Genitourinary syndrome of the menopause (GSM) is an umbrella term to more accurately describe a range of vulvovaginal and lower urinary tract symptoms related predominately to low oestrogen levels. Signs of GSM include atrophic changes of the external and internal female genitalia with regression and thinning of the labia minora, retraction of the introitus, and prominence of the urethral meatus (Nappi et al, 2013). Symptoms may include genital dryness, painful intercourse, post-coital bleeding, burning, soreness, irritation and itching of the vulva or vagina, including urinary frequency and urgency (Portman and Gass, 2014). Some of these symptoms can lead to repeated oral antibiotic courses for suspected urinary tract infections (UTIs) and can have a significantly negative impact for women in terms of intimate relationships, sexual function and quality of life (Phillips et al, 2022).

Up to 80% of postmenopausal women report troublesome GSM symptoms and despite this, only 25% of women seek help and less than 10% start any treatment. (Nappi and Kokot-Kierepa, 2012). There are long-held beliefs and attitudes among women (including healthcare professionals) that GSM symptoms are a natural and unavoidable part of the ageing process (Sturdee and Panay, 2010). Embarrassment, anxiety and confusion continue to exist in both women and their healthcare providers leading to patients not presenting in the first place and clinician reluctance to prescribe.

Indeed, in a survey of healthcare professionals, 70% admitted that they never, or rarely asked about troublesome symptoms relating to vaginal dryness (Nappi and Kokot-Kierepa, 2012). Given the significant impact on women’s quality of life and evidence that only a minority of these symptomatic ladies present, it should be seen as an ideal opportunity to screen all menopausal women regardless of what they present with in primary care (Pitkin and British Menopause Society [BMS], 2018; Newson et al, 2021). It should also be noted that those with atypical presentations, such as irritability and behaviour changes, and those who may not be able to articulate symptoms, such as those with learning disabilities or dementia, may also go undetected (Martin et al, 2003; Newson et al, 2021).


Around 10–25% of women on systemic hormone replacement therapy (HRT) will also need local oestrogen, particularly for those with recurrent UTIs (Newson et al, 2021). Hormone treatment using low-dose vaginal oestrogen is still considered the gold standard and is safe and well tolerated (Pitsouni et al, 2018). However, many women remain reluctant to use them because of historical misguided concerns regarding long-term safety issues with hormone exposure, including breast cancer risks and potential side-effects. These apprehensions are further compounded by alarmist, inaccurate and outdated boxed warnings in oestrogen products (Pitsouni et al, 2018).

Local oestrogen can be started in the presence of a good clinical history and examination is not always necessary or possible during remote consultations. However, examination should be completed if there are any worrying symptoms, such as lumps or abnormal vaginal bleeding, to suggest underlying pathology, or when there is no response to treatment or symptoms worsen after starting treatment (Newson et al, 2021). If speculum examination can be performed, a cervical smear can also be offered to those who are eligible to save a further appointment. If, however, speculum insertion is uncomfortable or painful, the woman should be advised to return for screening a few months after gaining informed consent to start local oestrogen treatment.


Table 1:
Summary of localised hormonal treatments
Depending on the vaginal product, initial treatment generally requires daily vaginal insertion or application for two to three weeks, then twice weekly for as long as needed. Treatment should be started promptly as the response can take time and will depend on the degree of atrophy at the time of presentation (Stuenkel et al, 2015). Vaginal epithelial absorption is greatest during the initial loading of local oestrogen when the tissue is most atrophic. Once the tissue quality has improved, absorption decreases and so smaller doses can be used indefinitely to maintain rigour in most preparations (Stuenkel et al, 2015).

Generally speaking, improvements are normally seen within three to four months, but the most severely affected women may take longer to respond. Treatment should be provided indefinitely with ongoing annual review (Newson et al, 2021). The only longer acting local oestrogen which does not require an initial loading schedule is the ESTRING vaginal ring (Pfizer), which is inserted high into the vagina and worn continually for three months (Table 1). Women should know that symptoms will likely recur on stopping treatment and that longterm use is safe.

Systemic absorption of vaginal estradiol has been found to be below the reference range in postmenopausal women (Santen et al, 2019). To further illustrate this point, using a vaginal oestrodial pessary twice weekly for one year equates to taking one dose of a 1mg oestrodial oral tablet (Hirschberg et al, 2021). There is therefore no need to protect the endometrium with progestogens (Hillard et al, 2017). Although local oestradiol preparations could cause minor problems, such as vaginal irritation and discharge, there is no evidence of an increased risk of cardiovascular disease, thromboembolism, colorectal cancer, endometrial cancer and primary or recurrent breast cancer (American College of Obstetricians and Gynecologists [ACOG], 2016; Laing et al, 2022).

Discouraging the use of soap or perfumed products is advisable and women can use simple emollients to both wash and moisturise with. Other local non-hormonal treatments, including vaginal lubricants and moisturisers (some of which are available on an NHS prescription), can be used on their own, or alongside, hormonal treatments (e.g. YES® and Sylk products).

Pelvic floor exercises and referral to physiotherapists who have specialised techniques to strengthen the pelvic floor and retrain the bladder can also be helpful (Women’s Health Concern, 2022). Other alternative treatments include vaginal dehydroepiandrosterone (DHEA), an oral selective oestrogen receptor modulator (ospemifene) and laser treatment. However, the evidence for these is less convincing and longer term data is lacking (Kearley-Shiers et al, 2022).


GSM can also affect sexual desire, responsiveness and pleasure and can be associated with hypoactive sexual desire disorder (HSDD). Testosterone replacement has demonstrated improvements with these troublesome symptoms (Davis et al, 2019) and should be considered for menopausal women with low sexual desire if HRT alone is not effective (National Institute for Health and Care Excellence [NICE] 2015). Testosterone may also have beneficial effects on urinary tract function, as a survey found that women with low circulating serum testosterone were much more likely to have urinary incontinence (Kim and Kreydin, 2018).

Practice points

  • ● Be prepared to ask questions about GSM symptoms
  • ● Vaginal oestrogen is safe, cost-effective and can be used long term
  • ● Women can be given systemic HRT and local oestrogen together 
  • ● Vaginal lubricants and moisturisers can be prescribed and used alongside HRT.


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