 503A pharmacy alternative. Intravaginal DHEA (prasterone, Intrarosa) is a non-estrogen FDA-approved option. Oral ospemifene (Osphena) is a selective estrogen receptor modulator approved for moderate-to-severe dyspareunia. Women with overlapping vasomotor symptoms often get GSM relief as a side effect of full systemic HRT.
Related terms
Sources
- NAMS GSM Position Statement (2020)
- ACOG Practice Bulletin on GSM (2024)
- Endocrine Society Clinical Practice Guideline
External references: Wikipedia: Atrophic vaginitis.