Primary Care in Rochester and Kasson

GSM: An unexpected 'surprise' of menopause

1/20/2020 by Jennifer (Jenna) Johnson, APRN, CNP, DNP


The transition to menopause can bring with it many expected changes from the end of monthly bleeding to shifts in weight distribution to changes in sleep patterns. But it can also bring a few unexpected surprises that many women wish they had known more about. One of these changes is atrophic vaginitis, which is now called genitourinary syndrome of menopause (GSM). Possibly related to declining estrogen levels, GSM leads to a: 

  • Shortening and thinning of the vagina/vaginal tissues
  • Decline in our natural lubrication, an increase in vaginal pH
  • Reduction in the normal vaginal flora

Symptoms of GSM

For many women, this means a vagina that isn't happy and doesn't feel the same as it used to. It's often experienced as: 

  • Burning and dryness in the tissues of the vagina and vulva (external vagina)
  • Increased vaginal discharge
  • Vaginal tissues that become easily irritated with intercourse
  • Increased pain, discomfort and bleeding with sex
  • Increased number of vaginal infections
  • Urinary changes, including recurrent urinary tract infections, increased urinary urgency and the need to use the restroom more often at night

Who's at risk

Those at higher risk of developing GSM are women who:

  • Have had their ovaries surgically removed
  • Never had a vaginal childbirth
  • Aren't sexually active
  • Don't exercise
  • Have an increased intake of alcohol
  • Smoke

GSM affects more than 50% of women, yet studies show that less than 25% of them actually bring it up to their primary care provider — and even less actually have treatment for it. that's a lot of women who are suffering unnecessarily!

What helps relieve GSM

What can help? The first line of treatment for mild symptoms includes using vaginal moisturizers routinely (two to three days a week, every week) and/or a water-based vaginal lubricant with intercourse. Both of these products can be found over the counter in the pharmacy section. For many women, this is all they need. 

Vaginal estrogen: Another option

For more moderate or persistent symptoms, vaginal estrogen treatment is recommended. Although this is a hormone, the effect on the body is primarily in the vaginal/vulvar tissues; many specialists don't feel vaginal estrogen is a system hormone at levels that bring significant risks. Most women can use it without concern. 

There are several delivery methods for vaginal estrogen therapy, including: 

  • Vaginal cream (Estrace or Premarin creams)
  • Vaginal tablet (Vagifem, Yuvafem) placed into the vagina two to three times a week
  • Insertion of a vaginal ring (Estring), which is left in the vagina for up to 90 days

Choosing the type of vaginal estrogen depends on several factors. Your primary care provider can help determine which one is best for you. Most women find significant improvement in as few as two to four weeks. 

Vaginal estrogen therapy is often needed indefinitely for ongoing management of GSM. If this therapy isn't effective or not an option for you, there are other treatments, including non-hormonal medications and laser therapy, which are less common. You may be referred to a gynecologist for these options. 

Not just menopausal women

Although GSM is most often related to menopause, there's a small percentage of women who may experience it any time estrogen levels have declined due to causes, including medication side effects, pregnancy or breastfeeding, or surgical changes affecting hormone levels. So even if you haven't started the transition to menopause, talk with your primary care provider if you're experiencing symptoms. 

Jennifer (Jenna) Johnson, APRN, CNP, DNP, is a primary care nurse practitioner with a special interest in Women's Health and has dual certifications in both Adult and Women's Health. She provides primary care through the Community Internal Medicine (CIM) Division and helps staff the Primary Care in Rochester Gynecology Clinic.