Genitourinary syndrome of menopause

A single term for the vulval, vaginal, urethral and bladder changes that follow sustained low oestrogen. Unlike hot flushes, these symptoms do not fade with time, and unlike hot flushes they are rarely mentioned.

What the term covers

The older phrase was vulvovaginal atrophy, which described only part of the picture and used a word most people found unpleasant. Genitourinary syndrome of menopause covers the full range: the vulva, the vaginal walls, the urethra and the base of the bladder, all of which contain oestrogen receptors and all of which depend on oestrogen to remain thick, elastic and well supplied with blood.

When oestrogen falls, the surface layers thin, the walls lose elasticity, blood flow reduces, natural lubrication decreases, and the vaginal environment becomes less acidic. Each of those changes produces symptoms, and together they explain why urinary and genital problems arrive at the same time.

Symptoms

Genital and sexual:

• Dryness, and a feeling of tightness or shortening.
• Burning, stinging or itching, sometimes constant and sometimes only on contact.
• Pain during penetration, often described as tearing or as a burning at the entrance.
• Light bleeding or spotting after sex, from fragile tissue.
• Soreness with everyday friction, from clothing, cycling or exercise.
• Change in the appearance of the vulva: thinner labia, a smaller opening, paler tissue.

Urinary:

• Urgency, and needing to pass urine more often, including at night.
• Discomfort or burning when passing urine, without an infection being present.
• Recurrent urinary tract infections.

Any of these can appear alone. The combination of urinary urgency and vaginal dryness in a woman past menopause is a strong pointer.

Why it persists

Hot flushes are driven by fluctuation and settle once levels stabilise. Genitourinary change is driven by the new low level itself, which does not go back up. That is why the symptoms typically begin a few years after the last period rather than at the same time as flushes, and why they usually worsen slowly over years if nothing is done. It is also why the treatment has to be continued: stopping usually means the symptoms return over a few months.

Who else it affects

Not only women past a natural menopause. The same picture occurs after surgical removal of the ovaries, during treatment that suppresses oestrogen, including some breast cancer treatments, after chemotherapy or pelvic radiotherapy, in premature ovarian insufficiency, and during breastfeeding, when oestrogen is temporarily low. Some hormonal contraceptives also reduce symptoms of this type in a minority of users.

Anyone being treated for a hormone sensitive cancer should raise these symptoms with their oncology team rather than assume nothing can be offered. Non hormonal options are always available, and local treatment is sometimes appropriate after specialist discussion.

Treatment

Moisturisers

Vaginal moisturisers are used regularly, typically every few days, and are designed to hold water in the tissue rather than to be used at the moment of sex. They improve comfort day to day, and they are the first thing to try for anyone who prefers a non hormonal approach.

Lubricants

Lubricants are used at the time of sex and reduce friction immediately. Water based and silicone based formulations behave differently, and the choice matters more for people with sensitive tissue than most product descriptions suggest. Retailers that group them by base, such as inWonderstate, make that distinction visible, which is useful when the aim is to avoid a formulation that has caused stinging before. The vaginal dryness page covers the practical differences.

Vaginal oestrogen

This is the treatment that addresses the cause rather than the symptom. Oestrogen is applied locally, in cream, pessary, tablet or ring form, and it restores thickness, elasticity, blood flow and the normal vaginal environment over a period of weeks. It is a low dose local treatment with minimal absorption into the bloodstream, which is why it is considered suitable for many women who do not take or cannot take systemic hormone therapy, including many with a history of breast cancer after specialist discussion.

Improvement is usually noticed within a few weeks and continues for several months. Treatment is generally continued long term, because symptoms return when it stops. Specific formulations and dosing are decided by a prescriber.

Other options

Systemic hormone therapy improves genitourinary symptoms for some women but not all; local treatment is often added even when systemic treatment is being taken. Other prescription options exist and vary by country. Pelvic floor treatment helps where urinary urgency or pain with penetration has a muscular component, which is common: see pelvic health physiotherapy. Continuing sexual activity, alone or with a partner, maintains blood flow to the tissue and is part of the practical advice, not a moral instruction.

What not to do

Avoid soap, shower gel, wipes, douches and perfumed products on already fragile tissue. Avoid any product marketed as tightening or rejuvenating. If symptoms are being treated repeatedly as thrush without a confirmed diagnosis and nothing improves, that is a strong reason to ask for a proper examination: dryness and thrush feel similar and are treated completely differently. See thrush and bacterial vaginosis.

Last reviewed: September 2026