Genitourinary syndrome of menopause (GSM) is a medical term used to describe a group of symptoms that affect the genital and urinary systems after menopause. The term was introduced by the Menopause Society (formerly the North American Menopause Society) to better capture the range of symptoms that occurs when estrogen levels decline.  GSM is very common but often underrecognized and undertreated.

Estrogen plays an important role in maintaining the health of the vaginal and urinary tissues. It helps keep the tissues thick, flexible, well-lubricated, and well supplied with blood flow. During menopause, estrogen levels decrease, causing these tissues to gradually become thinner, drier, and less elastic. These physical changes can lead to a range of symptoms that fall under the umbrella of GSM.

Question: What symptoms tend to fall under the GSM umbrella? Why can these symptoms make sex uncomfortable, painful, or even impossible?

Common symptoms of GSM include vaginal dryness, irritation, burning, itching, decreased lubrication, and pain during intercourse. Some people may also notice small tears in the vaginal tissue during sexual activity or even after wiping. Urinary symptoms are also common and can include urinary urgency, frequent urination, and recurrent urinary tract infections.

Because vaginal tissues become thinner and less lubricated, friction during sexual activity often causes discomfort or pain. Over time, this can make sexual activity difficult or even impossible for some individuals. Without treatment, symptoms often worsen.

Question: Do you see a domino effect happen in patients with GSM? For example, do people begin to develop protective muscle tension or anticipatory pain around sex after experiencing GSM symptoms?

Yes, this type of domino effect occurs. When pain is felt repeatedly, the body may begin to anticipate this discomfort. The pelvic floor muscles can tighten in a protective way, even before penetration occurs. This protective response is a normal reaction of the nervous system trying to prevent further injury or discomfort. However, increased muscle tension can make intercourse even more painful, creating a cycle of fear, tension, and pain.

Question: Why might it be helpful to focus also on the nervous system and pelvic floor responses that may develop after painful experiences?

Addressing the nervous system and pelvic floor is important because pain is not only a tissue issue but also a body response. When repeated pain occurs, the nervous system may remain in a protective state. Pelvic floor physical therapy can help patients relax these muscles, improve circulation to the pelvic tissues, and restore more comfortable movement.

Question: What are the most effective medical treatments currently available for GSM?

Medical treatments for GSM are often very effective. One of the first-lines of treatment and most commonly recommended is low-dose vaginal estrogen. ACOG and American Family Physician both highlight that vaginal estrogen helps restore the thickness, elasticity, and moisture of vaginal tissue while using very small amounts of hormone.  This vaginal estrogen acts locally, right at the site that it’s needed.

Another treatment option is vaginal dehydroepiandrosterone (DHEA), also called prasterone. This medication is converted locally within the vaginal tissue into hormones that support tissue health and lubrication.

Question: How do treatments like vaginal estrogen, DHEA, moisturizers, lubricants, or pelvic floor physical therapy work to relieve symptoms?

Vaginal estrogen works by directly restoring estrogen to the localized vaginal tissue, improving blood flow, lubrication, and tissue elasticity. Vaginal DHEA supports similar improvements through local hormone conversion. Vaginal moisturizers help maintain hydration in the vaginal tissue when used regularly, while lubricants reduce friction during sexual activity and can make intercourse more comfortable.

Pelvic floor physical therapy focuses on the muscles surrounding the vagina and pelvis. Therapists are expertly trained to help patients learn exercises and relaxation techniques to reduce muscle tension and improve pelvic floor function.  Pelvic floor tone can decrease after childbirth and especially through the menopause transition.

Question: Why might body-based approaches like somatic therapy be helpful for people who experience painful sex after menopause?

Some clinicians are increasingly recommending body-based approaches such as somatic therapy for patients who have experienced pain during sexual activity. These approaches help individuals reconnect with bodily sensations and calm the nervous system. Techniques such as breathing exercises, relaxation practices, and body awareness can help reduce tension and fear associated with intimacy.  Involving a sexual partner is also helpful.

Question: Anything else you’d like to add about the intersection of GSM and somatic care?

Menopause is a predictable condition which often causes genitourinary symptoms.  The most effective approach often combines medical treatment with attention to the body’s stress and pain responses. When treatments restore the health of vaginal tissue and patients also learn ways to relax the pelvic floor and regulate the nervous system, many people experience meaningful improvement. Addressing both the physical and nervous system aspects of GSM can help patients regain comfort, confidence, and a healthier relationship with intimacy.