As women approach menopause—a stage known as perimenopause—they often experience hot flashes, night sweats, vaginal dryness, mood changes, and sleep disturbances, driven by declining estrogen levels.
For many, these symptoms gradually ease once menopause officially begins, defined as 12 months without a menstrual period. However, one condition bucks that trend, causing persistent discomfort well beyond menopause.
Known as genitourinary syndrome of menopause (GSM), the condition encompasses vaginal and urinary changes that can worsen with age rather than improve. Studies estimate that between 27% and 84% of women may experience GSM, yet public awareness remains low.
“Women often assume these changes are just part of aging,” says Lauren Streicher, medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause. “It rarely occurs to them that this is a treatable aspect of menopause.”
GSM manifests as a range of symptoms, including vaginal and vulvar dryness, itching, irritation, decreased lubrication, loss of libido, abnormal discharge, painful sexual intercourse, and urinary discomfort such as burning or frequent urination. The syndrome can also increase susceptibility to recurrent urinary tract infections.
While some women experience these symptoms during perimenopause, they are more common after menopause, sometimes emerging 10 to 12 years later. The term GSM replaced the older designation of vulvovaginal atrophy about a decade ago, aiming to highlight the broad spectrum of symptoms and encourage treatment. “The goal was for women to recognize that help is available,” says Stephanie Faubion, medical director of the Menopause Society and director of the Mayo Clinic Center for Women’s Health.
The Role of Estrogen
GSM stems from declining estrogen, which normally maintains vaginal moisture, elasticity, and tissue thickness. Reduced estrogen affects the vagina, vulva, urethra, and bladder. “Estrogen receptors are present in both the urethra and bladder,” explains James Simon, clinical professor of obstetrics and gynecology at George Washington University. Lower hormone levels can promote growth of harmful bacteria such as E. coli, increasing irritation and infection risk.
The condition also impacts sexual health. Untreated GSM often leads to painful intercourse, which may become a frequent issue. A 2013 study of over 3,000 postmenopausal women found that one in four reported painful sex at least weekly. “For women accustomed to penetrative sex, this can create anxiety and avoidance,” says Sheryl A. Kingsberg, professor of reproductive biology and psychiatry at Case Western Reserve University.
Pain can trigger pelvic floor muscle spasms, meaning that even after treating vaginal dryness, discomfort may persist unless the muscles are addressed.
GSM’s consequences extend beyond sexual activity. “It’s not just about sex,” Faubion emphasizes. “Women may feel discomfort in everyday activities—riding a bike, wearing jeans, or even using toilet paper.” Experts stress that recognition and treatment are key to preserving both comfort and quality of life.
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