You stopped wanting to have sex. Not because the desire disappeared entirely, but because it hurt. Maybe it started with dryness, a feeling of friction where there used to be none. Then it became burning. Then it became something you quietly started avoiding, telling yourself this is just what getting older is like. Your doctor, the one time you mentioned it, told you it was normal. So you accepted it. You stopped talking about it. And the pain continued.

This is genitourinary syndrome of menopause, GSM for short, and it is one of the most common and most undertreated conditions in midlife women. It is not just a nuisance. It is a medical condition with effective treatments. And you should not have to live with it.

This article will explain exactly what GSM is, why it so often goes undiagnosed, and what the current evidence says about every available treatment, from simple over-the-counter options to low-dose vaginal estrogen, vaginal DHEA, oral medications, and newer laser-based therapies. By the end, you will know what to ask for and why you deserve better than silence.

What GSM actually is

Genitourinary syndrome of menopause is the umbrella term that replaced the older phrase “vulvovaginal atrophy.” The name changed because the condition affects far more than the vagina. GSM encompasses changes to the vulva, vagina, urethra, and bladder that occur when estrogen levels decline during perimenopause and menopause.

Estrogen is the hormone that keeps vulvovaginal tissues supple, moist, and well-supplied with blood. When estrogen drops, those tissues thin, dry out, lose elasticity, and become more easily irritated. The vaginal pH also shifts, becoming less acidic, which changes the balance of bacteria in the vaginal microbiome and increases susceptibility to infections.

Symptoms include vaginal dryness, burning, and irritation; pain during sex; urinary symptoms including urgency, frequency, and recurrent urinary tract infections; and a general sense of discomfort that can make everyday activities like sitting or exercising uncomfortable.

According to the 2025 American Urological Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, and American Urogynecological Society joint guideline published in the Journal of Urology, GSM affects between 13% and 87% of menopausal women depending on the diagnostic criteria used. That extraordinary range reflects both the variability of symptoms and the underreporting problem: many women do not mention these symptoms to their doctors, and many doctors do not ask.

Unlike hot flashes and night sweats, which often improve after the menopause transition, GSM tends to worsen over time without treatment. The tissues do not recover on their own once estrogen has declined. This makes early recognition and treatment especially important.

Why it goes undiagnosed

The underdiagnosis of GSM is a combination of patient silence and clinical failure. Women do not raise it because they are embarrassed, because they have been told this is normal aging, or because they assume nothing can be done. Clinicians often do not ask because pelvic and sexual health remain undertaught in medical education, because appointments are short, or because they too assume these symptoms are an inevitable part of aging that patients simply adjust to.

Dr. Kelly Casperson, a board-certified urologist and outspoken advocate for women’s sexual health, has documented this gap extensively in her work on sexual medicine and menopause. She notes that GSM is frequently misattributed to low libido, relationship problems, or psychological factors when the root cause is straightforwardly physiological: tissue that has changed due to hormone loss.

The naming history matters here too. “Vulvovaginal atrophy” was clinical and unappealing. GSM is more neutral, but neither term is one women tend to google when they experience pain during sex. The symptom-to-diagnosis pathway is full of barriers, and the result is that women suffer for years with something that is genuinely, effectively treatable.

Non-hormonal first-line options

The 2025 AUA/SUFU/AUGS clinical guideline recommends non-hormonal treatments as an appropriate first step for women with mild symptoms or women who prefer to avoid hormones.

Vaginal moisturizers are designed for regular use, not just for sexual activity. Applied two to three times per week, they help maintain vaginal tissue hydration and can reduce baseline discomfort. Hyaluronic acid-based products have shown particular promise in studies comparing them to low-dose estrogen for dryness symptoms, though they do not address tissue thinning or pH changes.

Lubricants are used during sexual activity to reduce friction and pain. Water-based and silicone-based formulations are both suitable. Oil-based lubricants should be avoided with latex condoms. Osmolality matters: very high osmolality lubricants can damage vaginal tissue over time. The World Health Organization recommends lubricants with osmolality below 1200 mOsm/kg.

These options help with comfort but do not reverse the underlying tissue changes. For women with moderate to severe symptoms, they are rarely sufficient on their own.

Low-dose vaginal estrogen: the gold standard

Low-dose vaginal estrogen is the most evidence-backed treatment for GSM and is considered the gold standard by the majority of menopause societies worldwide. It is available as a cream, a ring, a suppository, or a tablet, and it is applied or inserted directly into the vagina.

Because the dose is local and low, systemic absorption is minimal. The estrogen acts on vaginal and urethral tissue, rebuilding thickness, restoring pH, improving lubrication, and reducing urinary symptoms. Studies consistently show that low-dose vaginal estrogen reduces pain during sex, decreases urinary urgency and frequency, and reduces recurrent UTI incidence.

Critically, the systemic absorption is low enough that the 2025 guidelines confirm it is considered safe for most women, including those with a history of hormone-sensitive cancers, though individual discussion with an oncologist remains appropriate for women with breast cancer history.

A 2022 review in Menopause: The Journal of The Menopause Society found that low-dose vaginal estrogen significantly improved all GSM symptom domains compared to placebo, with benefits typically apparent within four to twelve weeks of consistent use.

Vaginal DHEA and ospemifene

For women who prefer alternatives to vaginal estrogen, two additional options have strong evidence behind them.

Vaginal DHEA (prasterone, sold as Intrarosa) is a naturally occurring hormone precursor that converts locally in vaginal tissue to both estrogen and testosterone. It has been shown in randomized controlled trials to improve vaginal dryness, tissue health, and pain during sex without meaningful systemic hormone elevation. It is available by prescription in the US.

Ospemifene (Osphena) is an oral selective estrogen receptor modulator that acts as an estrogen agonist in vaginal tissue. It is taken as a daily pill rather than applied locally. Studies show it is effective for moderate to severe dyspareunia (painful sex) from GSM. It has estrogen-like effects on bone and estrogen-antagonist effects in breast tissue, which is a favorable profile for many women. It does carry a small increased risk of hot flashes and should not be used in women with estrogen-sensitive cancers.

Newer options: laser and energy-based treatments

Fractional CO2 laser and radiofrequency devices for vaginal health have attracted significant attention over the past decade. The theory is that controlled thermal energy stimulates collagen production in vaginal tissue, improving thickness, moisture, and elasticity.

Early trial data was promising, but larger, more rigorous studies have produced mixed results. A 2021 randomized trial published in JAMA found that fractional CO2 laser was not significantly more effective than sham treatment for GSM symptoms. More recent meta-analyses suggest benefit in some subgroups, particularly for tissue changes, but the evidence is not yet strong enough for these treatments to be considered equivalent to hormonal options.

The 2025 AUA guideline notes that laser and energy-based therapies may be considered for women who cannot or prefer not to use hormonal treatments, but recommends shared decision-making with clear discussion of the current evidence limitations. Costs are significant and these procedures are not typically covered by insurance.

What to do next

If you recognize yourself in the description at the beginning of this article, the most important step is bringing this up with your doctor and specifically requesting an evaluation for GSM. If your doctor dismisses your symptoms as normal aging, you are entitled to a second opinion.

Ask about a low-dose vaginal estrogen prescription if your symptoms are moderate or severe. If you have concerns about estrogen use due to health history, ask specifically about vaginal DHEA or ospemifene as alternatives. And start with a high-quality vaginal moisturizer in the meantime because your comfort matters now, not just eventually.

GSM is not something you have to accept. It is a medical condition. It has treatments. And you have every reason to expect relief.

Medical disclaimer: This article is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider regarding any medical condition or before starting any new treatment.