Genitourinary syndrome of menopause is the current clinical term for what was previously called vulvovaginal atrophy or atrophic vaginitis. It is caused by the reduction in oestrogen that accompanies the menopause and produces changes in the vulval, vaginal, and urinary tract tissues that include thinning of the vaginal epithelium, reduced lubrication and elasticity, decreased vaginal acidity, and altered innervation. The resulting symptoms include vaginal dryness, burning, and irritation, pain with intercourse, urinary urgency and frequency, and recurrent urinary tract infections. In contrast to vasomotor symptoms, which improve spontaneously over time in many women, genitourinary syndrome does not resolve without treatment and typically progresses.
Prevalence and Underreporting
Studies consistently show that 50 to 60 percent of postmenopausal women experience genitourinary syndrome symptoms, yet only 25 percent discuss it with their healthcare provider. The reasons for underreporting include embarrassment, the mistaken belief that symptoms are an inevitable consequence of ageing, and the erroneous assumption that nothing can be done. In the Vaginal Health Insights, Views and Attitudes survey, 78 percent of women said the condition significantly affected their quality of life and intimate relationships. The condition represents a substantial unmet treatment need.
Treatment Options: Efficacy and Safety
Local oestrogen therapy, applied directly to the vaginal tissue as cream, pessary, tablet, or vaginal ring, is the most effective treatment for genitourinary syndrome. It restores vaginal epithelial thickness, normalises vaginal pH, improves lubrication, and reduces urinary symptoms. Critically, local vaginal oestrogen is absorbed minimally into systemic circulation: serum oestrogen levels remain in the postmenopausal range even with continued use. The safety concerns associated with systemic HRT do not apply to local oestrogen therapy, making it appropriate for the majority of women including those in whom systemic HRT is contraindicated, such as breast cancer survivors in many cases.
Non-Hormonal Options
For women who decline or cannot use hormonal options, regular use of vaginal moisturisers containing hyaluronic acid or polycarbophil, applied every two to three days, and lubricants during intercourse significantly reduce symptoms. Ospemifene, a selective oestrogen receptor modulator taken orally, has regulatory approval for dyspareunia due to genitourinary syndrome in women for whom local oestrogen is not preferred. DHEA vaginal pessaries are a further licensed option that converts to oestrogen and testosterone locally without systemic absorption.
- Do not accept genitourinary symptoms as an inevitable consequence of menopause: effective treatment exists
- Request local vaginal oestrogen from your GP: it is safe for the majority of women including many breast cancer survivors
- Use vaginal moisturisers regularly, not only during intercourse: they are a non-hormonal maintenance option
- Penetrative intercourse with appropriate lubrication maintains vaginal tissue health by promoting blood flow and tissue elasticity
- Pelvic floor physiotherapy is a valuable adjunct for women with pain during intercourse alongside genitourinary syndrome
Sources
- NICE. (2015, updated 2019). Menopause: diagnosis and management. NICE guideline NG23.
- Portman, D.J., & Gass, M.L.S. (2014). Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the Menopause Society. Menopause, 21(10), 1063-1068.