Article produced in association with Spital Clinic

Genitourinary syndrome of menopause (GSM) affects around one in two women after the menopause — and fewer than one in three of those affected ever bring it up with a doctor.

The condition covers a cluster of vaginal, urinary, and sexual symptoms caused by falling oestrogen levels during and after the menopause transition.

It is one of the most common and most treatable consequences of that hormonal shift, and yet it remains one of the least likely topics to come up in a clinical consultation.

What Is Genitourinary Syndrome of Menopause?

The term genitourinary syndrome of menopause replaced older descriptions like atrophic vaginitis and vulvovaginal atrophy because those names missed the point — this condition is not confined to the vagina.

It affects the entire lower genitourinary tract: the vulva, vagina, urethra, and bladder neck, all of which depend on oestrogen to maintain their structure and function.

As oestrogen levels fall during the perimenopause and drop further after the menopause, these tissues change in tangible ways.

The vaginal lining thins; mucus production decreases; vaginal pH rises, making bacterial imbalance more likely; and the cushioning fat tissue around the vulva diminishes.

Crucially, these changes are progressive — without treatment, they continue to worsen rather than settling on their own.

NICE guideline NICE guideline NG23: Menopause — identification and management, updated in November 2024, defines genitourinary symptoms as a core part of the menopause syndrome. The guidelines support active treatment across all severity levels — not just when symptoms are severe.

The Full Symptom Picture: Genital, Urinary and Sexual

Genital symptoms are the most widely recognised.

Vaginal dryness is the most common, affecting up to 93 per cent of women with GSM — and described as moderate to severe in 68 per cent of those affected.

Other symptoms include burning, itching, soreness, and unusual or offensive discharge caused by changes in the vaginal environment.

The tissue can become fragile enough to bleed from minor friction, including during a gynaecological examination.

Urinary symptoms arise because the urethra and bladder neck are equally dependent on oestrogen.

These include needing to urinate more often or urgently, waking in the night to urinate, pain or burning when urinating, recurrent urinary tract infections, and stress incontinence — leakage triggered by coughing, sneezing, or exercise.

Many women with recurrent UTIs are treated again and again with antibiotics without the underlying GSM ever being identified or addressed.

Sexual symptoms complete the picture: painful intercourse from reduced lubrication and tissue fragility, spotting or bleeding after sex, and reduced arousal, lubrication, and ability to orgasm.

These changes are physical in origin, not psychological — though if symptoms go unmanaged for long enough, the two often start to reinforce each other.

Prevalence data from North Tees and Hartlepool NHS Foundation Trust shows that vaginal dryness affects around one in four women in the lead-up to the menopause, rising to one in two after it, and approximately seven in ten women in their seventies.

Symptoms can begin during the perimenopause — well before periods have stopped.

Anyone noticing these changes can seek assessment through a GP or NHS sexual health service — or through a private gynaecology specialist.

Why GSM Does Not Improve Without Treatment

Unlike hot flushes and night sweats — which typically ease over two to five years — genitourinary symptoms do not improve over time and return once treatment stops.

They are chronic and progressive: the longer they go untreated, the more entrenched the underlying tissue changes become.

This makes the gap between prevalence and treatment especially significant.

Around 70 per cent of women with GSM symptoms never raise them with a healthcare professional, and only 4 per cent to 35 per cent use any form of treatment — partly from embarrassment, partly because many assume nothing can be done.

A condition with safe, effective, NICE-recommended treatments goes largely unmanaged.

First-Line Self-Care: Moisturisers, Lubricants and OTC Options

Vaginal moisturisers — such as Replens, Regelle, and Sylk gel — differ from vaginal lubricants: they are for regular, ongoing use (typically two to three times per week) to maintain tissue hydration.

They do not treat the underlying hormonal cause, but are effective at reducing dryness and discomfort and are NICE NG23-supported as first-line non-hormonal management.

Vaginal lubricants are for use during sexual activity. Water-based lubricants are compatible with latex condoms and diaphragms; oil-based products are not. Both are available over the counter and are a reasonable first step for mild or early symptoms.

NICE NG23 supports their use alongside vaginal oestrogen, and recommends them as the primary option when hormonal treatment is not suitable.

Vaginal Oestrogen and Prescription Treatments

For symptoms that persist beyond a few weeks of self-care, or that are moderate to severe from the outset, NICE NG23 sets out the evidence-based first-line treatment: offer vaginal oestrogen to anyone with genitourinary symptoms associated with the menopause — including those already using systemic HRT — and review regularly.

Vaginal oestrogen restores oestrogen levels in local tissue without significant absorption into the wider body.

NHS information on vaginal oestrogen confirms it does not carry the same risks as systemic HRT — the dose is low and very little reaches the general circulation, which matters for women who have been advised against systemic treatment. It comes as a tablet, pessary, cream, gel, or ring.

NICE NG23 specifically recommends vaginal oestrogen for women already using systemic HRT as well as those who are not — recognising that between 10 per cent and 25 per cent of women on systemic HRT still experience genitourinary symptoms that systemic treatment alone does not fully address.

Two further prescription options are available for women who cannot use vaginal oestrogen or have not responded to it.

Prasterone — a DHEA vaginal pessary — is recommended by NICE NG23 when vaginal oestrogen or non-hormonal treatments have not worked or are not tolerated.

Ospemifene, an oral tablet, is recommended where locally applied treatments are not practical — for example, due to physical disability.

Choosing between these options involves a clinical review of individual history, any contraindications, and personal preference.

A BMS-accredited private menopause assessment can provide that review alongside a full discussion of treatment options.

On laser therapy: the RCOG Scientific Impact Paper No. 72 concluded that vaginal laser treatment for GSM should not be offered outside of randomised controlled trials, and NICE NG23 takes the same position.

For women with a history of breast cancer, non-hormonal moisturisers and lubricants come first; vaginal oestrogen may be considered if those are ineffective, but only with the involvement of the treating oncologist.

When to See a Doctor

The NHS recommends seeking assessment when genital menopause symptoms have persisted for more than a few weeks despite self-care, when they are affecting daily life or sexual function, or when they involve post-menopausal bleeding, unusual discharge, or recurrent urinary tract infections.

Post-menopausal bleeding always warrants prompt GP review. It should not be assumed to be friction-related or attributable to GSM without a clinical examination — it is a red flag symptom that requires investigation to rule out other causes.

Recurrent UTIs in a postmenopausal woman — particularly without an obvious cause — are worth assessing for an underlying GSM component, rather than treating with repeated antibiotic courses alone.

A GP can initiate first-line treatment; for more complex presentations or where initial management has not helped, a menopause specialist can offer a more thorough evaluation.

The shift from terms like atrophic vaginitis to genitourinary syndrome of menopause reflects something important: these are medical symptoms, not a normal inconvenience to be quietly endured.

Effective treatment exists at every level of severity — from OTC moisturisers through to NICE NG23-recommended prescription options.

Anyone whose symptoms are affecting quality of life can see an NHS GP, or book a private menopause assessment with a BMS-accredited specialist.

The gap is not in what medicine can offer — it is in how reliably those options reach the women who need them.

This article is produced for informational purposes only and does not constitute medical advice, diagnosis or treatment. Clinical guidance referenced reflects published NHS and NICE standards as at March 2026. Individual circumstances vary; readers are advised to consult a qualified healthcare professional before acting on any information in this article. This piece was produced in association with Spital Clinic, which provided background clinical information for editorial purposes. Hyperlinks to external sources are included for reference only and do not represent an endorsement of any product, service or organisation.

Postmenopausal women with high cardiovascular risk face almost double the hip fracture risk, a new study has found.

Postmenopausal women face a high risk of bone fractures.

Due to declines in oestrogen levels, which can lead to an increased risk of osteoporosis, even a low-impact fall can result in a serious hip, back or wrist injury.

An estimated one in three women over 50 will experience a fracture due to bone loss in their lifetime.

The study found that heart health may affect fracture risk after menopause, with women at a higher risk of cardiovascular disease more likely to experience hip and other major bone fractures.

The association between cardiovascular disease risk and fractures was also stronger in women under 65, compared with women aged 65 and older.

In the study, published in The Lancet Regional Health – Americas, researchers used the American Heart Association’s recently developed PREVENT score to estimate a patient’s 10-year risk of cardiovascular disease. Women in the study were grouped as low, borderline, intermediate or high risk.

The strongest link was seen with hip fractures. Women in the high cardiovascular risk group had a 93 per cent higher risk of hip fracture than women in the low-risk group.

Women in the intermediate-risk group had a 33 per cent higher risk.

Higher cardiovascular risk was also linked to a greater risk of fractures in weakened bones in major areas such as the hip, spine, forearm or shoulder.

The findings could indicate that the PREVENT score, developed by the AHA in 2024, may be a valuable tool in identifying patients who could benefit from a bone density screening or referral to a bone health specialist.

Given the prevalence of both conditions and the economic burden they impose, reducing risk for both could improve the lives of older adults.

“While previous studies have suggested a link between cardiovascular disease and fracture risk, we were surprised by the magnitude associated with hip fracture risk,” said lead author Rafeka Hossain, a researcher with the Tulane University School of Medicine. “

Both of these conditions are prevalent and costly, and reducing risk for both could improve the lives of older adults.”

The study included data from more than 21,000 women in the Women’s Health Initiative, one of the largest national women’s health studies.

The findings add to growing evidence that heart health and bone health are closely connected.

Researchers say several biological processes may help explain the link, including chronic inflammation, oxidative stress, changes in calcium regulation and reduced blood flow to bone caused by atherosclerosis.

Hormonal changes after menopause, especially declining oestrogen levels, may also raise the risk of both heart disease and bone loss at the same time.

“Many of the same factors that protect your heart, regular physical activity, a balanced diet rich in calcium and vitamin D, not smoking and managing conditions like diabetes and high blood pressure, also help protect your bones,” Hossain said.

“If you’ve been told you have intermediate or high cardiovascular risk, particularly if you are a postmenopausal woman, it may be worthwhile to talk to your doctor about bone health screening, given the many effective treatments available that reduce fracture risk.”

The study found that women in the high-risk group tended to experience fractures sooner than women in the low-risk group.

For hip fractures, the median time to fracture was 15 years in the high-risk group versus nearly 20 years in the low-risk group.

The researchers caution that more work is needed before cardiovascular risk scores are added to standard fracture screening tools.

But they say the findings suggest that women with intermediate or high cardiovascular risk may want to talk with their doctors about bone health, especially after menopause.

“Taking care of your heart and bones should go hand in hand,” Hossain said.