Genitourinary syndrome of menopause: what are the treatment options?

The genitourinary syndrome of menopause (GSM) can cause dryness, a burning or irritating sensation, pain during sex, and various urinary symptoms. These changes can affect daily comfort, sexual health, and quality of life.

Unlike many symptoms of the menopausal transition, GSM rarely tends to resolve on its own. Without adequate management, changes in the vulvar, vaginal, and urinary tissues can persist or progress over time. Fortunately, several treatment options can relieve symptoms and, in some cases, act directly on the health of the affected tissues.

At a Glance

• Vaginal lubricants and moisturizers can relieve some mild symptoms or complement a prescribed treatment.
• Low-dose vaginal estrogen is the best-studied pharmacological treatment and is available in several forms.
• Vaginal prasterone and oral ospemifene are other prescribed options.
• Pelvic floor physiotherapy can be helpful when pain, muscle tension, or certain urinary symptoms persist.
• Treatment often needs to be continued over the long term, since symptoms tend to return when it is stopped.

Should GSM treatment be the same for every woman?

There is no single approach that suits every situation. The choice of treatment depends notably on the symptoms present, their intensity, their repercussions, the treatments already tried, medical history, the woman's preferences, as well as the ease of use and coverage of the product.

Some women are mainly looking for relief from dryness. Others also have pain, vulvar irritation, urinary urgency, or recurrent urinary tract infections. Personalized management therefore makes it possible to choose the option that best matches each woman's symptoms, priorities, and health context.

Vaginal lubricants and moisturizers

Lubricants and vaginal moisturizers are often grouped together, but they do not play exactly the same role.

Lubricants

Lubricants act on an as-needed basis. They are mainly used at the time of sexual activity in order to reduce friction and discomfort. Their effect is temporary, and they do not directly change the thickness, elasticity, or long-term health of the vaginal tissues.

Vaginal moisturizers

Moisturizers are instead used regularly, independently of sexual activity. They can provide more lasting relief from dryness and discomfort. They may be sufficient when symptoms are mild or be used to complement a prescribed treatment.

When tissue changes are more significant, however, lubricants and moisturizers do not always provide adequate relief on their own. It is generally preferable to choose fragrance-free products that contain as few irritating ingredients as possible. Vaginal douches, scented cleansers, and intimate deodorants can worsen irritation.

Pelvic floor physiotherapy and complementary approaches

Hormonal deficiency is not always the only factor that contributes to pain or discomfort. When sex, a gynecological exam, or the insertion of a product becomes painful, the pelvic floor muscles can contract involuntarily. This tension can then maintain the pain, even when the dryness begins to improve.

Physiotherapy specialized in pelvic health can be relevant in the presence of pain during penetration, tension or overactivity of the pelvic floor, difficulty inserting a tampon or an applicator, certain urinary symptoms, or persistent vulvar and pelvic pain.

Vaginal dilators may also be offered in certain situations, particularly when vaginal narrowing or pain with penetration has developed. A consultation with a sex therapist can also be helpful when symptoms have repercussions on desire, arousal, intimacy, or the relationship.

Low-dose vaginal estrogen

Low-dose vaginal estrogen is the best-studied pharmacological treatment for GSM. It is applied directly in the vaginal area in order to act mainly on the genital and urinary tissues.

It can help improve tissue hydration and elasticity, decrease dryness, burning, and irritation, reduce pain during sex, and relieve certain urinary symptoms. In women who have recurrent urinary tract infections, it can also reduce the risk of new infections.

What are the different forms available?

In Canada, several formulations are available. The available data indicate that the different vaginal estrogen formulations have broadly comparable efficacy. The choice therefore often rests on the area to be treated, preferences, dexterity, frequency of application, cost, and insurance coverage.

Vaginal cream. The cream makes it possible to adjust the amount used and to treat the vaginal tissues as well as, when indicated, the vulva, the vestibule, or the area surrounding the opening of the urethra. Some women, however, find it messier or less easy to measure.

Vaginal tablet or insert. These formulations provide a predetermined dose. For several products, treatment begins with a daily application for about 14 days, followed by maintenance treatment two or three times a week.

Low-dose vaginal ring. The ring stays in place and releases a small amount of estradiol continuously. It is generally replaced every three months.

The regimens presented are general examples. The exact dose and frequency vary according to the product, its monograph, the symptoms, and the prescription received.

Is this the same as systemic hormone therapy?

No. Low-dose vaginal preparations produce mainly a local action and generally result in much lower blood exposure than estrogens administered orally or transdermally.

With the low-dose vaginal formulations usually used, adding a systemic progestogen is generally not necessary. Routine monitoring of the endometrium is not recommended solely because of their use in a woman without concerning symptoms. Some formulations may, however, include specific instructions in their monograph.

Any unexplained vaginal bleeding, particularly after menopause, must nonetheless be assessed.

Vaginal prasterone

Prasterone, also called DHEA or dehydroepiandrosterone, is another local hormonal option. It is administered as a vaginal insert, generally at a dose of 6.5 mg once a day.

Once inside the cells of the vaginal tissues, prasterone is converted locally into estrogens and androgens. It can improve dryness and pain during sex. As with other prescribed treatments, its use must take into account the history, symptoms, preferences, and precautions specific to the product.

Oral ospemifene

Ospemifene is a selective estrogen receptor modulator, sometimes referred to by the acronym SERM. It is taken orally, usually at a dose of 60 mg per day with food.

It can be used in menopausal women to treat vaginal dryness or moderate to severe pain during sex. Oral administration may represent an option when applying a vaginal treatment is difficult or impossible.

Ospemifene is not, however, a strictly local treatment. It has its own precautions, contraindications, and possible adverse effects. Its profile must therefore be evaluated separately from that of low-dose vaginal estrogen.

What is the role of systemic hormone therapy?

Systemic hormone therapy can be relevant when a woman has both GSM and other menopause symptoms, such as hot flashes or night sweats.

It can improve certain genitourinary symptoms, but it is generally not the first choice when GSM is the only manifestation to be treated. In that situation, a local treatment makes it possible to target the affected tissues directly while limiting exposure of the rest of the body.

Some women who already use systemic hormone therapy continue to have dryness, pain, or urinary symptoms. A local treatment can then be added after an individualized assessment.

What about recurrent urinary tract infections?

During menopause, changes in the vaginal and urinary tissues can alter the vaginal pH and reduce the presence of certain protective bacteria. These changes can promote urinary tract infections in some women.

In women in perimenopause or menopause who have recurrent urinary tract infections, guidelines recommend low-dose vaginal estrogen in order to reduce the risk of new infections, when no contraindication applies.

A large data analysis published in 2026 also observed that prescribing vaginal estrogen shortly after a diagnosis of recurrent urinary tract infections was associated with a decrease in hospitalizations, sepsis episodes, and deaths (LaClair et al., 2026). Since this is an observational study, it demonstrates an association and not a cause-and-effect relationship.

A burning sensation, urgency, or urinary frequency does not, however, always mean that an infection is present. When symptoms persist, recur quickly, or occur despite negative cultures, other causes must be investigated.

What about a history of breast cancer?

Genitourinary symptoms can be particularly significant in women who have received certain breast cancer treatments, notably aromatase inhibitors.

In this context, non-hormonal options are generally considered first. When symptoms remain significant despite adequate use of lubricants and moisturizers, low-dose vaginal estrogen can sometimes be considered as part of a shared decision.

The discussion must take into account the type of cancer, the risk of recurrence, current treatments, the severity of symptoms, and the woman's preferences. Collaboration with the oncology team is particularly important in women taking an aromatase inhibitor.

What about vaginal laser and radiofrequency?

Treatments using vaginal laser or radiofrequency are sometimes offered for dryness, pain, or other manifestations of GSM.

The available data, however, remain insufficient to recommend their routine use. Longer-term comparative studies are still needed to better establish their efficacy, safety, and the duration of their effects. These interventions should therefore not be presented as equivalent or superior to treatments whose efficacy is better established.

How long does it take to see improvement?

Some women notice a decrease in dryness or discomfort during the first few weeks. A period of up to about three months may, however, be needed before the effect of a local treatment can be properly assessed.

A follow-up after starting or changing the treatment makes it possible to check how symptoms are evolving, that the product is being used correctly, tolerance, and whether the dose, form, or chosen approach needs to be modified.

When the response is insufficient despite appropriate use, it is important to reconsider the other possible causes of the symptoms. A change of formulation or another treatment option can then be considered.

How long can treatment be continued?

GSM is generally a chronic condition. Unlike hot flashes, which may eventually ease, genitourinary changes tend to persist when the hormonal deficiency is maintained.

A local treatment can therefore be continued for as long as the symptoms remain bothersome and its use remains appropriate. Symptoms frequently return when treatment is stopped. The need to continue, adjust, or change the treatment can be reassessed periodically.

When is a new assessment especially important?

A new assessment is indicated when symptoms do not improve as expected or when something unusual appears. It is especially important in the presence of:

• unexplained vaginal bleeding or bleeding after menopause;
• significant, new, or persistent pain;
• lesions, sores, or visible changes of the vulva;
• unusual discharge or a persistent odour;
• urinary symptoms that recur despite treatment;
• a lack of improvement despite appropriate use of the treatment;
• a history of hormone-dependent cancer;
• significant difficulty inserting or applying the treatment.

These situations may require an in-person examination or a search for other causes, such as an infection, a dermatological condition, pelvic floor dysfunction, vulvodynia, or another gynecological or urological condition.

Key Takeaways

• The genitourinary syndrome of menopause is common, chronic, and treatable.
• Lubricants and moisturizers can be helpful, particularly when symptoms are mild, but they do not always correct the tissue changes linked to hormonal deficiency.
• Low-dose vaginal estrogen is the best-studied pharmacological treatment and is available in several forms of comparable efficacy.
• Vaginal prasterone, oral ospemifene, pelvic floor physiotherapy and, in certain situations, systemic hormone therapy can also be part of management.
• Because symptoms tend to recur when treatment is stopped, treatment is often considered from a long-term perspective, with periodic reassessment.

Looking Ahead

This article follows “Genitourinary syndrome of menopause: common but under-discussed symptoms”, which presents the mechanisms of GSM, its vulvar, vaginal, sexual, and urinary manifestations, as well as the situations in which an assessment is important.

Understanding the difference between a lubricant, a moisturizer, vaginal estrogen, prasterone, and ospemifene helps to better grasp why treatment should be chosen according to the symptoms rather than following a one-size-fits-all approach.

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. American College of Obstetricians and Gynecologists. (2021). Treatment of urogenital symptoms in individuals with a history of estrogen-dependent breast cancer: Clinical consensus. Obstetrics & Gynecology, 138(6), 950–960. https://doi.org/10.1097/AOG.0000000000004601

2. Canadian Menopause Society. (2025). Menopausal hormone therapy products in Canada: Pharmacologic options for GSM [Medication table].

3. Institut national d'excellence en santé et en services sociaux. (2024, revised February 24, 2026). Prise en charge des manifestations cliniques liées à la ménopause par l'hormonothérapie : Outil d'aide à la prise en charge. Gouvernement du Québec. https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/prise-en-charge-des-manifestations-cliniques-liees-a-la-menopause-par-lhormonotherapie.html

4. 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

5. 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

6. 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. Advance online publication. https://doi.org/10.1016/j.urology.2026.06.004

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