Part 5 of our 6-week menopause series
If sex has become uncomfortable, or if you feel dry, burning, or irritated, I want you to hear this first: this is common, it is not something you have to just live with, and it is very treatable.
So far in this series, we've covered hot flashes and what helps and the early signs of perimenopause. This week is about vaginal, vulvar, and urinary changes that, unlike hot flashes, tend to get worse over time if we don't treat them. Whether you live here in Princeton or you're driving in from the surrounding area, you don't have to figure this out on your own.
What Is Genitourinary Syndrome of Menopause?
Doctors now use the term genitourinary syndrome of menopause, or GSM, for changes that can follow a drop in estrogen. GSM can include dryness, burning, irritation, and pain with sex, as well as urinary symptoms such as burning with urination, urgency, and recurrent urinary tract infections. Women who are not sexually active can be bothered by GSM too.
The Menopause Society's 2020 position statement estimates that GSM affects about 27% to 84% of postmenopausal women. In a U.S. survey of 1,858 postmenopausal women with these symptoms, half had never used any treatment. Unlike hot flashes, GSM is generally progressive without effective treatment, but in most cases we can manage it well.
What About Urinary Symptoms and Recurrent UTIs?
Because the bladder and urethra are affected by the same estrogen loss, some women urinate more often, feel a sudden urge, or get one bladder infection after another. If you leak with a cough, a laugh, or exercise, that may be stress urinary incontinence, which we wrote about here. GSM and leaking can overlap.
For recurrent UTIs after menopause, the 2025 AUA/SUFU/AUGS guideline on GSM and earlier AUA recurrent-UTI guidance recommend low-dose vaginal estrogen to lower the chance of future infections, when estrogen is appropriate for you. A Cochrane review found that vaginal estrogen reduced UTIs compared with placebo in two small studies, while oral estrogen did not.
What Actually Helps?
The plan depends on how bothersome your symptoms are, your health history, and your preferences.
Moisturizers and lubricants. For milder symptoms, these are the usual first step. Use a vaginal moisturizer regularly, often several times a week, and a lubricant at the time of sex. They can also be used with prescription treatments.
Low-dose vaginal estrogen. This is the most studied prescription treatment for GSM. The Menopause Society recommends it for moderate to severe symptoms, or when moisturizers and lubricants aren't enough. It comes as a cream, a tablet or softgel insert, or a ring worn for three months. A 2016 Cochrane review found that these preparations improved dryness and pain with sex, with no clear difference among the forms.
This is not the same as the systemic hormone therapy we use for hot flashes and night sweats. The dose is much lower, and very little is absorbed into the bloodstream. When only vaginal and urinary symptoms are present, low-dose vaginal estrogen is preferred. If you are already on systemic hormone therapy, you may still need a local vaginal treatment. A progestogen is not routinely added with low-dose vaginal estrogen, vaginal DHEA, or ospemifene, unlike systemic estrogen, which does require a progestogen if you have a uterus. Any bleeding after menopause still needs to be evaluated.
In November 2025, the FDA asked manufacturers to remove boxed-warning language about heart disease, breast cancer, and probable dementia from menopausal hormone therapy labels, including local vaginal estrogen. In February 2026, it approved the first updated labels. Labels are being updated product by product. Estring, a low-dose vaginal estradiol ring, was in that first group; some other vaginal estrogen products still carry the older warning. The decision is always individualized. If you have a history of breast cancer, we start with nonhormonal options and involve your oncologist before considering a hormone-based treatment.
GSM often returns if treatment is stopped, so we continue a therapy that is helping, with regular follow-up.
Vaginal DHEA (prasterone). This nightly vaginal insert (brand name Intrarosa) is approved for moderate to severe pain with sex. The vaginal tissue converts it locally into estrogens and androgens.
Ospemifene. This once-daily pill (brand name Osphena) is approved for vaginal dryness and moderate to severe pain with sex. It can cause or worsen hot flashes in some women.
Pelvic floor physical therapy. Pain with sex is not always only about dry tissue. Pelvic floor muscles can tighten in response to pain, and a pelvic floor physical therapist can help, often alongside treatment that restores tissue health. If leaking is also part of the picture, pelvic floor training is a first-line treatment, as we explained in our incontinence post.
What about vaginal laser or energy devices? You may see these marketed for "vaginal rejuvenation." I want to be honest about the evidence. The FDA has not approved laser or other energy-based devices for menopause symptoms, incontinence, sexual problems, or cosmetic vaginal procedures, and it has warned that they can cause burns, scarring, and lasting pain. The Menopause Society's 2020 statement said there were not enough good sham-controlled trials to recommend them, and the 2025 AUA/SUFU/AUGS guideline does not support routine use and considers them experimental.
You Don't Have to Just Live With This
Patients come to us from across southern West Virginia and southwest Virginia, from Beckley and Lewisburg to Peterstown, Giles County, and the Blacksburg and Christiansburg area. Dr. Samantha Snyder, Megan Lingenfelter, PA-C, VaLeah Bradshaw, CNM, and I are here to help you get comfortable again.
Summit Women's Health 411 12th Street Ext, Princeton, WV 24740
Next Friday, week 6: protecting your bones and metabolism after menopause.
This post is for general education and isn't a substitute for personal medical advice.
Call 681-282-5591 to schedule an appointment, and we'll make a plan together.
Sources
The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992. https://doi.org/10.1097/GME.0000000000001609
American College of Obstetricians and Gynecologists. Experiencing Vaginal Dryness? Here's What You Need to Know. https://www.acog.org/womens-health/experts-and-stories/the-latest/experiencing-vaginal-dryness-heres-what-you-need-to-know
American College of Obstetricians and Gynecologists. I've heard about vaginal laser therapy for vaginal problems. What is it? (reviewed November 2025). https://www.acog.org/womens-health/experts-and-stories/ask-acog/vaginal-laser-therapy-what-is-it
Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. Journal of Urology. 2025. https://doi.org/10.1097/JU.0000000000004589
Anger J, Lee U, Ackerman AL, et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. Journal of Urology. 2019;202(2):282-289. https://doi.org/10.1097/JU.0000000000000296
Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews. 2016;(8):CD001500. https://www.cochrane.org/evidence/CD001500_use-postmenopausal-women-creams-pessaries-or-vaginal-ring-apply-oestrogen-vaginally-symptoms-vaginal
Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database of Systematic Reviews. 2008;(2):CD005131. https://www.cochrane.org/evidence/CD005131_oestrogens-preventing-recurrent-urinary-tract-infection-postmenopausal-women
U.S. Food and Drug Administration. FDA Requests Labeling Changes Related to Safety Information to Clarify the Benefit/Risk Considerations for Menopausal Hormone Therapies (Nov. 10, 2025). https://www.fda.gov/drugs/drug-alerts-and-statements/fda-requests-labeling-changes-related-safety-information-clarify-benefitrisk-considerations
U.S. Food and Drug Administration. FDA Approves Labeling Changes to Menopausal Hormone Therapy Products (Feb. 12, 2026). https://www.fda.gov/news-events/press-announcements/fda-approves-labeling-changes-menopausal-hormone-therapy-products
U.S. Food and Drug Administration. Menopausal Hormone Therapies with Updated Prescribing Information. https://www.fda.gov/drugs/drug-safety-and-availability/menopausal-hormone-therapies-updated-prescribing-information
Kingsberg SA, Krychman M, Graham S, Bernick B, Mirkin S. The Women's EMPOWER Survey: identifying women's perceptions on vulvar and vaginal atrophy and its treatment. Journal of Sexual Medicine. 2017;14(3):413-424. https://pubmed.ncbi.nlm.nih.gov/28202320/