What is GSM and Why Do 50% of Women Experience It During Menopause?

Everything you and your vagina need to know about genitourinary syndrome in perimenopause and menopause 

As a menopause specialist, I see many women experiencing Genitourinary Syndrome of Menopause, or GSM. It's a common condition that occurs in about 50% of menopausal women.

You might not be familiar with the term, but the symptoms can be quite disruptive. GSM is caused by the natural decline in estrogen and testosterone throughout perimenopause and menopause. Estrogen plays a vital role in keeping the vulva, vagina, urethra, and bladder healthy. When these hormone levels drop, it can lead to dryness, irritation, and even an increased risk of UTIs.

Here's the thing: GSM is treatable. There are effective options available to address these changes and restore comfort.

What is GSM?

Genitourinary Syndrome of Menopause (GSM) is a natural condition of the vulva, vagina, and bladder that occurs due to the decrease of available estrogen and testosterone to those organs after menopause. The vagina and vulva need estrogen to stay moisturized, soft, stretchy, and also to stay acidic so that bacteria do not thrive and enter the urethra and create urinary tract infections. The vagina and the urethra/bladder also need estrogen and testosterone to reduce inflammation and pain. 

GSM is any and all of these issues affecting the vagina, vulva, urethra and bladder: recurrent urinary tract infections, urinary or bladder changes in how often you need to go, vaginal dryness, vulvar dryness, vaginal narrowing, and leakage of urine (see our article on menopausal bladder changes). 

The Sex Factor

“It just hurts so much during and throbs with pain after.” Marie* told me.

My patient, Marie,* explained that sex was always an important part of her relationship with her partner, equally for both of them. She wanted to continue having vaginal penetrative intercourse to maintain the intimacy it brought them, but she just could not tolerate anything going inside anymore. The anticipation of the pain made her avoid intimacy altogether. She told me that her desire has decreased, but she’s not sure if that’s menopause or because of the pain.

“Probably a little of both,” I told her. 

When sex begins to hurt, it loses its appeal. If you are unaware of how to reduce the pain, you might decide that intimacy is gone and this aspect of your life is no longer worth being part of your relationship. Of course there are other ways to be intimate.

I told Marie I would like to examine her first to assess the physical source of her pain. However, based on her description, I can already make two educated guesses.

First, the fact that she experiences pain from the very beginning of penetration suggests vaginal narrowing. This is a common symptom of GSM, especially if someone hasn't had vaginal intercourse or used a vibrator for a while.

Second, her description of soreness or a "rug burn" feeling afterward indicates insufficient lubrication.

If a person is feeling pain with vaginal sex from the point of penetration, her body is going to stop the process of arousal which causes lubrication. Not only that, without as much estrogen in her vaginal tissues due to menopause, she does not have the same baseline moisture in the vaginal tissues. Therefore, the friction of vaginal intercourse is literally going to be more friction than is pleasurable. 

Because of this, the pelvic floor muscles tend to brace themselves when a person is anticipating pain. Therefore, Marie, like many other women with GSM, may have begun forming hyper-tense or tightened muscles, which will also cause pain and discomfort with penetration.

Is GSM Treatable? YES!

A daily vulvar moisturizer can provide regular relief and may be necessary to make everything more comfortable. There are also many lubricants available to help with this, but not all are equal. A silicone-based lubricant is going to provide more protection to her vaginal tissues.

Vaginal estrogen is a key element to a healthy vagina. Estrogen keeps the environment of the vagina acidic, which keeps the bacteria burden low (or at least low enough as to not cause a urinary tract infection). It also improves healthy blood supply to the tissues, which helps with moisture and natural lubrication. This moisture in turn, contributes to the “stretchiness” of the tissue. 

After menopause, we lose the estrogen in the vagina, therefore, to improve symptoms of genitourinary syndrome of menopause (formerly known as vaginal atrophy), we prescribe a synthetic estrogen to apply vaginally. This prescription estrogen can be a cream, tablet, ring, or suppository. 

Easing the Pain

If GSM is causing painful sex or just discomfort in general, you can do something about it. This information is not meant to replace your health care provider’s recommendations, but is purely a resource for you! So take it with a grain of salt and not as a personal prescription.

Replace the moisture: Hyaluronic acid or a non-irritating moisturizer can be used on the days you don’t use a hormone treatment or in addition. 

Stretch: Start using a vaginal dilator so that the stretching happens gently and on your own terms. This should not hurt. Three times a week for about 10-15 minutes using a comfortably fitting dilator (Soul Source makes my favorite ones, or try the Milli by MaternaMD) with a water-based lubricant and gently insert it into the vagina. In small turning motions the dilator should gently stretch the opening. Once in, you can also gently sweep it from side to side to help relax the muscles. I usually tell my patients that after a couple of months with a vaginal dilator, they should “graduate,” to a vibrator to make this exercise more pleasurable! 

Prescription options to regulate the hormones creating GSM. These can include:

Again, this is a natural process and you don’t have to do anything about it if you don’t want to. But, if you are experiencing pain with intercourse or with anything genitourinary, please see a specialized women’s healthcare provider. 

Author Note: This blog post is intended for informational purposes only and should not be interpreted as medical advice. Please consult with your healthcare provider for personalized recommendations.

*image credit: Our Womanity

**names are fictional