What Is Actually Happening, Why It Matters Beyond the Bedroom, And The Full Evidence-Based treatment landscape – including the landmark 2025 guidelines

The Problem Most Women Suffer in Silence

Of all the symptoms of perimenopause and menopause, vaginal dryness and genital discomfort are among the most prevalent, most distressing, and most consistently undertreated. Unlike hot flushes – which are widely discussed and frequently treated – vaginal and urinary changes are shrouded in the kind of silence that comes from embarrassment, from the assumption that nothing can be done, and from a healthcare system that historically asked about these symptoms far too rarely.

The clinical picture that has emerged from the past decade of research is unambiguous: this is not a minor inconvenience, not simply a sexual health issue, and not something to be accepted as inevitable. Genitourinary syndrome of menopause (GSM), previously known as vulvovaginal atrophy, is a chronic, progressive hypoestrogenic condition affecting vulvovaginal, urinary and sexual health in women. Common symptoms include vaginal dryness, itching, dyspareunia, urinary urgency and recurrent urinary tract infections. Despite the high prevalence, GSM is underdiagnosed and undertreated, thereby negatively impacting women’s quality of life.

This article explains what is happening biologically, maps the full spectrum of symptoms, presents the 2025 updated clinical guidelines, and provides the complete evidence-based treatment approach – from first-line non-hormonal options to the most advanced interventions now available.

Part 1: The Biology – Why the Genitourinary System Is So Vulnerable to Estrogen Loss

The Anatomical Foundation

The vagina, vulva, urethra, and bladder share a common embryological origin – they all develop from the same tissue. And they all express estrogen receptors throughout their structure. This anatomical kinship is why estrogen loss at menopause does not produce isolated vaginal dryness but rather a syndrome affecting the entire genitourinary system simultaneously.

In the estrogen-rich environment of the reproductive years, the vaginal epithelium is thick, well-lubricated, elastic, and richly folded (the folds are called rugae). Its surface is colonized by Lactobacillus species that metabolize glycogen – a carbohydrate stored in the epithelial cells – into lactic acid, maintaining vaginal pH at approximately 3.5–4.5. This acidic environment is both the product and the guardian of vaginal health: it protects against pathogenic bacteria, suppresses Candida overgrowth, and is maintained by the continuous presence of estrogen.

The Cascade of Estrogen Withdrawal

When estrogen falls during perimenopause and menopause, every element of this system is disrupted simultaneously:

The hypoestrogenic state results in hormonal and anatomical changes in the genitourinary tract, with vaginal dryness, dyspareunia, and reduced lubrication being the most prevalent and bothersome symptoms.

Specifically: the vaginal epithelium thins from approximately 30 cell layers to 5–10 layers; glycogen content falls, depriving Lactobacillus of its substrate; Lactobacillus populations decline; lactic acid production falls; pH rises to 5.5–7.0; pathogenic and commensal bacteria proliferate; inflammatory cells infiltrate the thinned epithelium; lubrication from Bartholin’s glands and transudation decreases; the rugae flatten and disappear; the vaginal opening (introitus) narrows; and collagen content of the vaginal walls falls, reducing elasticity and compliance.

This is the biological reality of what women describe as “dryness.” It is structural, measurable, and – critically – progressive. Unlike hot flushes, which typically improve over time as the body adapts, GSM worsens without treatment.

The Urinary Dimension

The bladder trigone (the base of the bladder, richest in estrogen receptors) and the urethra are equally affected. As estrogen falls, urethral tissue thins, the resting urethral pressure decreases, and the urethral microbiome shifts in ways that increase susceptibility to ascending bacterial infection. In patients with GSM and recurrent urinary tract infections, clinicians should recommend local low-dose vaginal estrogen to reduce the risk for future urinary tract infections – a Moderate Recommendation with Grade B evidence level from the 2025 AUA/SUFU/AUGS Guideline.

The prevalence of recurrent urinary tract infections (three or more per year) increases dramatically in postmenopausal women – a pattern that is not simply a product of ageing, but a direct consequence of genitourinary estrogen withdrawal that is partially or wholly reversible with local estrogen treatment.

Part 2: The Full Symptom Spectrum – What GSM Actually Includes

The name “genitourinary syndrome of menopause” was adopted in 2014 to replace the older term “vulvovaginal atrophy” precisely because the clinical picture extends far beyond the vagina. Presence of at least one GSM symptom ranges from 14% to 87% in postmenopausal women, with vaginal dryness and dyspareunia being the two most common symptoms. The most reported GSM symptom is vaginal dryness (47–100%) followed by dyspareunia (20–77.6%). Dysuria and urgency commonly co-occur, and even the prevalence of urinary incontinence varies between 23% and 50%.

Vulvovaginal symptoms:

• Vaginal dryness – the defining symptom, present in nearly every affected woman
• Vaginal irritation, burning, and itching – often mistaken for infection
• Dyspareunia (painful intercourse) – from insufficient lubrication, reduced tissue elasticity, and vaginal narrowing
• Post-coital bleeding or spotting – from friable, thinned epithelium
• Vaginal discharge – from altered microbiome and pH
• Loss of labia minora tissue – the labia minora may disappear entirely in advanced GSM
• Clitoral atrophy – reduced clitoral hood tissue, with implications for sexual sensation and orgasm

Urinary symptoms:

• Urinary urgency and frequency
• Dysuria (burning on urination)
• Urinary incontinence – stress, urgency, or mixed
• Recurrent urinary tract infections
• Nocturia

Sexual symptoms:

• Reduced lubrication during arousal
• Delayed or absent arousal response
• Reduced orgasmic intensity or frequency
• Avoidance of sexual contact due to anticipated pain
• Secondary loss of desire (driven by the pain-avoidance cycle)

The sexual and urinary dimensions are often treated as if they are separate problems. They are the same problem, originating from the same cause.

Part 3: The 2025 Clinical Guidelines – What the Evidence Now Requires

The AUA/SUFU/AUGS 2025 Guideline

The most significant development in the GSM clinical landscape in 2025 is the publication of the first joint guideline from three major American urological and gynecological societies – the American Urological Association, the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, and the American Urogynecological Society.

This guideline provides the most comprehensive, evidence-graded recommendations for GSM management ever published. Its key clinical recommendations:

Clinicians should offer the option of local low-dose vaginal estrogen to patients with GSM to improve vulvovaginal discomfort/irritation, dryness, and/or dyspareunia (Strong Recommendation; Evidence Level: Grade C). Clinicians should offer the option of vaginal dehydroepiandrosterone (DHEA) to patients with GSM to improve vulvovaginal dryness and/or dyspareunia (Moderate Recommendation; Evidence Level: Grade C). Clinicians may offer the option of ospemifene to patients with GSM to improve vulvovaginal dryness and/or dyspareunia (Moderate Recommendation; Evidence Level: Grade C). Clinicians should recommend the use of vaginal moisturizers and/or lubricants, either alone or in combination with other therapies, to improve vaginal dryness and/or dyspareunia in patients with GSM (Moderate Recommendation; Evidence Level: Grade C).

The guideline also addresses two populations who have historically been left without adequate guidance: women with recurrent UTIs (for whom local vaginal estrogen is now a strong recommendation) and women who have had breast cancer (for whom the evolving evidence on local estrogen and non-estrogen options is addressed directly for the first time).

NICE 2024 Updated Guidance

The UK’s NICE updated its menopause guidance in 2024, adding new recommendations on two non-estrogen treatments. Prasterone is recommended as a second-line option for GSM after vaginal estrogen, non-hormonal moisturizers, and/or lubricants. Ospemifene is recommended as a first-line option specifically for those with dexterity issues. Ospemifene can be used in women who have had breast or endometrial cancer, as long as treatment is complete – groups for whom HRT provision can be difficult, so this is a welcome addition to the range of treatment options.

The Fifth International Consultation on Sexual Medicine (ICSM 2024)

The Fifth ICSM, publishing recommendations in Sexual Medicine Reviews in 2025, synthesized data from eight researchers and clinicians with expertise in menopause medicine, confirming the step-up approach to GSM management as the evidence-based standard: non-hormonal first, then local hormonal, then systemic hormonal, then energy-based – with the choice at each step guided by individual clinical context, preferences, and contraindications.

Part 4: The Treatment Landscape – From First to Last Line

Step 1: Non-Hormonal – Lubricants and Moisturizers

These are first-line regardless of symptom severity, and they are not the same thing:

Vaginal moisturizers are used regularly (2–3 times per week) independent of sexual activity. They are designed to restore baseline vaginal hydration, support the mucosa, and – in formulations containing hyaluronic acid or polycarbophil – partially restore the tissue environment over time. They address the underlying tissue condition, not merely the acute friction of intercourse. Hyaluronic acid-based vaginal gels have the strongest evidence for maintaining pH and tissue hydration, with a good tolerability profile.

Personal lubricants are used specifically during sexual activity to reduce friction and prevent micro-trauma. They are not therapeutic – they do not reverse the underlying tissue changes – but they substantially reduce dyspareunia while other treatments are initiated.

The WHO recommends lubricants with an osmolality below 1,200 mOsm/kg – hyperosmolar products (including many widely-used commercial lubricants) can damage vaginal mucosa cells. Women should check osmolality information or choose water-based lubricants labelled “iso-osmolar” or “body-safe.” Silicone-based lubricants are longer-lasting and osmolality-neutral but are incompatible with silicone toys. Oil-based lubricants are deeply hydrating but degrade latex condoms.

Step 2: Local Hormonal Therapy – Vaginal Estrogen

Local vaginal estrogen is the gold standard pharmacological treatment for GSM. It restores vaginal pH, thickens the epithelium, induces collagen synthesis, increases vaginal secretions, restores Lactobacillus populations, and reduces the urinary symptoms associated with urethral thinning – all with minimal systemic absorption.

Available forms include:

• Vaginal cream (estradiol or estriol) – applied with an applicator; very effective but can be messy and requires compliance
• Vaginal tablet or suppository (estradiol) – clean, simple to use, strong evidence
• Vaginal ring (estradiol) – replaced every 90 days; maximizes convenience and compliance
• Vaginal gel – newer formulation with good tolerability

The systemic absorption of local vaginal estrogen is extremely low – studies consistently demonstrate serum estradiol levels remaining within the postmenopausal reference range. The historic clinical hesitancy about prescribing vaginal estrogen to women with a history of breast cancer is being actively revised: the 2024 NICE guidelines and the 2025 AUA guidelines both provide frameworks for its use in selected cancer survivors after discussion with the oncology team.

There is no evidence that local vaginal estrogen needs to be “cycled” or used at the lowest possible dose – effective symptom control should be the dose target, and long-term use (indefinitely, for as long as symptoms are present) is supported by the evidence.

Step 3: Vaginal DHEA (Prasterone)

Prasterone – intravaginal DHEA – works through a different mechanism from estrogen. DHEA is converted within vaginal tissue to both estrogens and androgens locally, without significant systemic absorption and without meaningful increase in systemic sex steroid levels. The DHEA in prasterone is converted to estrogens and androgens in the vagina; it is contraindicated if there is a history of breast cancer.

It is administered as a daily vaginal pessary (6.5 mg). Clinical trial data confirms significant improvements in vaginal dryness, dyspareunia, and sexual function with a tolerability profile superior to some formulations of vaginal estrogen. Under the 2024 NICE guidelines, it is positioned as a second-line option after vaginal estrogen and non-hormonal treatments.

Step 4: Ospemifene

Ospemifene is the only oral (tablet) treatment for GSM – administered as a once-daily 60 mg tablet. It is a selective estrogen receptor modulator (SERM) that acts as an estrogen agonist in vaginal tissue but as an antagonist in breast and endometrial tissue. This dual action makes it the most clinically important treatment for women who cannot use topical estrogen (due to compliance difficulty, preference, or contraindications) and who have had hormone-sensitive cancers – provided treatment is complete and the decision is made with oncology input. Ospemifene can be used in women who have had breast or endometrial cancer, as long as treatment is complete – these are groups for whom HRT provision can be difficult, so this is a welcome addition to the range of treatment options.

Clinical trial data confirm significant improvements in vaginal dryness and dyspareunia with ospemifene, with the largest positive impact on Female Sexual Function Index scores among all GSM treatments in at least one Bayesian network meta-analysis. Side effects include vasomotor events (some women experience hot flushes) and a theoretical – though clinically unsubstantiated at standard doses – thromboembolic risk.

Step 5: Energy-Based Therapies – Laser and Radiofrequency

Vaginal laser therapy has generated substantial clinical interest since its introduction in 2014 – and equally substantial controversy about the appropriate level of evidence required before widespread adoption.

Two primary laser technologies are used: the fractional microablative CO₂ laser and the non-ablative photothermal Erbium:YAG laser. Both work by creating controlled thermal stimulation of vaginal tissue, stimulating collagen synthesis, and promoting restoration of epithelial thickness and glycogen content. Radiofrequency devices produce similar tissue effects through different energy delivery.

A systematic review of 25 studies investigating CO₂ laser treatment for GSM involving 1,152 patients found significant improvements in dryness, dyspareunia, itching, burning, and dysuria, and no major adverse events were reported.

However, a landmark randomized controlled trial published in JAMA in 2021 – the most rigorously designed study to date, comparing fractional CO₂ laser to sham treatment – found no statistically significant difference in symptom severity between active and sham laser, raising important questions about the placebo contribution to the positive results seen in uncontrolled studies.

The current clinical consensus is that laser therapy is a reasonable second or third-line option for women who are non-responsive to or intolerant of hormonal treatments, and particularly for women with contraindications to both estrogen and ospemifene (such as those on active aromatase inhibitor therapy for breast cancer). It is not, on current evidence, a first-line or superior-to-estrogen option. Shared decision-making, informed by the evolving evidence, is essential.

Pelvic Floor Physiotherapy

In patients with GSM and pelvic floor dysfunction, clinicians may refer to a physical therapist specialising in pelvic floor conditions (Expert Opinion from the 2025 AUA/SUFU/AUGS Guideline).

Pelvic floor physiotherapy addresses the muscular and connective tissue dimensions of GSM symptoms that pharmacological treatments cannot reach. A trained pelvic physiotherapist can address: hypertonic pelvic floor muscles (the protective tightening that develops in response to anticipated pain during intercourse); reduced vaginal caliber; bladder dysfunction contributing to urgency and incontinence; and the breathing and relaxation strategies that modify the nervous system’s pain response. Vaginal dilator therapy – when used progressively and in collaboration with physiotherapy – can restore vaginal capacity in women who have experienced significant narrowing.

Part 5: What Women Can Do at Home

The Daily Vulvovaginal Care Routine

Cleansing: The vulva (external genitalia) should be cleansed with water only, or with an unperfumed, pH-balanced intimate wash if preferred. No soaps, shower gels, feminine hygiene products, douches, or deodorants should enter the vaginal area – these disrupt the microbiome and worsen symptoms. Internal washing (douching) should be avoided categorically.

Moisturizing: A vaginal moisturizer applied 2–3 times weekly is the non-prescription foundation of care. Hyaluronic acid-based gels (available over the counter) have the strongest evidence. For external vulvar dryness and irritation, a plain emollient – coconut oil, vitamin E oil, or an unscented intimate moisturizer – applied to the vulvar skin (not internally) can provide significant comfort.

Lubricants: Keep a body-safe lubricant available and use it proactively – before any discomfort is anticipated, not as a response to pain already occurring. Using lubricant is not a failure; it is an evidence-based adaptation.

Clothing: Breathable, natural-fiber underwear (cotton or bamboo) reduces the moisture and heat that promote bacterial and fungal overgrowth in an already-compromised environment. Tight synthetic fabrics should be avoided, particularly in women with active symptoms.

Sexual activity: Regular consensual sexual activity – alone or with a partner – promotes vaginal blood flow, maintains epithelial health, and prevents progressive vaginal narrowing. This is not a social recommendation; it is a physiological one, supported by clinical evidence. This may require lubricants, positioning changes, more time for arousal, and – ideally – treatment of the underlying tissue condition. The goal is pleasurable activity without pain, not forcing through pain.

Nutritional Support

Omega-3 fatty acids – reduce systemic inflammation that contributes to mucosal dryness, and support the lipid content of cell membranes throughout the genitourinary tract.

Vitamin E – has evidence for external vulvar application and, as a dietary antioxidant, supports tissue health throughout the body. Vitamin E suppositories have small but positive evidence for vaginal dryness specifically.

Phytoestrogens – soy isoflavones, red clover, and flaxseed have weak estrogenic activity that may provide modest benefit for mild GSM. Evidence is not strong enough to use as primary therapy, but dietary inclusion is safe and may supplement other treatments.

Adequate hydration – systemic dehydration worsens all mucosal symptoms, including vaginal dryness.

Part 6: The Conversation You Need to Have – With Your Clinician and With Yourself

Only an estimated 25% of women with GSM symptoms discuss them with a healthcare provider. The barriers are real: embarrassment, normalization (“it’s just part of getting older”), and the expectation of being dismissed or offered inadequate treatment. These barriers are not unfounded – historically, clinicians have underperformed on this question.

But the clinical landscape has materially changed. The 2025 AUA guideline, the 2024 NICE update, and the ICSM 2024 recommendations collectively represent the most comprehensive, evidence-graded clinical framework for GSM ever available. Treatment options now span from simple over-the-counter moisturisers to oral medications, multiple forms of local hormonal therapy, and energy-based devices – with a clinical escalation pathway that can be personalized to individual medical history, preferences, and symptom severity.

If you experience vaginal dryness, itching, burning, dyspareunia, recurrent UTIs, or urinary urgency – these are symptoms that warrant clinical assessment and that have evidence-based treatments. You do not need to manage them alone, and you do not need to accept them.

The Conclusion

GSM is a chronic, progressive condition that affects the majority of postmenopausal women to some degree, and that – untreated – worsens over time. Unlike the hot flushes and mood changes of perimenopause that many women experience as transient, the genitourinary changes of menopause do not resolve with time. They require active management.

The good news is that the treatment landscape has never been richer: local vaginal estrogen is safe, effective, and broadly accessible; prasterone and ospemifene offer genuine alternatives for women who need them; pelvic floor physiotherapy addresses the muscular dimension that pharmacology cannot; and daily moisturization and body-safe lubrication are immediately accessible and evidence-supported for every woman.

You deserve a healthcare provider who asks аnd a treatment plan that works.For more useful articles and expert guidance, explore the Womeno app – your personal digital companion through the hormonal transition. Download the app HERE

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