Your Guide to a Dry Vagina, GSM, and How to Ask For Help

Visiting the doctor as a woman with mysterious symptoms can be an uncomfortable experience at any age. If you aren’t written off immediately as being overdramatic, you’re likely to walk away with a prescription for birth control, SSRIs, or an exercise plan to treat one of the three syndromes a woman can have: a period, sadness, or obesity. Once you reach a certain age, a fourth syndrome gets added to the list: a dry vagina. Seemingly the only symptom of perimenopause most doctors will tell you about, vaginal dryness is a symptom experienced by 75% of perimenopausal and menopausal women. While a dry vagina can be a problem all on its own, it is often connected to a larger issue called genitourinary syndrome of menopause (GSM). Despite the name, GSM can occur in both menopausal and perimenopausal women, and the severity can vary over time and from person to person. Depending on the study, GSM impacts 27% to 84% of postmenopausal women. Though its occurrence in perimenopausal women is not as well-researched, it is suggested that roughly 15% of premenopausal women experience some form of GSM. In spite of its prevalence, approximately 70% of women experiencing GSM do not raise their concerns with their doctor. It is therefore important to discuss the signs and symptoms of GSM to equip women with the knowledge they need to seek proper treatment. The sources are all linked, so you can read them for yourself.

GSM encompasses a broad range of symptoms in the genitals and lower urinary tract, stemming from a lack of estrogen. While women of any age can experience low estrogen levels, estrogen production begins to drop drastically during perimenopause, leading to an overall reduction of 95% once menopause is complete. This reduction of estrogen causes many of the symptoms of menopause and perimenopause, including many affecting the genitourinary system (primarily the vagina, vulva, clitoris, bladder, and urethra).

Symptoms of GSM include vaginal dryness, irritation/burning, pain during sex, frequent urinary tract infections due to an increase in vaginal pH, pain during urination, urinary incontinence, reduced vaginal discharge, and thinning and lightening of the vulva and vagina. Perhaps most horrifyingly, atrophy (shrinking, thinning, loss of sensation, and reduced functioning) can occur to the vulva, vagina, and clitoris.

Atrophy (shrinking, thinning, loss of sensation, and reduced functioning) can occur to the vulva, vagina, and clitoris.

There is no specific test for GSM as estrogen levels tend to fluctuate too much to get an accurate reading, so it is often diagnosed through qualitative evidence. Doctors may ask the patient to describe their symptoms, a pelvic exam may be performed, and the vaginal pH may be tested. These evaluations are flawed, as many women do not feel comfortable speaking with their practitioner about their sexual health, and pelvic exams can be incredibly painful for those with vaginal atrophy. This method of testing also puts the responsibility on the patient to speak up about and correctly identify their symptoms, rather than being a part of a screening. There do exist tools such as the Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire and the Vaginal Health Index (VHI) which could contribute to a more thorough screening process of GSM, however these are primarily used in scientific studies rather than during the diagnostic process.

There are a range of treatments for GSM depending on the severity and comorbidity with other perimenopause and menopause symptoms. Topical, non-hormonal options are typically explored when the primary symptoms are vulvo-vaginal, with little contribution from urinary symptoms. Vaginal lubricants can be used to treat pain and dryness during sex, with water-based lubricants being preferred over oil-based or silicone-based, as they can increase vulnerability to yeast infections. Additionally, lubricants with a higher osmolality (tendency to draw water out of a substance) and higher pH than the vagina can increase the risk of contact dermatitis, bacterial vaginosis, and can further irritate and dry the vagina and vulva. As such, lubricants with an osmolality of less than 350 mOsm/kg and a pH of ~4.5 are recommended. Look for lubricants with osmolality listed on the packaging or specified on the website, as many commercial lubricants have osmolality much higher than the acceptable standard.

For longer-term relief from vaginal dryness, itchiness, and burning pain, vaginal moisturizers can be used. Vaginal moisturizers work by clinging to the mucosal layer in the vagina and on the vulva, and are generally applied every 1-3 days. Active ingredients such as hyaluronic acid and polycarbophil can promote tissue integrity, therefore addressing symptoms of atrophy. Vaginal moisturizers with these active ingredients have demonstrated similar effectiveness at treating vulvo-vaginal symptoms of GSM as local estrogen treatments.

In more severe cases of GSM, or in cases that do not respond to non-hormonal options, estrogen treatments may be explored. Local estrogen treatments include topical creams, suppositories, and insertable rings which release estrogen. These options treat the issue at the source, increasing estrogen supply to the genitourinary region, which in turn can decrease pH, increase vaginal moisture, address symptoms of atrophy, reduce pain during sex, and prevent frequent, involuntary, and painful urination. Local, low-dose estrogen treatments are not expected to significantly raise systemic estrogen levels, so they are generally considered a safer option if systemic treatment is not necessary. When GSM presents with additional troubling perimenopausal or menopausal symptoms such as hot flashes, difficulty sleeping, mood dysregulation, and indicators of osteoporosis, systemic estrogen may be prescribed. While there are risks to systemic estrogen therapy, such as increased risk of stroke and some cancers, it may be necessary in some cases to improve quality of life.

In the modern day, aging should not spell a death sentence for your sexual health and wellbeing. You deserve to have a vagina that is not only not in pain, but that also brings you quality of life and pleasure.

There are alternative therapies to estrogen-containing therapies, which may address symptoms without the direct use of estrogen. Ospemifene is a selective estrogen receptor modulator, which behaves like estrogen in vaginal tissue, but not in other tissues such as breast tissue. This option is therefore a lower-risk option for those with a higher risk of breast cancer than systemic estrogen therapy. Laser therapy is another alternative option, though more clinical research needs to be performed to determine its efficacy. This method works by stimulating collagen production in the vulva and vagina, and rebuilding connective tissue, which can address symptoms of GSM (Cedars-Sinai, United States). While more research is required to determine long-term efficacy, laser therapy is an option for treatment-resistant cases of GSM.

Despite impacting millions of women worldwide, GSM is still not considered, talked about, screened for, or treated nearly enough. While talking to a doctor about symptoms in the genitourinary region can be uncomfortable, especially if your doctor is not well-educated about menopause and perimenopause, self-advocacy is the first step. In the modern day, aging should not spell a death sentence for your sexual health and wellbeing. You deserve to have a vagina that is not only not in pain, but that also brings you quality of life and pleasure.

If you would rather have a shorter plain-English version of this post, we have one here.

The key sources behind this piece, for anyone who wants to read further:

• Mehta J, Kling JM, Manson JE. Genitourinary syndrome of menopause. StatPearls, 2024.
• Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The genitourinary syndrome of menopause: an overview of the recent data. Cureus, 2020.
• Patel P, Patil S, Kaur N. Estrogen and metabolism: navigating hormonal transitions from perimenopause to postmenopause. Journal of Midlife Health, 2025.
• Wasnik VB, Acharya N, Mohammad S. Genitourinary syndrome of menopause: a narrative review focusing on its effects on the sexual health and quality of life of women. Cureus, 2023.
• American Urological Association; Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction; American Urogynecologic Society. Genitourinary syndrome of menopause: AUA/SUFU/AUGS guideline. 2025.
• Rodas A, Sanabria G, González-Isaza P. Narrative review of clinical indices and imaging tools, with a proposal for an integrative grading scale for vulvovaginal aging. Cureus, 2025.
• Ayehunie S, Wang YY, Landry T, Bogojevic S, Cone RA. Hyperosmolal vaginal lubricants markedly reduce epithelial barrier properties in a three-dimensional vaginal epithelium model. Toxicology Reports, 2017.
• Shifren JL. Genitourinary syndrome of menopause. Clinical Obstetrics and Gynecology, 2018.
• Agrawal S, LaPier Z, Nagpal S, et al. A randomized, pilot trial comparing vaginal hyaluronic acid to vaginal estrogen for the treatment of genitourinary syndrome of menopause. Menopause, 2024.
• Carter J, Goldfarb S, Baser RE, et al. Ospemifene: a novel option for the treatment of vulvovaginal atrophy. PMC, 2017.
• Hoffman BL, et al. Hormone therapy for menopausal symptoms. StatPearls.
• Cai B, Simon J, Villa P, et al. No increase in incidence or risk of recurrence of breast cancer in ospemifene-treated patients with vulvovaginal atrophy. Maturitas, 2020.
• What you should know about genitourinary syndrome of menopause. Cedars-Sinai, 2025.

This article is for informational purposes only and does not constitute medical advice. Always consult your healthcare provider for personal medical guidance.