Gynae

Vaginal Atrophy & GSM

Creator: Dr Nadira Awal
Published: 2026-01-15

Genitourinary syndrome of menopause — dryness, discomfort, UTIs and the treatments that work.

By Dr Nadira AwalBMS Specialist3 min readMedically reviewed 9 July 2026

Folded peach silk scarf and a single dried rose on cream linen

GSM affects the majority of women after menopause and is very treatable. Local vaginal oestrogen is safe long-term and can transform comfort, intimacy and urinary health.

Genitourinary Syndrome of Menopause (GSM) — the umbrella term for what used to be called vulvovaginal atrophy plus lower urinary tract symptoms — affects the majority of postmenopausal women. Unlike hot flushes, it does not fade with time; without treatment it steadily worsens. It is also one of the most rewarding menopausal problems to treat: highly effective, extremely safe, evidence-based options exist, and the vast majority of women who use them describe the effect as life-changing. If you take one thing away from this page, it is that GSM is treatable, and treatment is safe long-term.

Symptoms — often mistaken for something else

Vaginal dryness, itching, burning or a rough, sandpapery feeling.
Pain, tearing or spotting during or after sex; loss of sensation and arousal.
Urinary urgency and frequency, waking at night to pass urine, and recurrent UTIs.
External discomfort with tight clothing, exercise, cycling or long walks.
Reduced vaginal secretions and a change in odour or discharge.

Why it happens

Oestrogen keeps vaginal, vulval and urethral tissues thick, elastic, well-lubricated and populated with protective lactobacilli.
Without oestrogen, the tissues thin, blood flow drops, pH rises and the microbiome shifts.
The urethra and bladder trigone share the same oestrogen receptors — that's why urinary symptoms come as part of the package.

Treatments that work

Vaginal oestrogen (cream: Ovestin/Blissel; tablet: Vagifem/Vagirux; ring: Estring) — first-line, effective in 4–12 weeks, applied nightly for 2 weeks then twice weekly indefinitely.
Prasterone (Intrarosa) — vaginal DHEA converted locally to oestrogen and testosterone; an option if oestrogen is unsuitable.
Vaginal moisturisers (Replens, YES, Regelle) 2–3 times a week — hydrate the tissue between doses of oestrogen.
Water- or silicone-based lubricants at intimacy — separate from moisturisers, both are useful.
Systemic HRT helps GSM in about half of women — many still need local treatment on top.

Reassurance on safety

Vaginal oestrogen has minimal systemic absorption — blood oestradiol levels stay in the postmenopausal range.
It is considered safe for long-term (lifelong) use in the majority of women.
BMS and international guidance support its use in most women with a personal history of breast cancer after oncology review — including many on aromatase inhibitors, where estriol is often preferred.
It does not need to be balanced with a progestogen at typical doses.

Practical tips for getting the most from treatment

Apply at night — it stays in place longer and won't leak into underwear.
Consistency matters more than dose — twice weekly for months beats daily for a fortnight.
If irritated initially, halve the dose for a week and build up.
Combine with a pelvic floor physiotherapy assessment if there are urinary or prolapse symptoms.

When to book a specialist review

Symptoms persisting despite 3 months of consistent local treatment.
Bleeding, unusual discharge or a lump — needs prompt assessment, not more moisturiser.
Uncertainty about whether local oestrogen is safe for you, particularly after cancer treatment.

Key takeaway

GSM is common, highly treatable and treatment is safe for the long term — women who use vaginal oestrogen consistently rarely regret starting it, and often regret not starting sooner.

How Dr Awal approaches this in clinic

Every consultation starts with your full story — symptoms, cycle, medical history, family history and what you've already tried. From there we look at whether hormonal treatment, non-hormonal options, lifestyle changes or a combination will give you the best result, and we tailor the plan to your age, risk factors and preferences.

A detailed 60 minute first appointment — no rushed 10-minute slots.
Evidence-based recommendations aligned with NICE NG23 and BMS guidance.
Body-identical HRT considered first-line where appropriate.
Shared-care letters sent to your NHS GP so treatment can continue affordably.
Follow-up at 3 months to fine-tune your regimen and address side effects.
Ongoing annual reviews so your plan evolves with you.

Common questions we hear about this

Do I need to be at a certain age to be seen?

No. We see women in early perimenopause (often late 30s and 40s), through post-menopause and beyond. Age alone doesn't decide whether treatment is right — symptoms, health history and goals do.

Will my GP continue the prescription?

In most cases yes. After your consultation we send a detailed shared-care letter with the diagnosis, treatment plan and rationale so your NHS GP can prescribe on the NHS. Not every practice accepts shared care — we'll discuss this in your appointment.

What if I've tried HRT before and it didn't suit me?

Very common — often the type, dose or route wasn't right rather than HRT itself. We review what you've tried, why it didn't work, and adjust accordingly. Many women who thought HRT wasn't for them do well on a different preparation.

How long will I need to stay on treatment?

There is no set upper time limit for HRT. Current BMS and NICE guidance supports continuing HRT for as long as the benefits outweigh the risks for you personally. We review this together every year so you stay in control of the decision.

Where do you see patients?

All consultations at Pause and Co Healthcare are conducted securely via video, allowing us to support patients anywhere in the UK. Prescriptions and shared care arrangements are managed in the same way, regardless of your location.

About the author

Dr Nadira Awal is a British Menopause Society Advanced Menopause Specialist with 15+ years' NHS and private experience. She holds the BMS Advanced Certificate in Menopause Care, sits on the BMS Programme Planning Group, and advises the UK Government Menopause Strategy Group. Read her full profile.

Sources & further reading

General information only — not a substitute for personalised medical advice. Always speak to your GP or a menopause specialist about your own situation.

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