Hot flashes get talked about. Night sweats get talked about. Mood changes, sleep problems, and weight changes get talked about.
But some of the most uncomfortable symptoms of menopause are often the ones women mention only reluctantly, if they mention them at all.
Vaginal dryness. Burning. Pain during sex. A sudden need to urinate. Recurrent urinary tract infections. Irritation that makes tight clothing uncomfortable. Bleeding or tearing after intercourse.
These symptoms may seem unrelated, but they can be part of the same condition: genitourinary syndrome of menopause, commonly called GSM.
GSM describes changes involving the vulva, vagina, urethra, bladder, and sexual function that can occur as estrogen and other sex hormone levels decline during the menopause transition and afterward. Current clinical guidelines recognize GSM as a collection of genital, urinary, and sexual symptoms associated with these hormonal changes.
And unlike hot flashes, which frequently become less intense with time, some genitourinary symptoms can persist or become more noticeable as women age if they are not addressed.
The problem is that many women never realize their symptoms are connected to menopause.
Some assume discomfort is an unavoidable part of getting older. Others feel embarrassed discussing sexual or urinary symptoms. And because GSM can look like a urinary tract infection, yeast infection, pelvic floor problem, or other condition, women may spend months or years treating individual symptoms without recognizing the underlying pattern.
Understanding GSM can make these symptoms much easier to discuss and, importantly, easier to treat.
What Is Genitourinary Syndrome of Menopause?
Genitourinary syndrome of menopause is a group of symptoms and physical changes affecting the genital and urinary tissues as sex hormone levels decline around and after menopause.
The term encompasses changes involving areas including the:
- Vulva
- Vaginal opening
- Vagina
- Clitoris
- Urethra
- Bladder
Estrogen receptors are present throughout these tissues. As estrogen levels decline, vaginal and vulvar tissue can become thinner, drier, less elastic, and less well lubricated. Changes can also occur within the urinary tract.
This is why GSM can produce symptoms that seem to belong to completely different categories.
A woman may experience vaginal dryness and urinary urgency.
Another may have painful intercourse and frequent UTIs.
Someone else may notice only mild itching or burning at first.
There is no single symptom that every woman with GSM experiences, and clinical guidelines do not require one specific combination of symptoms for the condition to be considered.
How Common Is Genitourinary Syndrome of Menopause?
GSM is far from rare.
Published prevalence estimates vary considerably because studies use different definitions, populations, and methods of measuring symptoms. The 2025 American Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, and American Urogynecologic Society guideline reports estimates ranging widely among postmenopausal women.
Yet awareness remains limited.
Part of the problem is that people may not recognize urinary or sexual symptoms as part of menopause. Even when symptoms are bothersome, they may not be brought up during routine medical appointments unless a clinician specifically asks.
The 2025 GSM guideline specifically encourages healthcare professionals to ask about symptoms including vaginal or vulvar dryness and irritation, urinary concerns, and pain during sexual activity because patients may otherwise never raise them themselves.
That matters because GSM can affect far more than physical comfort.
Symptoms can influence sleep, exercise, relationships, intimacy, confidence, and everyday quality of life.
10 Genitourinary Syndrome of Menopause Symptoms Women Rarely Mention
1. Vaginal Dryness That Does Not Go Away
Vaginal dryness may be one of the most recognized symptoms of GSM, but many women still hesitate to discuss it.
Some describe it as a lack of lubrication during sexual activity.
Others notice dryness throughout the day, regardless of whether they are sexually active.
The tissue may feel tight, delicate, irritated, or generally uncomfortable.
Because reduced estrogen can affect tissue thickness, elasticity, and natural lubrication, dryness can become persistent rather than occasional.
Women sometimes assume they simply need more lubricant during sex. Lubricants can certainly help reduce friction, but persistent dryness outside sexual activity may indicate broader vulvovaginal changes that deserve attention.
2. Burning or Stinging Around the Vulva
Burning around the vaginal opening or vulva can easily be mistaken for an infection.
Women may repeatedly wonder whether they have a yeast infection or UTI, especially when no obvious explanation appears.
GSM can cause burning, itching, irritation, and general vulvovaginal discomfort.
The sensation may be mild and intermittent, or significant enough to make sitting, exercising, wiping after urination, or wearing certain clothing uncomfortable.
Because infections and dermatologic conditions can cause similar symptoms, persistent vulvar burning should be evaluated rather than automatically attributed to menopause.
3. Pain During Sex
Painful sex is one of the most important and least openly discussed symptoms of GSM.
The medical term is dyspareunia.
As vaginal tissue becomes drier and less elastic, penetration can become uncomfortable. Some women notice pain near the vaginal opening. Others describe deeper discomfort, soreness afterward, or a sensation of excessive tightness.
The discomfort may gradually lead someone to avoid sexual activity altogether.
Unfortunately, this can sometimes be interpreted as a loss of interest in sex when the real problem is simply that sex has become painful.
Pain is not something a woman should be expected to tolerate as an inevitable consequence of menopause.
Clinical guidance recognizes pain with penetration as a major GSM symptom, and several treatment options may help depending on the cause and severity.
4. Tiny Tears or Bleeding After Intercourse
Thinner, more fragile vaginal tissue may be more vulnerable to friction.
As a result, some women notice spotting, minor bleeding, or small fissures after sexual activity.
The 2025 GSM guideline specifically identifies fissuring during intercourse and postcoital bleeding among potential genital manifestations of GSM.
However, bleeding after menopause should always be discussed with a healthcare professional.
GSM may be one possible explanation, but postmenopausal bleeding can have other causes that require evaluation. It should not automatically be assumed to be hormonal.
5. Feeling Like You Have a UTI When Tests Are Negative
Burning with urination can feel exactly like a urinary tract infection.
But sometimes urine testing does not reveal an infection.
Changes associated with GSM can affect tissues surrounding the urethra and lower urinary tract, potentially contributing to symptoms such as burning with urination, also called dysuria.
This does not mean urinary symptoms should simply be assumed to be GSM.
An actual UTI requires appropriate diagnosis and treatment. But when UTI-like symptoms keep appearing without clear evidence of infection, GSM may be one condition worth discussing with a clinician.
6. Needing to Urinate More Often
One of the surprising aspects of GSM is that it is not exclusively a vaginal condition.
Urinary frequency may occur as well.
A woman who previously went several hours without thinking about a bathroom may suddenly find herself urinating much more frequently.
Urinary frequency can have many causes, including overactive bladder, diabetes, medication effects, infection, pelvic floor changes, and other medical conditions.
But menopause-related genitourinary changes may also contribute.
This overlap is one reason proper evaluation matters. Current urologic guidelines note that urinary symptoms associated with GSM can overlap with other common conditions such as overactive bladder.
7. Sudden Urinary Urgency
Frequency means going more often.
Urgency is different.
Urgency is the sudden, powerful sensation that you need to urinate immediately.
Some women begin planning errands around bathrooms or worrying about whether they can make it through a long meeting, flight, workout, or car ride.
Because bladder symptoms are rarely presented as classic menopause symptoms, women may not connect the change with hormonal transitions.
Yet increased urinary urgency is recognized among symptoms that can occur with GSM.
Again, urinary urgency can have multiple causes. A clinician can help determine whether GSM, overactive bladder, pelvic floor dysfunction, infection, or another condition is playing a role.
8. Recurrent Urinary Tract Infections
Repeated UTIs can become increasingly common for some women after menopause.
Hormonal changes may alter tissues and the local genitourinary environment in ways that affect susceptibility to urinary infection.
The Menopause Society includes increased risk of urinary tract infections among possible manifestations of GSM.
This connection matters because recurrent UTIs may otherwise be treated as isolated events.
Women experiencing repeated infections should receive a clinical evaluation to confirm that the episodes are actually UTIs and to discuss prevention strategies based on their individual medical history.
For appropriate patients with recurrent UTIs associated with menopause, clinicians may sometimes discuss local vaginal estrogen as part of a prevention strategy. Treatment decisions should be individualized.
9. Discomfort During a Pelvic Exam
A routine Pap test or pelvic examination that once felt merely awkward may suddenly become painful.
Why?
Reduced lubrication and changes in vaginal elasticity can make insertion of a speculum uncomfortable.
The Menopause Society notes that GSM-related tissue changes can cause discomfort not only during sexual activity but also during routine pelvic examinations.
Women do not need to silently tolerate this.
Tell your clinician if pelvic examinations have become painful. Adjustments to the examination technique, equipment, positioning, lubrication, or treatment of underlying GSM may make future exams more comfortable.
10. Avoiding Intimacy Because You Expect It to Hurt
This symptom is less physical, but its impact can be enormous.
If someone repeatedly experiences burning or pain during sex, the body begins to anticipate discomfort.
That can create a cycle:
Pain leads to anxiety about penetration.
Anxiety can lead to muscle tightening.
Muscle tightening can make penetration more difficult or painful.
Sexual activity is avoided.
Relationships may become strained.
Some women conclude that their libido has simply disappeared, when pain, dryness, or fear of discomfort may actually be contributing.
GSM can affect sexual satisfaction and relationships, not merely vaginal tissue.
Addressing both the physical symptoms and any pelvic floor or sexual health concerns can therefore be important.
Why Does GSM Happen During Menopause?
The central driver of GSM is the decline in sex hormones associated with the menopause transition, particularly estrogen.
These hormones influence the structure and function of tissues throughout the vagina, vulva, and lower urinary tract.
As hormone concentrations decline, tissue may become:
- Thinner
- Drier
- Less elastic
- Less naturally lubricated
- More susceptible to irritation
These changes help explain why GSM can produce vaginal, sexual, and urinary symptoms simultaneously.
GSM may occur during the menopausal transition as well as after menopause.
Symptoms may also be particularly relevant for women experiencing abrupt hormonal changes related to surgical removal of the ovaries, certain cancer treatments, or medications that substantially reduce estrogen activity, such as aromatase inhibitors.
Does Genitourinary Syndrome of Menopause Go Away?
This is an important difference between GSM and some other menopause symptoms.
Hot flashes and night sweats frequently improve with time.
GSM does not necessarily follow the same pattern.
The Menopause Society notes that GSM often progresses or becomes more bothersome over time without treatment.
That means waiting for vaginal dryness or painful sex to disappear on its own may not always work.
Fortunately, there are multiple treatment approaches.
How Is Genitourinary Syndrome of Menopause Diagnosed?
There is no single blood test that confirms GSM.
Diagnosis generally involves discussing symptoms and medical history and, when appropriate, performing a physical examination.
A clinician may ask about:
- Vaginal dryness
- Burning or irritation
- Pain with penetration
- Sexual function
- Urinary urgency or frequency
- Pain with urination
- Recurrent UTIs
- Bleeding
- Current medications
- Menstrual and menopause history
An examination may also help identify tissue changes or alternative explanations for symptoms.
Importantly, similar symptoms can occur with infections, vulvar skin disorders, pelvic floor dysfunction, overactive bladder, sexually transmitted infections, and other conditions.
The Menopause Society recommends clinical evaluation when symptoms persist because vulvar and vaginal symptoms are not always caused by menopause.
Genitourinary Syndrome of Menopause Treatment Options
Treatment depends on which symptoms are present, how severe they are, medical history, personal preference, and whether hormone therapy is appropriate.
Current treatment options generally fall into several categories.
Vaginal Moisturizers
Vaginal moisturizers are designed for regular use rather than only during sex.
They can help maintain moisture and may improve everyday dryness or irritation.
The Menopause Society identifies regularly used vaginal moisturizers as a potential first approach for less severe GSM symptoms.
Vaginal Lubricants
Lubricants are primarily used during sexual activity to decrease friction.
Water-, silicone-, and oil-based products are available.
People using condoms should pay attention to product compatibility because some oil-based lubricants may damage certain condoms. Products containing fragrances, warming agents, or other potentially irritating ingredients may also bother sensitive tissue.
Lubricants can make sex more comfortable, but they do not necessarily address all of the underlying tissue changes associated with GSM.
Low-Dose Vaginal Estrogen
For women with persistent or more bothersome GSM symptoms, clinicians may discuss local low-dose vaginal estrogen.
Depending on the product, vaginal estrogen may be available as a cream, tablet or insert, or ring.
Local therapy is designed to deliver estrogen primarily to vaginal tissues and can be considered differently from systemic menopausal hormone therapy, depending on the patient’s health history and treatment goals.
The 2025 multidisciplinary GSM guideline includes local low-dose vaginal estrogen among evidence-based treatment options and emphasizes shared decision-making between patients and clinicians.
Women with a history of breast cancer or another hormone-sensitive cancer should discuss GSM treatment with their healthcare team so decisions can be individualized to their cancer history and current therapy.
Vaginal DHEA
Prescription vaginal dehydroepiandrosterone, or DHEA, is another option used for certain GSM symptoms.
The Menopause Society lists vaginal DHEA among prescription therapies that may be considered for GSM.
Ospemifene
Ospemifene is an oral prescription medication that acts on estrogen receptors and may be considered for certain vulvovaginal symptoms related to menopause.
Whether it is appropriate depends on an individual’s symptoms, medical history, medication use, and risk factors.
Pelvic Floor Physical Therapy
Sometimes GSM is only one part of the picture.
After months or years of painful intercourse, pelvic floor muscles may become tense or dysfunctional.
Pelvic floor physical therapy may help selected patients, particularly when muscle tension or pain contributes to penetration difficulties.
The Menopause Society also notes options such as lubricated vaginal dilators and sexual activity, with or without a partner, as approaches that may support vaginal comfort and function in appropriate individuals.
What About Vaginal Laser or Radiofrequency Treatments?
Energy-based vaginal treatments are heavily marketed for vaginal dryness, urinary symptoms, and sexual function.
However, marketing claims should not be confused with established evidence.
The 2025 AUA/SUFU/AUGS guideline notes limitations in the research on energy-based treatments such as vaginal laser and radiofrequency, including short study durations and insufficient long-term evidence regarding effectiveness and potential harms.
Anyone considering these treatments should discuss the quality of available evidence, potential risks, costs, and established alternatives with a qualified healthcare professional.
When Should You Talk to a Doctor About GSM Symptoms?
Consider making an appointment if you experience persistent or bothersome:
- Vaginal dryness
- Vulvar burning or irritation
- Painful intercourse
- Bleeding after sex
- Urinary burning
- Increasing urinary urgency or frequency
- Recurrent UTIs
- Pain during pelvic examinations
You do not have to wait for symptoms to become severe.
And some symptoms warrant particularly prompt medical evaluation.
Postmenopausal vaginal bleeding should always be discussed with a healthcare professional. Blood in the urine, fever, significant pelvic pain, unexplained vaginal discharge, or persistent urinary symptoms should also be medically evaluated rather than assumed to be GSM.
How to Bring Up GSM With Your Healthcare Provider
You do not need medical terminology to start the conversation.
You can simply say:
“My vagina has become much drier since menopause.”
“Sex has started hurting.”
“I keep feeling like I have a UTI.”
“I suddenly need to urinate much more often.”
“I have burning around my vaginal opening.”
“My pelvic exams have become painful.”
A clinician experienced in menopause, gynecology, urogynecology, urology, pelvic health, or sexual medicine can help determine what may be contributing to your symptoms.
The important part is saying something.
These concerns are medical symptoms, not embarrassing personal failures.
Frequently Asked Questions About Genitourinary Syndrome of Menopause
What does genitourinary syndrome of menopause feel like?
GSM can feel different from one woman to another. Common experiences include vaginal dryness, itching, burning, irritation, pain during penetration, urinary burning, urinary urgency or frequency, and recurrent urinary infections.
Can GSM cause UTI symptoms without an infection?
GSM can cause symptoms such as burning with urination and urinary urgency or frequency, which may resemble a UTI. However, infections and other urinary conditions can cause the same symptoms, so persistent or recurrent urinary problems should be evaluated rather than self-diagnosed.
Can menopause cause painful sex?
Yes. Declining estrogen can contribute to vaginal dryness, reduced elasticity, tissue fragility, and pain with penetration. Painful sex is a recognized symptom of genitourinary syndrome of menopause.
Does GSM happen only after menopause?
No. Genitourinary symptoms related to declining hormones can begin during the menopause transition. GSM can also affect people with low estrogen levels due to surgical menopause, certain cancer therapies, medications, or other circumstances.
Is vaginal estrogen the same as systemic hormone replacement therapy?
Not exactly. Low-dose vaginal estrogen is a local treatment intended primarily to treat vaginal and nearby genitourinary tissues, whereas systemic menopausal hormone therapy is designed to circulate throughout the body. Which option is appropriate depends on symptoms, medical history, and individual goals.
Can you have GSM if you are not sexually active?
Yes. GSM is not a condition caused by sexual activity.
Dryness, irritation, burning, urinary symptoms, and tissue changes can occur regardless of whether someone is sexually active.
Does GSM eventually disappear?
Not necessarily. Unlike hot flashes, GSM symptoms may persist or become more significant with time without treatment.
Is genitourinary syndrome of menopause treatable?
Yes. Management options include nonhormonal lubricants and moisturizers, prescription vaginal therapies, oral medications for selected patients, pelvic floor therapy, and individualized combinations of treatments.
The Bottom Line: Menopause Symptoms Extend Far Beyond Hot Flashes
For decades, the public conversation about menopause has centered on hot flashes.
That has left millions of women unprepared for some of the changes that can occur below the waist.
Vaginal dryness, burning, painful intercourse, urinary urgency, recurrent UTIs, and discomfort during routine examinations are not symptoms women simply need to accept in silence.
They may be signs of genitourinary syndrome of menopause.
Recognizing the connection is often the first step toward finding relief.
There are multiple treatment options, and the right approach depends on symptoms, health history, preferences, and goals. A healthcare professional can also help rule out infections and other conditions that may resemble GSM.
Most importantly, women should feel able to talk about these symptoms openly.
Menopause affects the vagina, vulva, bladder, urethra, and sexual health just as legitimately as it affects sleep or body temperature.
The symptoms people talk about the least may be the ones most worth bringing up at the next appointment.
This article is for educational purposes only and is not intended to diagnose or treat any medical condition. Speak with a qualified healthcare professional about persistent vaginal, vulvar, sexual, or urinary symptoms and before starting prescription or hormonal therapy.
References:
- American Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, and American Urogynecologic Society. Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline. Published 2025.
https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause - The North American Menopause Society. The 2020 Genitourinary Syndrome of Menopause Position Statement of The North American Menopause Society. Menopause. 2020;27(9):976-992. doi:10.1097/GME.0000000000001609.
https://pubmed.ncbi.nlm.nih.gov/32852449/ - Simon JA, Nappi RE, Chedraui P, et al. Genitourinary syndrome of menopause (GSM): recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024). Sexual Medicine Reviews. 2026;14(1). doi:10.1093/sxmrev/qeaf055.
https://pubmed.ncbi.nlm.nih.gov/40981832/ - Phillips NA, Bachmann GA. The genitourinary syndrome of menopause. Menopause. 2021;28(5):579-588. doi:10.1097/GME.0000000000001728.
https://pubmed.ncbi.nlm.nih.gov/33534428/ - Danan ER, Sowerby C, Ullman KE, et al. Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause: A Systematic Review. Annals of Internal Medicine. 2024;177(10):1400-1414. doi:10.7326/ANNALS-24-00610.
https://pubmed.ncbi.nlm.nih.gov/39250810/ - Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. New England Journal of Medicine. 1993;329(11):753-756. doi:10.1056/NEJM199309093291102.
https://pubmed.ncbi.nlm.nih.gov/8350884/ - Eriksen B. A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing vaginal ring on recurrent urinary tract infections in postmenopausal women. American Journal of Obstetrics and Gynecology. 1999;180(5):1072-1079. doi:10.1016/S0002-9378(99)70597-1.
https://pubmed.ncbi.nlm.nih.gov/10329858/
