Vaginal dryness & genitourinary syndrome of menopause (GSM): talking about it, understanding it, finding relief

There are subjects we rarely talk about, including with our doctor. Intimate dryness is one of them. It is often lived through in silence, a little embarrassed, telling ourselves that "that is how it is after a certain age" or that it belongs to private life. The result: many women put up with a discomfort that weighs on their daily life, their intimacy and their well-being, without knowing that simple and effective solutions exist. Yet what we now call the genitourinary syndrome of menopause (GSM) is one of the most common effects of the fall in estrogen. It is in no way inevitable and, above all, there is nothing shameful about it. This article is here to put clear words on what you may be feeling, and to show you that the subject deserves to be raised, calmly, with a health professional.

A precise name for a set of symptoms

For a long time, people spoke of "vulvovaginal atrophy", a term judged both reductive and off-putting. In 2014, two leading learned societies, the North American Menopause Society (today The Menopause Society) and the International Society for the Study of Women's Sexual Health (ISSWSH), proposed a more accurate and more complete term: genitourinary syndrome of menopause^[1]. This new vocabulary is not just a matter of words: it recognizes that the phenomenon is not limited to the vagina, but affects the whole genital and urinary region.

In concrete terms, GSM brings together three families of signs^[1]: genital symptoms (dryness, a burning sensation, irritation), sexual symptoms (lack of lubrication, discomfort or pain during intercourse), and urinary symptoms (urgency, burning on passing urine, recurrent urinary tract infections). All these manifestations stem from one and the same cause: the fall in estrogen, which makes the tissues of this area thinner, less elastic and less well lubricated. It is important to note that GSM is distinct from low libido: you can very much feel desire and, at the same time, suffer from a physical discomfort that makes sex painful.

A condition far more common than people think

If you recognize yourself in these lines, know that you are far from alone. In the large international VIVA survey conducted among postmenopausal women, about 45% of them reported vaginal symptoms^[2]. And in the European REVIVE survey, vaginal dryness came top of the symptoms, affecting about 70% of the women concerned^[3]. These figures describe a massive reality, but one that is largely unspoken.

What is most striking is the gap between how common the problem is and the silence around it. In the VIVA survey, a small minority of the women concerned made the link between their symptoms and a phenomenon related to menopause, and a majority did not know that this was a chronic condition^[2]. That is an essential point, and we come to it right away.

A major difference from hot flashes: it does not go away on its own

Here is probably the most important message of this article. Hot flashes, however trying they are, tend to ease with time in many women. The genitourinary syndrome behaves differently: it is chronic and progressive. Without treatment, the symptoms persist, and even tend to intensify over the years, as estrogen deficiency sets in^[4]. So this is not a bad patch to get through while waiting for things to "settle down".

This particularity changes everything in how the subject should be approached. Waiting for the problem to disappear on its own most often leads to a slow worsening. Conversely, talking about it and putting a suitable solution in place brings real relief. And since the treatment acts on tissues that need regular upkeep, it is generally designed to be used over the long term. There is nothing worrying about that: it is simply a matter of supporting your body, as you would moisturize skin that needs it.

What can relieve you

Good news: there is no shortage of options, and they range from a very simple step, available without a prescription, to a treatment prescribed by a doctor. The idea is not to try everything, but to find, with a professional, what matches the intensity of your symptoms and your personal situation.

Moisturizers and lubricants: the first step available to everyone

It is useful to distinguish clearly between these two products, because they do not play the same role. Lubricants are used at the time of intercourse to reduce friction and discomfort; their effect is momentary. Vaginal moisturizers, by contrast, are applied regularly (several times a week, for example), independently of sexual activity, to maintain tissue hydration over time. These non-hormonal products are often a reasonable first approach, particularly for mild symptoms, and they can bring real comfort^[5]. In some trials, vaginal moisturizers provided relief of the most bothersome symptoms comparable to that of other options^[5]. They can also be combined with a local hormone treatment if needed.

Low-dose vaginal estrogen: effective and reassuring

This is where we have to be precise about the order of things, because the French guidelines are. For the management of GSM, the CNGOF and the GEMVi recommend prescribing lubricants and moisturizers as first-line treatment, with vaginal hormone therapy coming second-line depending on how things progress. When moisturizers are not enough, then, low-dose locally applied estrogen (as a cream, a pessary, a vaginal tablet or a ring) is a reference treatment. A Cochrane review, which pools data from comparative trials, concluded that these local preparations effectively improve the signs and symptoms of vaginal atrophy compared with a placebo^[6]. One fear comes up often: "hormones, isn't that dangerous?" It is a legitimate question. Now, unlike hormone therapy taken systemically, low-dose vaginal estrogen acts mainly locally and leads to only very limited exposure of the body as a whole^[6]. These treatments are considered effective and, overall, well tolerated for GSM, which explains why they hold a central place in the guidelines^[4]. Of course, the decision and the follow-up are always made with a doctor.

The case of a history of breast cancer deserves to be stated clearly, rather than summed up in a passing clause. The CNGOF and the GEMVi write that the safety of using this type of local treatment in women with a history of breast cancer is uncertain. The joint recommendations of The Menopause Society and the ISSWSH devoted to this situation set out the same logic : you start with the non-hormonal options, moisturizers and lubricants, to which pelvic floor rehabilitation and vaginal dilators can be added ; a local hormone treatment is only considered afterwards, and in consultation with the oncologist. This is not a ban, it is a decision made together.

Two further points, drawn from the same French text. There is no predefined treatment duration, and stopping leads to a rapid return of symptoms, which fits the chronic nature of GSM. And routinely adding a progestogen is not required with low-dose vaginal estrogen : no effect on the endometrium has been observed for treatment durations of under two years at low dose.

Ospemifene and the other options

Other treatments exist for women who cannot or do not wish to use a local estrogen. Ospemifene, for example, is a tablet taken by mouth belonging to the family of selective estrogen receptor modulators (SERMs): it acts on vaginal tissue without being a classic estrogen. Controlled trials have shown its effectiveness in relieving vaginal dryness and pain during intercourse in postmenopausal women, with a good tolerability profile^[7]. Still other approaches exist, such as prasterone, vaginal DHEA, which is among the options cited by the French guidelines. One reservation to know about, however : the 2021 text from the CNGOF and the GEMVi does not deal with ospemifene. So we cannot say that it is recommended in France for this indication, only that controlled trials have shown its effectiveness. Its place, if it is offered to you, is to be discussed with your doctor. What all these solutions have in common: they require medical advice in order to choose the most suitable one. The data are, moreover, more solid for some options than for others, and research continues to clarify their respective places.

Vaginal laser: what the French guidelines say

Vaginal laser is offered in a growing number of practices, often at a high price and with no reimbursement. On this point, the guidelines of the CNGOF and the GEMVi are explicit : it is not recommended to use a laser as a first-line option for the management of GSM symptoms (grade C), pending a fuller evaluation. If you are offered a laser before you have even tried a moisturizer or a local estrogen, you are entitled to ask about that ordering.

A signal that must never be put down to dryness

GSM can cause light bleeding, notably after intercourse, because the tissues are fragile. That never removes the need to have it checked. Faced with abnormal bleeding in a postmenopausal woman, the CNGOF and the GEMVi recommend looking for an organic cause (grade A) and suggest performing a pelvic ultrasound ; in the event of recurrent bleeding or a thickened endometrium, further investigations, hysteroscopy and tissue analysis, are recommended. In other words : bleeding after menopause is always reported and investigated, even when dryness seems the obvious explanation.

The real first step: daring to talk about it

Of all the steps mentioned here, the most decisive one costs nothing: it is opening the conversation. Too many women never raise these symptoms at a consultation, often out of modesty, sometimes because they think nothing can be done. Yet it is precisely the opposite: putting words on dryness, discomfort or pain allows your doctor, your gynecologist or your midwife to offer you a concrete solution. You do not need to find the technical terms. A simple sentence is enough: "I have intimate discomfort, dryness, sex has become painful, and I would like to talk about it."

What you should take away is that the genitourinary syndrome of menopause is common, that it is chronic but responds well to treatment, and that no woman should have to endure it in silence. Your comfort, your intimacy and your quality of life count, at any age. The subject is in no way taboo: it is simply part of women's health.

⚠️ This article is provided for informational and educational purposes only. It does not replace medical advice, diagnosis or treatment. Always consult your doctor or a qualified health professional with any questions about your health.

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