Genitourinary Syndrome of Menopause (Vaginal Atrophy)
If you’re going through menopause or soon will be, you may have problems with vaginal dryness and irritation, urinary problems, or painful sex. The official medical term for this group of symptoms is genitourinary syndrome of menopause (GSM).
Some people call these symptoms vaginal atrophy or atrophic vaginitis. The condition is caused by thinning, drying, and inflammation of the vaginal walls because your body has less estrogen. GSM is more accurate because it describes the urinary as well as the vaginal symptoms of the condition.
Symptoms of vaginal atrophy/GSM
“The most common symptoms of genitourinary syndrome of menopause are vaginal dryness, vaginal irritation and stinging, painful sex, but also, recurrent bladder infections or urinary tract infections,” Kristin Rojas, MD, FACS, said during an episode of The Breastcancer.org Podcast on GSM. Rojas is a breast cancer surgeon and founder of the Menopause, Urogenital, Sexual Health and Intimacy Program (MUSIC) at the Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine. She’s a national leader in treating sexual dysfunction in women receiving cancer treatment.
Other vaginal symptoms may include:
vaginal burning
itching in the vagina or around the vulva
pain during sex
spotting or bleeding during or after sex
pelvic floor muscle spasms
Urinary symptoms may include:
frequent urinary tract infections (UTIs)
having to pee more frequently than usual
an inability to hold your pee (incontinence)
burning or pain when you pee
Besides sexual and urinary issues, vaginal atrophy/GSM can affect day-to-day life, making it difficult to ride in a car or sit anywhere for a long time, ride a bike, put on jeans, and wipe after going to the bathroom.
Causes of vaginal atrophy/GSM
Vaginal atrophy/GSM is caused by lower estrogen levels, which make your vaginal tissues get thinner, drier, and less elastic. Your body starts making less estrogen in the months before menopause (peri-imenopause) and these levels continue to drop during menopause. Lower estrogen levels can also happen because of breast cancer treatments or if you’ve had your ovaries removed.
Vaginal atrophy/GSM risk factors
Being peri-menopausal or menopausal is the biggest risk factor for vaginal atrophy/GSM. This is because your body produces less estrogen as you move through menopause. Other procedures, medicines, and lifestyle factors can also lower estrogen levels and lead to vaginal atrophy/GSM, including:
breast cancer treatments, including chemotherapy and hormonal therapy
having your ovaries surgically removed or shut down with medicine
certain autoimmune diseases, such as lupus, Sjogren's syndrome, or Hashimoto’s disease
breastfeeding
smoking cigarettes
having penetrative sex infrequently; frequent sex makes blood flow to your vagina, which keeps the tissues more elastic
Diagnosing vaginal atrophy/GSM
There’s no one test that can tell if you have vaginal atrophy/GSM. Instead, it’s up to your doctor to make the diagnosis based on your medical history and a thorough pelvic exam. During the exam, your doctor will look at both your vagina and cervix to see if there is any dryness, redness, swelling, or loss of elasticity, as well as if the vagina has shortened or narrowed. Your doctor may also recommend taking a urine sample or doing certain tests, like a Pap smear or vaginal pH (acid test), to rule out anything else that might be causing your symptoms, such as an infection.
Treating vaginal atrophy/GSM
Can vaginal atrophy/GSM be reversed with treatment? The short answer is yes.
In 2025, three professional organizations released the first guideline for recognizing and managing GSM.
The MUSIC Sexual Health After Cancer Program treats the vaginal symptoms of vaginal atrophy/GSM with a four-step program that combines many of the recommendations in the guideline.
Step one: Eliminate irritants. Rojas advises the women she treats to take stock of everything that touches the vulva — the outside of the vagina — and the vagina. This includes any chemicals in the toilet paper you use, the fragrance in the detergent you wash your underwear with, and any soap or feminine hygiene products you use. If there are chemicals or fragrances, she recommends finding a different product with no chemicals or fragrances.
Step two: Moisturize. Many people have a daily skincare routine. Rojas recommends making a non-irritating vaginal moisturizer part of the routine.
“My go-to for our patients is single-ingredient organic coconut oil,” Rojas explained. “It’s a natural antimicrobial and antifungal. Or you could use a hyaluronic acid-containing vaginal moisturizer. It lasts a long time and really holds moisture on the skin. Just pick a product that’s non-irritating and doesn’t have any extra gimmicks.”
Rojas recommends women with a history of breast cancer start with a non-hormonal moisturizer, like single-ingredient coconut oil. If this doesn’t ease dryness enough, then she recommends very low-dose, topical hormonal moisturizers. Both topical estrogen and DHEA (dehydroepiandrosterone) in the form of creams, rings, or tablets can be applied or placed directly into the vagina. While there has been controversy in the past about women with a history of breast cancer using hormonal moisturizers, recent studies have found that topical vaginal estrogen is safe for women with breast cancer. Because the estrogen is topical and low-dose, it stays in the vagina and doesn’t raise estrogen levels throughout the body.
Doctors don’t recommend systemic (the hormones travel through your bloodstream to your entire body) hormone replacement therapy for anyone with a history of breast cancer.
Step three: Lubricate. “Moisturizers are for maintenance, lubricants are for sexual activity or anything being placed in the vagina, including dilators, sexual devices, the penis,” Rojas said.
Vaginal dilators stimulate and stretch the vaginal muscles and help to reverse the narrowing of your vaginal canal.
Lubricants can be water- or silicone-based. Rojas recommends products that are super slippery without any added chemicals or fragrances.
Step four: Treat any pelvic floor muscle pain or spasms, called levator spasms by doctors. Rojas refers people to a pelvic floor physical therapist who may use massage, exercises, and vaginal dilators. The American Physical Therapy Association’s Academy of Pelvic Health Physical Therapy has a locator tool to help you find a licensed physical therapist who specializes in pelvic health.
Many companies and cosmetic surgery offices promote vaginal lasers as a way to rejuvenate and plump up vaginal tissues, as well as treat incontinence and improve sexual function. But few high-quality studies have been done and there is little or no evidence that vaginal lasers can treat any vaginal atrophy/GSM symptoms.
Rojas advises people to avoid these devices.
“They have gentle-sounding names and are often marketed to breast cancer patients, especially in October,” she said. “In the MUSIC program, we’ve taken care of patients who have chronic pain, burns, and scarring; they’ve been physically harmed by these devices. It’s very concerning.”
Topical, low-dose vaginal estrogen also treats the urinary symptoms of GSM, including overactive bladder and frequent UTIs after sex. If you’re still having UTIs and other urinary issues while using topical estrogen, it’s likely that your doctor will recommend a gentle antibiotic, such as Macrobid (chemical name: nitrofurantoin).
Vaginal atrophy/GSM FAQs
Vaginal atrophy symptoms can be successfully treated with many different treatment options. But talk to your doctor so you can ask any questions you have and ensure you pick something that is safe and makes sense for you.
GSM causes vaginal dryness and other vaginal symptoms that can lead to light spotting or bleeding, especially during sex.
Urinary symptoms affect the urinary tract and can include a variety of sensations that can be very bothersome. These include frequent UTIs, burning during peeing, frequent urination, and/or feeling like you have to pee more than usual and not being able to make it to the bathroom. Genitourinary symptoms include symptoms that affect both your genitals and urinary tract. So in addition to urinary symptoms, you might have vaginal dryness or vaginal discharge. These symptoms often require a more involved evaluation by either a gynecologist with extra specialization in the urinary tract or a urologist.
— Last updated on September 8, 2025 at 8:21 PM