Introduction
Maybe sex has started to hurt, and you've begun to avoid it. Maybe you feel dry, itchy, or irritated most of the time, even when you're not doing anything at all. Maybe you're getting one urinary tract infection after another, or you feel like you always need to find a bathroom.
If any of this sounds familiar, you are far from alone. Many women never mention these symptoms to anyone, including their clinicians. Some feel embarrassed. Some assume nothing can be done. Many don't realize the symptoms are connected, or that they have a name. They do. It's called genitourinary syndrome of menopause. It is a recognized medical condition. It is common, and it is treatable.
What is Genitourinary Syndrome of Menopause (GSM)?
GSM is the name for a group of changes that affect the vulva, vagina, bladder, and urethra (the tube that carries urine out of the body) when estrogen and other hormone levels decline during menopause. It used to be called "vaginal atrophy," but the newer name reflects the fact that it affects much more than the vagina.
Estimates suggest that GSM affects roughly 27% to 84% of postmenopausal women [1]. That wide range reflects differences in how studies define and measure it, but the message is the same: this is common. Even so, it is widely underdiagnosed and undertreated.
A large study of more than 1.8 million Medicare beneficiaries aged 66 and older with diagnoses indicative of GSM found that only 9% filled a prescription for vaginal estrogen [15]. This study does not tell us the treatment rate among all women with GSM, but it highlights how many older women with a GSM-related diagnosis may not be receiving this treatment.
Why does it happen?
The tissues of the vulva, vagina, urethra, and bladder are rich in estrogen receptors. As estrogen declines, these tissues can become thinner, less elastic, less well lubricated, and more fragile [2]. The balance of vaginal bacteria can also shift, which may contribute to an environment more favorable to infection-causing bacteria.
Common symptoms include:
Vaginal dryness, burning, itching, or irritation
Pain or discomfort with sex, or light bleeding after sex
A feeling of tightness or reduced stretch in the vagina
Needing to urinate urgently or often
Burning with urination, even when no infection is found
Urinary tract infections that keep coming back
Can it start before my periods stop?
Yes. Hormone levels begin to fluctuate and decline during perimenopause, the years leading up to your final period, so some women notice dryness or discomfort before menopause is "official" [2].
Will it go away on its own?
Usually not. This is one of the most important things to know about GSM. Hot flashes and night sweats often ease over time, but GSM symptoms tend to persist or gradually worsen without treatment [3], [4]. Waiting it out generally doesn't work, and there is no reason you need to.
How GSM affects sex and intimacy
When vaginal tissue becomes thin, dry, and less elastic, friction during sex can cause pain, burning, or small tears. Over time, many women understandably begin to anticipate pain. That anticipation can sometimes lead the pelvic floor muscles to tighten protectively, which can make sex even more uncomfortable. It is easy to see how desire and closeness can suffer, and how this can affect a relationship.
Please hear this: painful sex is not something you need to accept. Treatments for GSM, including vaginal estrogen, can improve vaginal dryness and discomfort with sex [5].
GSM is not the only possible cause of painful sex. Pelvic floor muscle tension, skin conditions of the vulva, infections, and other issues can also play a role, which is one reason a careful evaluation matters. Pelvic floor physical therapy can be a helpful part of treatment for some women.
Menopause, bladder symptoms, and recurrent UTIs
Many women are surprised to learn that their urinary symptoms may be connected to menopause. Lower estrogen affects the tissues around the urethra and vagina and can change the vaginal environment in ways that may make it easier for infection-causing bacteria to take hold [2].
The good news is that vaginal estrogen can help prevent recurrent urinary tract infections. The American Urological Association recommends vaginal estrogen for perimenopausal and postmenopausal women with recurrent UTIs to reduce the risk of future infections, unless there is a reason not to use it [6]. Estrogen taken by mouth has not been shown to provide the same benefit, and women already using systemic hormone therapy can still benefit from adding vaginal estrogen for UTI prevention [6].
In an observational study of 5,638 women prescribed vaginal estrogen for recurrent UTIs, the average number of infections was 52% lower in the year following the prescription than in the preceding year [7]. This before-and-after study is encouraging, although it cannot prove that vaginal estrogen alone caused the reduction.
Two important points: vaginal estrogen helps prevent future infections, but it does not treat an active infection, which still needs proper testing and treatment. And not every urinary symptom is caused by GSM; overactive bladder, pelvic floor problems, and other conditions can feel similar.
Vaginal estrogen: what it is, and is it safe?
What is it?
Vaginal estrogen is a low dose of estrogen placed directly in the vagina, where it acts on the tissues that need it. It comes in several forms: creams, small tablets or soft inserts, and low-dose vaginal rings. One commonly used low-dose ring, Estring, stays in place for three months before it is replaced [4].
It is important to distinguish Estring from Femring. Although both are vaginal rings, Femring delivers systemic estrogen and is used to treat whole-body menopausal symptoms; it is not the same as the low-dose local vaginal estrogen ring.
There isn't clear evidence that one low-dose vaginal estrogen formulation is best for every woman. The choice depends on symptoms, preferences, convenience, cost, and medical history [8].
The American Urological Association, the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, and the American Urogynecologic Society recommend offering local low-dose vaginal estrogen to women with GSM. The guideline describes it as an established treatment option for symptoms such as vaginal dryness, irritation, and painful sex [8]. In clinical studies, vaginal estrogen has improved women's reported genitourinary symptoms, although the degree of improvement varies [3].
Is it the same as Hormone Replacement Therapy (HRT)?
No. This is the most important distinction to understand. Systemic hormone therapy (pills, patches, gels, or sprays) is designed to raise estrogen levels throughout the body, mainly to treat hot flashes, night sweats, and other whole-body symptoms. Low-dose vaginal estrogen is designed to treat the local tissues. It is a different treatment with a different purpose, not simply a smaller version of HRT [4].
Some women already using systemic HRT still have GSM symptoms and benefit from adding vaginal treatment.
Does any of it get into my bloodstream?
A small amount can. It would not be accurate to say vaginal estrogen stays entirely in the vagina. Absorption varies with the dose, formulation, and condition of the vaginal tissue. With standard low-dose products, blood estrogen levels generally remain within or near the postmenopausal range, although small increases can occur [2], [8].
Low-dose tablets, inserts, and rings may have lower systemic absorption than some creams, although the amount absorbed depends on the specific product and dose [8]. The clinical significance of small changes in blood estrogen levels has not been fully established for every outcome [3].
Does it raise my risk of breast cancer, heart disease, or blood clots?
The evidence here is reassuring. Two large, long-term observational studies have followed women using vaginal estrogen:
The Women's Health Initiative Observational Study followed 45,663 women for a median of 7.2 years and found that the risks of heart disease and cancer were not elevated among vaginal estrogen users [9].
The Nurses' Health Study, with 18 years of follow-up, found no higher risk of heart disease, stroke, blood clots, cancer, or hip fracture among users [10].
To be transparent about the limits: these are observational studies, which follow people over time but cannot prove cause and effect the way a randomized trial can. No randomized trials have been designed to determine whether GSM treatments change rare, long-term outcomes such as cancer or cardiovascular events [3]. So while no one can promise zero risk, the evidence is consistently reassuring, and the risks of systemic HRT should not simply be assumed to apply to low-dose vaginal estrogen.
What about the warning on the package?
For years, many vaginal estrogen products carried boxed-warning language similar to that used for systemic hormone therapy, even though low-dose vaginal products generally result in much lower systemic exposure. This contributed to confusion and concern among women and clinicians [4].
In February 2026, the FDA approved labeling changes for six menopausal hormone therapy products, removing certain boxed-warning statements about cardiovascular disease, breast cancer, and probable dementia. The changes included a vaginal estrogen product [11]. This reflects how safety labeling has evolved as the evidence has been re-examined. It does not mean that any hormone therapy is risk-free, and the full prescribing information continues to provide product-specific safety information.
Do I need to take progesterone too?
No, for women with a uterus, progesterone is usually added to systemic estrogen to protect the uterine lining. With standard low-dose vaginal estrogen, a progestogen is generally not needed [1], [8].
Studies of the uterine lining have been reassuring, but clinical trial data beyond about one year are limited [1], [3]. That is why any vaginal bleeding after menopause should always be checked, whether or not you use hormones.
How long does it take, and how long will I use it?
Many women begin to notice improvement within a few weeks, though it can take a couple of months to feel the full benefit. Because GSM is a chronic condition, symptoms often return when treatment stops. Many women continue treatment long term, with periodic follow-up to make sure it is still appropriate and effective [8].
What if I don't want to use estrogen?
That is a completely valid choice, and there are other options. A systematic review found that several treatments may improve some GSM symptoms, although the certainty of evidence varies and long-term comparisons are limited [5].
Vaginal moisturizers (used regularly) and lubricants (used during sex) can ease dryness and discomfort. They are a good starting point for mild symptoms, although they do not reverse the underlying tissue changes.
Vaginal DHEA (prasterone) is a prescription insert used to treat vaginal dryness and painful sex associated with menopause.
Ospemifene is a daily prescription pill approved for moderate to severe painful sex and vaginal dryness due to menopause.
Pelvic floor physical therapy can help when muscle tension contributes to pain.
You may have also seen ads for vaginal laser treatments. At this time, the evidence does not support routinely using vaginal laser or radiofrequency treatments for GSM symptoms. The 2025 AUA/SUFU/AUGS guideline considers these approaches experimental outside clinical trials [8].
Long-term data comparing all of these treatments head-to-head are limited [5]. The right choice depends on your symptoms, health history, and what matters most to you.
What if I've had breast cancer?
Breast cancer treatments, especially medications called aromatase inhibitors (such as anastrozole, letrozole, and exemestane), can cause severe GSM symptoms. Many survivors have been told never to use any estrogen, and they suffer in silence. You deserve a more nuanced conversation.
The American College of Obstetricians and Gynecologists recommends starting with nonhormonal treatments. If those don't work well enough, low-dose vaginal estrogen may be considered after discussing risks and benefits, including for women taking tamoxifen. For women taking aromatase inhibitors, the decision should be made together by the patient, her menopause or gynecologic clinician, and her oncologist [12].
A 2025 analysis combining observational studies of more than 24,000 breast cancer survivors found no increase in breast cancer recurrence, breast cancer deaths, or overall deaths among women using vaginal estrogen [13]. However, a large Danish study, while finding no overall increase in recurrence, did find a higher recurrence rate in the subgroup of women using vaginal estrogen while taking aromatase inhibitors. It did not find an increase in mortality in that subgroup [14].
These findings are not necessarily contradictory: the studies used different populations and methods, and both are observational. Because evidence in women taking aromatase inhibitors remains limited, shared decision-making with the oncology team is especially important. When vaginal estrogen is considered, lower-absorption formulations such as low-dose tablets, inserts, or rings may be discussed [8].
So vaginal estrogen is not automatically off-limits after breast cancer, but it is not automatically right for everyone either. This is a decision best made thoughtfully and individually, with your oncology team involved.
How is GSM diagnosed, and when should I seek care?
GSM is usually diagnosed by talking through your symptoms and, when appropriate, a gentle pelvic exam to look at the tissues and rule out other causes. A focused medical, sexual, and symptom history, along with an appropriate examination, is often enough. Blood hormone tests are generally not needed to make the diagnosis [8].
Other conditions can look like GSM, including yeast or other infections, skin conditions of the vulva such as lichen sclerosus, irritation from soaps or products, overactive bladder, and pelvic floor muscle problems. That's why it's worth being evaluated rather than guessing.
Please seek care promptly if you have:
Any vaginal bleeding or spotting after menopause
Blood in your urine
Fever, back or side pain, or feeling unwell with urinary symptoms
A new sore, lump, or skin change on the vulva
Symptoms that aren't improving with treatment
Why work with a menopause specialist?
GSM touches many parts of your life: comfort, intimacy, bladder health, and confidence. A clinician with menopause expertise can:
Recognize that vaginal, sexual, and urinary symptoms may share a common hormonal cause
Explain the real differences between local vaginal treatment and systemic hormone therapy
Weigh your personal health history, including cancer history, when discussing options
Recognize when symptoms need further testing or referral
Address GSM as part of your overall menopause health, not in isolation
At Radiant Health for Women, Kari Waddell, FNP, MSCP, is a Menopause Society Certified Practitioner who focuses on helping women in Boulder navigate menopause with accurate information and individualized care. Our goal is not to push any one treatment, but to help you understand what is happening in your body and choose the approach that fits your life.
You deserve to feel comfortable
Vaginal dryness, painful sex, and bladder changes are common, but they are not something you simply have to endure. GSM is a real, treatable condition, and you have options. If these symptoms are affecting your comfort, relationships, or quality of life, we would be glad to talk with you. Schedule a free discovery call today.
References
The NAMS 2020 GSM Position Statement Editorial Panel. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 27(9), 976–992. https://doi.org/10.1097/GME.0000000000001609
Perelmuter, S., Srivastava, M., Freedman, K. P., Hanfling, S., & Rubin, R. S. (2026). Vaginal estrogen: Pearls for the practitioner—A practical review of evidence, guidelines, and prescribing strategies for genitourinary syndrome of menopause. Journal of Women's Health, 35(10), 900–907. https://pubmed.ncbi.nlm.nih.gov/42381200/
Crandall, C. J., Mehta, J. M., & Manson, J. E. (2023). Management of menopausal symptoms: A review. JAMA, 329(5), 405–420. https://doi.org/10.1001/jama.2022.24140
Cho, L., Kaunitz, A. M., Faubion, S. S., et al. (2023). Rethinking menopausal hormone therapy: For whom, what, when, and how long? Circulation, 147(7), 597–610. https://doi.org/10.1161/CIRCULATIONAHA.122.061559
Danan, E. R., Sowerby, C., Ullman, K. E., et al. (2024). Hormonal treatments and vaginal moisturizers for genitourinary syndrome of menopause: A systematic review. Annals of Internal Medicine, 177(10), 1400–1414. https://pubmed.ncbi.nlm.nih.gov/39250810/
American Urological Association. (2025). Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline (2019, confirmed 2022, amended 2025). https://www.auanet.org/documents/Guidelines/PDF/2025%20Guidelines/rUTI%20Update/rUTI%202025%20Unabridged%20Final.pdf
Tan-Kim, J., Shah, N. M., Do, D., & Menefee, S. A. (2023). Efficacy of vaginal estrogen for recurrent urinary tract infection prevention in hypoestrogenic women. American Journal of Obstetrics and Gynecology, 229(2), 143.e1–143.e9. https://pubmed.ncbi.nlm.nih.gov/37236032/
Kaufman, M. R., Ackerman, A. L., Amin, K. A., et al. (2025). The AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause. The Journal of Urology, 214(3), 242–250. https://www.auanet.org/documents/Guidelines/PDF/2025%20Guidelines/GSM%20Unabridged%202025.pdf
Crandall, C. J., Hovey, K. M., Andrews, C. A., et al. (2018). Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women's Health Initiative Observational Study. Menopause, 25(1), 11–20. https://pubmed.ncbi.nlm.nih.gov/28816933/
Bhupathiraju, S. N., Grodstein, F., Stampfer, M. J., et al. (2019). Vaginal estrogen use and chronic disease risk in the Nurses' Health Study. Menopause, 26(6), 603–610. https://pubmed.ncbi.nlm.nih.gov/30562320/
U.S. Food and Drug Administration. (2026, February 12). FDA approves labeling changes for menopausal hormone therapy products [Press announcement]. https://www.fda.gov/news-events/press-announcements/fda-approves-labeling-changes-menopausal-hormone-therapy-products
American College of Obstetricians and Gynecologists' Committee on Clinical Consensus–Gynecology. (2021). Treatment of urogenital symptoms in individuals with a history of estrogen-dependent breast cancer (Clinical Consensus No. 2). Obstetrics & Gynecology, 138(6), 950–960. https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2021/12/treatment-of-urogenital-symptoms-in-individuals-with-a-history-of-estrogen-dependent-breast-cancer
Beste, M. E., Kaunitz, A. M., McKinney, J. A., & Sanchez-Ramos, L. (2025). Vaginal estrogen use in breast cancer survivors: A systematic review and meta-analysis of recurrence and mortality risks. American Journal of Obstetrics and Gynecology, 232(3), 262–270.e1. https://doi.org/10.1016/j.ajog.2024.10.054
Cold, S., Cold, F., Jensen, M. B., et al. (2022). Systemic or vaginal hormone therapy after early breast cancer: A Danish observational cohort study. Journal of the National Cancer Institute, 114(10), 1347–1354. https://pubmed.ncbi.nlm.nih.gov/35854422/
Gallo, K., Zhang, C. A., Burton, C., Kamdar, N., & Enemchukwu, E. A. (2025). Vaginal estrogen utilization among Medicare beneficiaries with genitourinary syndrome of menopause. JAMA Network Open, 8(12), e2549822. https://doi.org/10.1001/jamanetworkopen.2025.49822
This content is for educational purposes only and is not a substitute for personalized medical advice. Consult your healthcare provider for guidance specific to your situation.