Let's Talk About Sex (Again): Genitourinary Syndrome of Menopause
- Sital Bhargava DO, MS
- 2 hours ago
- 4 min read
In an effort not to disappoint Salt-N-Pepa, we need to finish talking about sex.
Over the last few weeks, we've talked about sexual dysfunction (https://www.rx4trauma.com/post/let-s-talk-about-sex-baby-the-truth-about-female-sexual-dysfunction) and pelvic floor dysfunction (https://www.rx4trauma.com/post/keep-calm-and-strengthen-your-core-understanding-pelvic-floor-dysfunction). Today, we're tackling another common—but surprisingly under-discussed—cause of painful sex:
Genitourinary Syndrome of Menopause (GSM).
Ouch.
What is GSM?
Genitourinary Syndrome of Menopause (GSM) is a collection of symptoms caused by falling estrogen levels that affect the vagina, vulva, labia, clitoris, bladder, and urethra.
As estrogen levels decrease, these tissues become thinner, drier, less elastic, and more fragile. What was once healthy, well-lubricated tissue gradually loses its cushioning and blood supply.
The result?
Vaginal dryness
Burning or irritation
Pain with sex
Painful urination
Frequent urinary tract infections
Urinary urgency and frequency
Ugh.
Who gets GSM?
Since we're talking about midlife, perimenopause and menopause is the most common culprit.
Depending on the study you read, somewhere between 27% and 84% of women experience symptoms of GSM. (Yes, that's a huge range—but the bottom line is that it's incredibly common.)
The symptoms often become more noticeable after menopause, once you've gone twelve consecutive months without a period.
But menopause isn't the only time estrogen drops.
Women who are breastfeeding, have had their ovaries removed, receive chemotherapy, or use certain medications that suppress estrogen can develop GSM as well.
How is GSM diagnosed?
One of my favorite lessons from medical school was this:
"Eighty percent of diagnoses can be determined from the history and physical exam."
In other words, listening and looking matters.
If a woman tells me she's experiencing vaginal dryness, painful intercourse, urinary discomfort, or recurrent bladder infections, GSM should move to the top on my list.
The physical exam often confirms the diagnosis. The tissue may appear pale, thin, dry, and fragile. Often times, even a routine pelvic exam is uncomfortable (well, MOOOOORE uncomfortable than the usual discomfort).
Fortunately, once you recognize it, treatment is usually very effective.
How do you treat GSM?
Start simple.
For mild symptoms, vaginal moisturizers and lubricants are often enough.
Skip the brightly colored, heavily scented products promising tropical rainforests and edible strawberries (EWWW).
Your vagina is not asking to smell like a piña colada.
Instead, choose a plain, water-based lubricant for sexual activity and a vaginal moisturizer containing polycarbophil or hyaluronic acid to improve hydration. Moisturizers are generally used every one to three days, depending on symptoms.
What if that's not enough?
Then it's time to bring estrogen back to where it's needed.
Low-dose vaginal estrogen comes as a cream, tablet, or ring that delivers estrogen directly to the affected tissues.
Unlike systemic estrogen (patches or pills), vaginal estrogen acts mostly where it's applied.
It can:
Increase the thickness and elasticity of vaginal tissue
Improve blood flow
Restore the normal acidic vaginal pH
Encourage healthy vaginal bacteria (lactobacilli)
Reduce urinary symptoms and recurrent urinary tract infections
One of the biggest advantages is that the amount of estrogen absorbed into the bloodstream is very low. For most women, additional progesterone is not needed when using low-dose vaginal estrogen alone.
One important caveat:
Local estrogen helps the vagina—not your hot flashes.
If you're treating hot flashes, night sweats, or other whole-body menopausal symptoms, you may still need systemic hormone therapy. And if you have a uterus and take systemic estrogen, you also need progesterone to protect the uterine lining.
But it’s important to note that you can take both types of estrogen simultaneously if needed.
A little estrogen for your whole body...
...and maybe a little extra for your nether regions.
What if estrogen isn't an option?
Fortunately, there are other choices.
Vaginal DHEA or dehydroepiandrosterone (try spelling that) is a nightly vaginal insert approved for pain during intercourse. Because it acts locally, it may be an option for some women who cannot or prefer not to use estrogen, including certain women with a history of breast cancer.
Another option is ospemifene, an oral medication that acts like estrogen in vaginal tissue.
It can improve painful intercourse but may worsen hot flashes and carries an increased risk of blood clots. Because of limited safety data, it is generally not recommended for women with breast cancer.
Other treatments, including vaginal laser therapy, continue to be studied. While early research is promising, we still need better long-term data and consideration of cost before routinely recommending it.
For women whose pain is also related to muscle tightness, pelvic floor physical therapy and vaginal dilators can be incredibly helpful.
The Bottom Line (quite literally)
Here's the part I want every woman to remember:
Pain during sex is not something you simply have to accept because you're getting older.
For generations, women were told that vaginal dryness, discomfort, bladder symptoms, and painful sex were just "part of menopause." They suffered quietly, often assuming there was nothing that could be done.
Thankfully, that's changing.
GSM is common. It's treatable. And you deserve to have conversations about it with your doctor without embarrassment or shame.
So, if you've been silently buying more lubricant, avoiding intimacy, or wondering if this is simply your "new normal," know this:
There are effective treatments. There are physicians who want to help. And yes...we really do need to keep talking about sex.
Because if Salt-N-Pepa taught us anything, it's that some conversations are worth having.
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