What is the Genitourinary Syndrome of Menopause (GSM)?

What is GSM?

GSM is a term introduced in 2014 by the International Society for the Study of Women’s Sexual Health and the North American Menopause Society to replace older terms such as “vulvovaginal atrophy”.

It refers to the spectrum of genital, urinary and sexual symptoms and physical changes that occur when the tissues of the vulva, vagina, urethra and lower urinary tract lose the support of sex steroids (especially oestrogen and to some extent androgens) during the menopausal transition and beyond.

Examples of common symptoms include:

• Vaginal or vulvar dryness, irritation, burning or itching.
• Pain with intercourse (dyspareunia).
• Urinary symptoms such as urgency, frequency, dysuria (pain on urination), recurrent urinary tract infection or new onset incontinence.
• Changes in the appearance or elasticity of the vaginal tissue: thinning walls, fewer folds, pallor, possibly introital narrowing.

How common is GSM?

Prevalence estimates vary widely, due to differing definitions, populations studied, symptoms included and methods used. According to one review, estimates in post-menopausal women range from roughly 27 % to 84 %. Another meta-analysis found prevalence up to ~50 % in postmenopausal women.
It is also important to note that many women do not raise these symptoms with clinicians, and the condition is under-diagnosed.
Hence, while we cannot give a single “how many women suffer” number, what is clear is that a very significant proportion of women transitioning into, through or post-menopause will experience at least some GSM symptoms.

What causes GSM?

The underlying cause is the decline in ovarian function, with resulting lower circulating oestrogen (and in some cases androgens). This leads to a cascade of tissue changes in the genitourinary tract:

• The vaginal epithelium becomes thinner, with fewer superficial cells, fewer blood vessels and reduced lubrication.
• The pH of the vagina may increase, protective Lactobacilli diminish, leading to more susceptibility to irritation, infection and trauma.
• The urethra and bladder tissues also may show changes: reduced vascularity, thinner mucosa, decreased support from surrounding tissues, which contributes to urgency, frequency or incontinence.
• Over time, these changes can worsen rather than improve on their own — unlike some menopausal vasomotor symptoms which may subside.

Why does it matter?

GSM has a real impact on quality of life. The genital-urinary symptoms can interfere with intimacy, comfort, sexual satisfaction, self-esteem, bladder-bowel habits and overall wellbeing.
Importantly for your practice, many women may attribute symptoms to “just ageing” and not realise that there are effective interventions. That means there is a real opportunity for you — as a pelvic health physiotherapist (Jessica Dingle) — to help women recognise the signs, understand that they are common yet treatable, and support them through appropriate care.

Summary

In short: GSM is a common but under‐recognised condition of the menopausal transition and beyond, affecting the genital and urinary tract as a result of sex-hormone decline. If you’re working with women aged 30-70, it’s worth screening for symptoms of GSM, discussing them openly, and collaborating with them and their other clinicians (GPs, gynaecologists) to manage the condition proactively.

 

References

Sarmento AC, Costa APF, Vieira-Baptista P, Giraldo PC, Eleutério Jr J, Gonçalves AK. Genitourinary syndrome of menopause: epidemiology, physiopathology, clinical manifestation and diagnostic. Frontiers in Reproductive Health. 2021;3:779398. doi:10.3389/frph.2021.779398.

The North American Menopause Society (NAMS). The 2020 Genitourinary Syndrome of Menopause (GSM) Position Statement of The North American Menopause Society. Menopause. 2020;27(9):976-992. doi:10.1097/GME.0000000000001609.

Woods NF, Shaver JF, Berg JA. Genitourinary syndrome of menopause: prevalence and predictors. Clin Obstet Gynecol. 2023;67(1):27-42. doi:10.1097/GRF.0000000000000847.

Agency for Healthcare Research and Quality (AHRQ). Danan ER, Diem S, Sowerby C, Ullman K, Ensrud K, Landsteiner A, Greer N, Zerzan N, Anthony M, Kalinowski C, Forte M, Abdi HI, Friedman JK, Nardos R, Fok C, Dahm P, Butler M, Wilt TJ. Genitourinary Syndrome of Menopause: A Systematic Review. Comparative Effectiveness Review No. 272. July 2024. doi:10.23970/AHRQEPCCER272.