The Latest Guidelines for GenitoUrinary Syndrome of Menopause (GSM)

For far too long, we’ve spoken about menopause as if the only things women lose are their periods and their patience. But the truth is, the hormonal shifts of midlife reach far deeper—impacting our brains, bones, hearts, and yes, our pelvic floor and urinary systems.

Yet when a woman shows up at her doctor’s office complaining of vaginal dryness, burning, discomfort with intimacy, or recurring urinary tract infections, she’s often met with a shrug, maybe a prescription for an antifungal, or worse—dismissal.

This is not a minor nuisance. It’s a condition with a name: Genitourinary Syndrome of Menopause, or GSM. And in April 2025, the American Urological Association, in collaboration with a few other organizations, finally gave GSM the attention it deserves in a newly released, evidence-based guideline.

Let’s unpack what it says—and what it means for the millions of women silently suffering from this condition.

What is GSM, Really?

GSM is not just vaginal dryness. It’s a chronic, progressive condition that arises from the loss of estrogen and testosterone in the tissues of the vulva, vagina, bladder, and urethra. It affects nearly half of all postmenopausal women, though the real number is likely much higher, since many never bring it up—and many clinicians don’t ask.

It can present as:

Vaginal burning, irritation, dryness, or itching
Pain or bleeding with intercourse (dyspareunia)
Urinary urgency, frequency, incontinence, or recurring UTIs

The discomfort can be physical, sexual, and deeply emotional—impacting confidence, relationships, and the sense of ownership over one’s body.

Diagnosing GSM: A Clinical Conversation

The thing that I love the most about this new guideline is its insistence that we believe women. That diagnosis should be based on symptoms, not hormone levels or fancy labs. A pelvic exam may help, but it isn’t necessary. A woman knows when something has changed. She knows when her body no longer feels like hers.

This means we no longer gatekeep treatment based on test results. If she says sex is painful, urination burns, or she feels dry and raw—we treat.

Treatment Options: Hormonal Therapies

When addressing GSM, it’s crucial to consider treatments that restore the hormonal balance affecting the genitourinary tract. The guideline emphasizes:

Local Low-Dose Vaginal Estrogen: This is a cornerstone therapy for GSM, effectively alleviating symptoms like vaginal dryness, irritation, and dyspareunia. It’s important to note that low-dose vaginal estrogen has a favorable safety profile, with minimal systemic absorption, making it suitable for many women, including those with certain contraindications to systemic hormone therapy.
Vaginal Dehydroepiandrosterone (DHEA): DHEA serves as a precursor to both estrogen and testosterone, and when administered vaginally, it can improve symptoms of GSM by replenishing local hormone levels. This option is particularly beneficial for women who prefer non-estrogen therapies or have concerns about estrogen use.
Ospemifene: As a selective estrogen receptor modulator (SERM), ospemifene mimics estrogen’s effects on vaginal tissue, improving GSM symptoms without stimulating the endometrium. It’s an oral option for women who may not tolerate or prefer not to use vaginal therapies.

These hormonal treatments should be considered based on individual patient needs, preferences, and medical history, engaging in shared decision-making to determine the most appropriate therapy.

Non-Hormonal Therapies

For women who cannot or choose not to use hormonal treatments, non-hormonal options are available:

Vaginal Moisturizers and Lubricants: Regular use of vaginal moisturizers can alleviate dryness and improve vaginal health, while lubricants can reduce discomfort during sexual activity. These are first-line therapies for mild GSM symptoms and can be used alone or in conjunction with other treatments.
Avoidance of Irritants: Educating patients to avoid potential irritants, such as certain soaps, douches, or tight-fitting clothing, can prevent exacerbation of GSM symptoms.

While these therapies may not be as effective as hormonal treatments for moderate to severe symptoms, they offer relief for many women and can be an essential part of a comprehensive management plan.

Energy-Based Therapies

The guideline addresses the use of energy-based devices, such as CO₂ lasers and radiofrequency treatments:

Current Evidence: The evidence supporting the efficacy and safety of these therapies for GSM is limited and of low quality. Therefore, they are not recommended as first-line treatments.
Consideration in Specific Cases: In situations where conventional therapies are contraindicated or ineffective, and after thorough counseling about the experimental nature and potential risks, these treatments may be considered.

It’s imperative to approach these options cautiously, ensuring patients are fully informed about the current lack of robust evidence and the need for further research.

Special Populations: Breast and Endometrial Cancer Survivors

Managing GSM in women with a history of hormone-sensitive cancers requires careful consideration:

Local Vaginal Estrogen: Evidence suggests that low-dose vaginal estrogen does not significantly increase the risk of breast or endometrial cancer recurrence. However, decisions should be made collaboratively with the patient’s oncology team, weighing the benefits and potential risks.
Non-Hormonal Options: For those who prefer to avoid any hormonal exposure, non-hormonal therapies remain viable options, though they may offer less symptom relief.

Personalized care and multidisciplinary collaboration are key in managing GSM in this population, ensuring that treatment aligns with the patient’s overall health strategy and personal comfort.

Follow-Up and Long-Term Management

GSM is a chronic condition that requires ongoing management:

Regular Reassessment: Patients should be regularly evaluated to monitor symptom progression and treatment efficacy, adjusting the management plan as needed.
Patient Education: Educating patients about the chronic nature of GSM and setting realistic expectations for treatment outcomes can enhance adherence and satisfaction.

Reference:

https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause

About the Author:

Dr. Manna Semby, ND

Functional Medicine Practitioner & Wellness Expert

Dr. Manna Semby, ND, IFMCP, MSCP, is a naturopathic and functional medicine doctor based in San Diego, California. She is the only doctor in the San Diego area who is both a Menopause Society Certified Practitioner and certified in the ReCODE 2.0 Protocol for preventing and reversing Alzheimer’s disease and dementia. She is also is a MoCA certified administrator. With over ten years in medicine, Dr. Manna has helped many women reverse early stages of cognitive decline through comprehensive brain, bone, metabolic, and midlife hormone medical care. She draws on years of clinical training and ongoing professional development to translate complex medical insights into practical, real-world precision medicine guidance.

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