It was never your fault

There is a condition that affects 100% of women going through menopause to some degree and yet most women have never heard of it, most doctors never bring it up, and most of us spend years quietly adapting to symptoms we have been told are just part of getting older.

It is called GSM, genitourinary syndrome of menopause. The reason you probably haven't heard that name is that the medical community spent decades calling it something else. The previous terms were senile vagina and then atrophic vaginitis, neither of which sounds like something a doctor should say to a living breathing woman with a straight face. GSM is at least clinical enough to get through a conversation. 

Here is everything you need to know…

What GSM actually is

Estrogen is what keeps the tissue of your vagina, vulva, and labia thick, elastic, lubricated, and healthy. When estrogen declines, which it does gradually through perimenopause and more significantly through menopause, that tissue starts to change. It thins, loses its stretch, and becomes fragile and dry in a way that affects daily life, not just sex. The labia and vulva can visibly shrink over time. 

This is a normal physiological process that happens to every woman and the question is only how much and how soon you do something about it.

The critical thing to understand is that unlike hot flashes or brain fog, which can ease up on their own over time, GSM does not improve without treatment, it actually progresses. The longer estrogen stays low, the more the tissue changes. Which means if you have been quietly adapting and assuming this is just what getting older feels like, your body has actually been asking for something.

The symptoms worth knowing

Because GSM comes on gradually, a lot of women never connect what they are experiencing to estrogen loss, they just adapt. 

Here’s what you should be looking for:

• Dryness that is not only during sex but generally throughout the day
• Itching or irritation without an obvious explanation
• Sex that has become uncomfortable or painful when it wasn't before
• Needing to pee more urgently or more frequently than you used to
• Recurring UTIs when that was not something you were dealing with before
• Changes in how things look, the tissue visibly thinning or labia appearing smaller than they used to

Any combination of those symptoms could be GSM. You do not need all of them and you may only notice one or two.

The connection to UTIs most women don't know about

This is one of the most underrecognized pieces of the GSM conversation. Vaginal estrogen is actually the most effective treatment for recurrent UTIs in menopausal women. The same tissue changes that cause dryness and discomfort also affect the urinary tract and make it more vulnerable to infection. If you or someone you love keeps getting handed round after round of antibiotics for recurring UTIs without anyone addressing the underlying cause, vaginal estrogen is the conversation that needs to happen. Antibiotics treat the infection, but vaginal estrogen addresses the reason the infections keep coming back.

Why vaginal estrogen is different from hormone therapy

This is the piece that matters most and that most women are never clearly told. Vaginal estrogen is local and it stays right where you put it, so is not absorbed into the bloodstream in any meaningful amount. It is not the same as systemic hormone therapy, the patch, the pill, the gel. Instead it is treating the tissue right where it needs help and nothing more.

This distinction matters enormously because it means essentially every woman can use vaginal estrogen, including women who have been told they cannot take hormones. If a doctor has ever said hormones are off the table for you, that answer applies to systemic hormone therapy. It does not automatically apply to local vaginal estrogen and you deserve to have that specific conversation.

You also do not need to be on any other hormones for vaginal estrogen to work. If you are already on systemic hormone therapy, you can still add vaginal estrogen and many women benefit from using both. If you are not on any hormones at all, vaginal estrogen stands completely on its own.

The treatment options

1. Estradiol cream is applied with a small applicator a few times a week. It is one of the most commonly prescribed options and has been used for decades with a strong safety record.

2. Vaginal tablets or inserts like Vagifem are small inserts used with a disposable applicator a few times a week, then tapered to a maintenance schedule. This is the option many women find the most straightforward.

3. The Estring is a soft flexible ring inserted like a diaphragm that releases a low steady dose of estrogen over 90 days. You insert it and essentially forget it until it needs to be replaced.

4. Intrarosa is a newer option for women who have been told estrogen is off the table. It is a vaginal DHEA insert, a building block hormone that your body converts into small amounts of estrogen and testosterone directly in the vaginal tissue without entering the bloodstream. Because technically it is a precursor rather than estrogen itself, it is worth asking about specifically if estrogen has been ruled out for you. Your doctor will need to weigh in on whether it is appropriate for your situation.

5. There is also an oral option for women who cannot or prefer not to use a vaginal form. It works specifically on vaginal tissue even though it is taken by mouth.

What lubricant can and cannot do

Lubricant helps in the moment, but it does not treat the tissue. If the tissue is thin and fragile, lubricant is a temporary solution for a progressive problem. Vaginal estrogen is what actually addresses the underlying change. You can and should use both, but lubricant is not a substitute for treatment.

What to say to your doctor

Be specific. Do not just say you have been having a little dryness. 

Say: I want to talk about vaginal estrogen for GSM and I want to understand my options for local estrogen treatment. 

Using the term GSM signals to your doctor that you have done your homework and that you are asking about a local treatment, not full hormone therapy. That distinction often makes the conversation faster and easier.

If your doctor says you cannot take hormones and closes the conversation there, push back gently. 

Say: I am asking specifically about local vaginal estrogen which is not absorbed systemically. Is that still off the table for me? 

In many cases, including for women with a history of breast cancer, the answer to that question is actually different from the answer to can I take hormone therapy.

If your regular doctor is not the right person for this conversation, a menopause certified clinician or urogynecologist can be a good option. 

The bottom line

This is not a vanity issue and this is not something to whisper about or feel embarrassed by. The tissue changes that come with estrogen loss are a health issue in the same way bone density and heart health are health issues. Something to pay attention to and address so you are okay later on.

The changes start in perimenopause and do not improve on their own. But with the right treatment the tissue can actually regenerate, lubrication returns, elasticity comes back, and the pain goes away. You do not have to adapt to this. There is something you can do about it and most women just need someone to tell them that clearly.

For more information, listen to the latest episode of The Tamsen Showhere or you can watch it here.