Vaginal Dryness, GSM, and the Treatments Most Women Have Never Heard Of

Vaginal dryness and GSM affect most women in perimenopause and almost all of them can be effectively treated. The conversation almost never happens.

Genitourinary syndrome of menopause is one of the most prevalent and most undertreated conditions associated with the perimenopause transition. Unlike hot flushes, which typically improve as hormonal transition completes and levels stabilise, GSM tends to worsen progressively over time without treatment. Despite being common, highly treatable, and having significant impact on quality of life, GSM is dramatically undertreated — primarily because women do not raise it and clinicians do not ask about it.

What Is GSM?

Genitourinary syndrome of menopause is the clinical term for the cluster of symptoms caused by declining oestrogen affecting the vulva, vagina, urethra, and bladder. Oestrogen maintains the health of all these tissues: it stimulates cell turnover and collagen production in vaginal tissue, promotes the acidic pH environment maintained by Lactobacillus bacteria, supports vascular supply to genital tissue (necessary for natural lubrication), and maintains the tone and elasticity of urethral and bladder tissue.

As oestrogen declines, these tissues change. Vaginal tissue thins, becomes less elastic, and loses its natural lubrication. Vaginal pH rises from the protective acidic range toward alkaline, creating an environment more susceptible to infection and inflammation. Urethral and bladder tissue loses tone and becomes more reactive. The symptoms this produces are wide-ranging: vaginal dryness and soreness (present at rest, not only during sex), discomfort or pain during penetrative sex ranging from mild to severe, recurrent vaginal infections due to changed pH, and urinary symptoms including frequency, urgency, burning on urination, and increased susceptibility to UTIs.

The progressive nature of GSM is clinically important. Unlike vasomotor symptoms, which improve spontaneously as hormonal transition completes, GSM continues to worsen with sustained oestrogen deficiency — which in postmenopause is indefinite without treatment. Early treatment produces better outcomes than delayed treatment, and the window of easy treatability is perimenopause rather than years into postmenopause.

Local Vaginal Oestrogen — Why It Is the First Treatment to Discuss

Local vaginal oestrogen is the most effective treatment for GSM and the treatment that most women experiencing genitourinary symptoms have never been offered or told about. It is available on NHS prescription in several forms: cream, pessary, tablet, ring, and foam. The critical clinical distinction — and the one that makes local oestrogen appropriate for the vast majority of women including many who cannot take systemic HRT — is its minimal systemic absorption.

The amount of oestrogen that enters the general circulation from a vaginal cream, pessary, or tablet is substantially smaller than from any systemic HRT preparation. For most women, the systemic exposure is clinically insignificant from a risk perspective. This means women with breast cancer history, blood clot history, or other contraindications to systemic HRT should not automatically assume local vaginal oestrogen is also contraindicated. Current guidance supports its use for most women in these groups — this is a specific conversation worth having with a clinician who knows the current evidence.

Yet local vaginal oestrogen remains dramatically underused. Women do not know it exists. Clinicians do not raise it proactively. The conversation about genitourinary symptoms almost never happens in standard perimenopause consultations. The practical implication is that if you have genitourinary symptoms, you need to raise them explicitly: "I'd like to discuss local vaginal oestrogen for the dryness and discomfort I've been experiencing." That is sufficient to open the conversation.

Other Effective Options

Non-hormonal vaginal moisturisers, applied regularly to vaginal tissue rather than only at the time of sexual activity, help maintain hydration and reduce chronic symptoms of dryness and soreness. They are not as effective as local oestrogen for addressing the underlying tissue changes, but they are meaningful as supplements to hormonal treatment and as options for women who prefer or require fully non-hormonal management.

Appropriate lubricants, used specifically during sexual activity, significantly reduce friction and discomfort during sex. Choosing a lubricant that is pH-appropriate for the vagina, free of glycerine (which can promote candida infections), and free of spermicides is important for both immediate comfort and longer-term vaginal health.

Pelvic floor physiotherapy addresses the physical changes of GSM — including pain during sex, urinary urgency, stress incontinence, and altered sensation — through manual treatment and exercise prescription that complement hormonal approaches. A specialist pelvic floor physiotherapist can both assess and treat these symptoms with expertise that exceeds what is possible in a standard GP consultation. In the UK, pelvic floor physiotherapy is available on NHS referral and through private practice, and it is worth requesting specifically rather than waiting for it to be offered.