Genitourinary syndrome of menopause: common but under-discussed symptoms

At a Glance

• The genitourinary syndrome of menopause can affect the vulva, the vagina, the urethra, and the bladder.
• It can present as dryness, burning, itching, sexual discomfort, or various urinary symptoms.
• Unlike some menopause symptoms that may ease over time, genitourinary changes often tend to persist or progress.
• These symptoms should not be automatically attributed to menopause: an assessment helps clarify the cause and rule out other conditions.

Menopause is often associated with hot flashes, night sweats, or changes in sleep and mood. Yet the decline in sex hormones can also lead to changes in the vulva, the vagina, and the urinary tract.

These changes are grouped under the term genitourinary syndrome of menopause, or GSM.

Although it can affect a significant proportion of women during the menopausal transition, GSM remains poorly recognized. Some women hesitate to bring up their symptoms. Others assume they are inevitable, that they are simply part of aging, or that they are not important enough to mention during routine medical appointments.

Yet these changes can have real repercussions on daily comfort, sleep, physical activity, urinary health, sexuality, and quality of life.

What is the genitourinary syndrome of menopause?

The genitourinary syndrome of menopause refers to a set of symptoms and physical changes associated with the decline in estrogen levels and other sex hormones during the menopausal transition.

These changes can affect several structures:

• the vulva;
• the vaginal lips;
• the clitoris;
• the vaginal opening;
• the vagina;
• the urethra;
• the bladder.

The term was adopted because the expressions previously used, such as vaginal atrophy, vulvovaginal atrophy, or atrophic vaginitis, described only part of the problem. GSM does not concern the vagina alone: it can also affect the vulva, sexual function, and the urinary tract.

In Canada, population data focusing specifically on the genitourinary syndrome of menopause remain limited. In a national survey of 1,023 Canadian women aged 40 to 60, 30% reported vaginal dryness, itching, or burning, 23% urinary leakage, 17% pain during sex, and 8% urinary tract infections (Menopause Foundation of Canada, 2022). These results describe symptoms that may be associated with GSM, but they do not constitute a diagnostic estimate of its prevalence and do not distinguish women in perimenopause from those in menopause.

Why do these changes occur?

The tissues of the vulva, the vagina, the urethra, and the bladder have receptors that are sensitive to sex hormones.

When estrogen levels decline, several changes can gradually occur:

• vaginal tissues may become thinner and more fragile;
• collagen content and elasticity may decrease;
• blood flow to the genital tissues may be reduced;
• lubrication may decrease;
• the vaginal canal may become less stretchy;
• the vaginal pH may rise;
• the composition of the vaginal microbiome may change.

The decline in glycogen-rich cells notably reduces the conditions favourable to lactobacilli, bacteria that normally help maintain an acidic vaginal environment. These changes can increase tissue sensitivity, promote irritation, and contribute to greater vulnerability to certain urinary tract infections.

These changes do not necessarily all happen at the same time. Some women first notice mild dryness, while others seek care for pain during sex or for repeated urinary symptoms.

What are the possible symptoms?

The genitourinary syndrome of menopause can present in different ways. A woman may experience a single symptom or several at once.

Vulvar and vaginal symptoms

Possible manifestations include:

• a sensation of dryness;
• burning;
• itching;
• irritation or increased sensitivity;
• a feeling of tightness;
• discomfort from contact with clothing;
• vaginal discharge that differs from usual;
• light bleeding caused by tissue fragility.

Some women also feel discomfort when wiping after urinating, during a gynecological exam, or during certain physical activities.

Urinary symptoms

GSM can also be associated with urinary changes, notably:

• a need to urinate more often;
• a sudden urge that is hard to hold back;
• waking at night to urinate;
• a burning sensation when urinating;
• recurrent urinary tract infections;
• an increase in or change to urinary leakage in some women.

These symptoms are not always caused by an infection. Conversely, a burning sensation should not be automatically attributed to menopause without assessment, particularly when it is new, intense, or accompanied by other symptoms.

Changes related to sexuality

GSM can also influence the sexual response and comfort during intercourse.

Possible changes include:

• reduced lubrication;
• discomfort or pain during penetration;
• a burning sensation after sex;
• small fissures or light bleeding;
• reduced arousal or pleasure;
• apprehension about sex because of pain.

A decrease in desire is not necessarily caused directly by a hormonal change. It can also be a consequence of discomfort, fear of pain, fatigue, or the anticipation of an unpleasant experience.

Over time, pain can lead to an involuntary contraction of the pelvic floor muscles, which can heighten the discomfort. Sexuality is, however, personal: the importance given to these changes and their repercussions varies from one woman to another.

When can symptoms appear?

Symptoms can begin during the menopausal transition, when hormone levels become more variable, but they are generally more common after menopause.

Their course sets them apart from many other manifestations of menopause.

Hot flashes and night sweats may eventually ease in some women. Genitourinary changes, on the other hand, tend to persist and can progress over time. GSM is therefore considered a chronic and progressive condition.

This does not mean that every symptom will necessarily worsen. The course remains individual. It is, however, less likely that persistent symptoms will resolve on their own simply because several years have passed since menopause.

Why does GSM remain so under-recognized?

Several factors may explain why these symptoms are not always addressed.

Some women:

• do not connect their symptoms to the menopausal transition;
• use words like dryness or discomfort without knowing that this may be a recognized clinical entity;
• consider their symptoms a normal consequence of age;
• feel embarrassed to talk about their vulva, their bladder, or their sexuality;
• assume the healthcare professional will bring up the subject if it is important;
• fear that their concerns will be minimized.

For their part, healthcare professionals do not always systematically ask questions about genitourinary or sexual health. Canadian guidelines nonetheless recommend actively looking for these symptoms on a regular basis in women in perimenopause and menopause.

It is possible to describe these changes in a simple, descriptive way: dryness, burning, pain, urinary urgency, repeated infections, or a change in sexual comfort. It is not necessary to know the medical term for the symptoms to deserve to be heard.

Are all genital or urinary symptoms caused by menopause?

No.

Several conditions can cause symptoms similar to those of GSM. Irritation, itching, pain, or burning can notably be associated with:

• a vaginal or urinary infection;
• a sexually transmitted infection;
• a reaction to a soap, a scented product, or another irritant;
• a dermatological condition of the vulva;
• a pelvic floor condition;
• vulvar or pelvic pain of another origin;
• a prolapse;
• certain medications or medical treatments;
• more rarely, a precancerous or cancerous lesion, and so on.

The presence of symptoms during or after the menopausal transition is therefore not enough, on its own, to conclude that they are caused by GSM. An assessment helps recognize the clinical picture and determine whether other explanations should be investigated.

How is GSM assessed?

The assessment generally begins with a discussion of the symptoms:

• when they appeared;
• their frequency and intensity;
• the factors that seem to worsen them;
• their effect on comfort, sleep, or activities;
• urinary changes;
• previous infections;
• the presence of pain;
• the repercussions on sexuality or the relationship;
• the products already used;
• medical, gynecological, and medication history.

An examination of the vulva and vagina may be recommended in order to observe the state of the tissues and rule out other conditions. Depending on the symptoms, a urine test, a vaginal swab, or other investigations may also be necessary. Recent guidelines emphasize the importance of a targeted history and, when appropriate, a pelvic exam to recognize the physical changes associated with GSM.

The assessment must be adapted to the woman's comfort. Anticipated pain, a difficult gynecological experience, or a particular concern can be discussed before the exam.

When is an assessment especially important?

It is relevant to address symptoms when they are persistent, when they recur, or when they affect quality of life.

Some signs, however, should not simply be attributed to GSM and require a clinical assessment, notably:

• vaginal bleeding after menopause;
• repeated bleeding after sex;
• a visible lesion, sore, or mass;
• new or persistent pelvic pain;
• blood in the urine;
• unusual discharge, particularly if it is foul-smelling;
• fever, chills, or back pain accompanying urinary symptoms;
• frequent or insufficiently documented urinary tract infections;
• significant pain or pain that worsens rapidly.

Light bleeding can sometimes be associated with tissue fragility, but bleeding that occurs after menopause must always be assessed in order to determine its cause.

Key Takeaways

The genitourinary syndrome of menopause is common, but still little known.

It can affect the vulva, the vagina, the bladder, the urinary tract, and sexual comfort. Its manifestations are not limited to vaginal dryness and can be mistaken for an infection or other conditions.

Unlike some manifestations of menopause that may ease over time, genitourinary symptoms often tend to persist. They are not, however, a consequence that should simply be dismissed or endured.

Recognizing these changes is an important first step toward better understanding what is happening and determining whether a more thorough assessment is needed.

Looking Ahead

The genitourinary syndrome of menopause can present in many ways, and not all women have the same symptoms, the same priorities, or the same health history.

Our article “Genitourinary syndrome of menopause: what are the treatment options?” focuses on the different treatment options for managing GSM. It explains how they differ, the symptoms they can address, and the factors to consider when guiding an individualized decision.

Disclaimer

This article presents general educational information. It does not replace a clinical assessment or the advice of a healthcare professional.

References and Further Reading

1. Gaddam, N. G., Kingsberg, S. A., & Iglesia, C. B. (2024). Sexual dysfunction and dyspareunia in the setting of the genitourinary syndrome of menopause. Clinical Obstetrics and Gynecology, 67(1), 43–57. https://doi.org/10.1097/GRF.0000000000000846

2. Johnston, S., Bouchard, C., Fortier, M., & Wolfman, W. (2021). Guideline No. 422b: Menopause and genitourinary health. Journal of Obstetrics and Gynaecology Canada, 43(11), 1301–1307.e1. https://doi.org/10.1016/j.jogc.2021.09.001

3. Kaufman, M. R., Ackerman, A. L., Amin, K. A., Coffey, M., Danan, E., Faubion, S. S., Hardart, A., Goldstein, I., Ippolito, G. M., Northington, G. M., Powell, C. R., Rubin, R. S., Westney, O. L., Wilson, T. S., & Lee, U. J. (2025). The AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause. The Journal of Urology, 214(3), 242–250. https://doi.org/10.1097/JU.0000000000004589

4. LaClair, J., Visingardi, J., Wells, B., Feustel, P., Deckert, J., & De, E. J. B. (2026). Vaginal estrogen prescription is associated with reduced risk of serious adverse outcomes in women of all age groups with recurrent urinary tract infection: An Epic Cosmos database analysis. Urology, S0090-4295(26)00358-4. Advance online publication. https://doi.org/10.1016/j.urology.2026.06.004

5. Menopause Foundation of Canada. (2022). The silence and the stigma: Menopause in Canada. https://menopausefoundationcanada.ca/wp-content/uploads/2022/10/MFC-Report_The-Silence-and-the-Stigma_Menopause-in-Canada_October-2022.pdf

6. Portman, D. J., Gass, M. L., & Vulvovaginal Atrophy Terminology Consensus Conference Panel. (2014). Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Maturitas, 79(3), 349–354. https://doi.org/10.1016/j.maturitas.2014.07.013

7. The NAMS 2020 GSM Position Statement Editorial Panel. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 27(9), 976–992. https://doi.org/10.1097/GME.0000000000001609

8. Waetjen, L. E., Crawford, S. L., Chang, P.-Y., Reed, B. D., Hess, R., Avis, N. E., Harlow, S. D., Greendale, G. A., Dugan, S. A., & Gold, E. B. (2018). Factors associated with developing vaginal dryness symptoms in women transitioning through menopause: A longitudinal study. Menopause, 25(10), 1094–1104. https://doi.org/10.1097/GME.0000000000001130