Vaginal & urinary

The most under-treated part of menopause also has the worst name: genitourinary syndrome of menopause, or GSM. Up to 80% of postmenopausal people have it. Almost nobody talks about it. It's very treatable, often dramatically, and the treatment is far safer than the 1990s scare stories made it sound.

GSM affects vaginal, vulvar and lower urinary tract tissues, they all share estrogen receptors. As estrogen falls, all of them change, often slowly enough that you don't connect the dots.

Vaginal tissue thins and loses elasticity. The lining becomes thinner, drier and more fragile. Natural lubrication drops. Sex that used to be fine becomes uncomfortable or painful, not because you don't want it, but because the tissue isn't producing the same response.

You don't have to push through painful sex. In a 2026 UK survey by the Menopause Research and Education Fund, 41% of people kept having sex despite pain, often from fear of losing a partner. Many didn't get what they needed from the first conversation with a doctor. If that's you, ask again or see someone menopause-trained: local estrogen and moisturizers are well studied. It's a self-selected survey, so read it as lived experience.

Discharge: what's normal, and what changes. Healthy discharge exists at every age, it's the vagina doing its job, and 'normal' is your own baseline, not a textbook description. In perimenopause the pattern often gets erratic first: stretchy, fertile-looking mucus at odd times when ovulation is unpredictable, then weeks of almost nothing. After menopause, lower estrogen usually means less discharge overall, though the cervix keeps making small amounts, so a little clear or white discharge can still be completely normal. The signal is a change from your baseline: new colour, new smell, much more of it, or any of it with blood, itch or pain.

The vaginal microbiome shifts. Lactobacilli decline, vaginal pH rises, and the protective ecosystem changes. This is one reason recurrent UTIs and BV become more common, the basic terrain has changed.

Urinary tissue is affected too, that's the 'GU' in GSM. The urethra and bladder neck have estrogen receptors. As estrogen drops, you can get urgency, frequency, leakage on coughing or laughing, and the recurrent-urinary tract infection (UTI) pattern. Many people never connect this to menopause.

Recurrent UTIs after menopause are usually GSM. If you keep getting urinary tract infections in your 50s when you didn't in your 30s, the cause is almost always genitourinary syndrome of menopause. Treating the GSM (vaginal estrogen) often stops the UTI cycle. Not antibiotics, estrogen.

The vulva changes too, not just the inside. The vulva is skin, not mucosa: labia, the vestibule at the entrance, the clitoral hood, the perineum. It thins, loses fat padding and gets a weaker barrier, which is why the burning, stinging, paper-cut feeling and rawness in underwear or jeans often sit on the outside. Plenty of people use an internal applicator faithfully and never treat the part that actually hurts.

It usually gets worse without treatment. Unlike hot flashes, GSM rarely improves over time. The longer you leave it, the more uncomfortable and harder to reverse it becomes. Early treatment is much easier than late.

Arousal and orgasm can change too. Lower arousal, less lubrication when aroused, and orgasms that feel weaker or harder to reach are part of the official GSM definition, not a separate desire problem. They're worth naming at an appointment alongside dryness and bladder symptoms.

It can happen while breastfeeding too. Breastfeeding keeps estrogen low, so dryness, painful sex and bladder leaks can show up in the months after a birth. Researchers have proposed calling this genitourinary syndrome of lactation (GSL). There are no treatment guidelines for it yet, so it's worth raising with whoever does your postpartum care.

Most of these are widely available and most doctors or specialists will prescribe them once asked. The real barrier is usually nobody asking.

Vaginal estrogen, the gold standard. A small dose applied locally as cream, ring, tablet or pessary. Little is absorbed into the bloodstream. After breast cancer, start with non-hormonal options and discuss persistent symptoms with your breast cancer specialist, especially if you take an aromatase inhibitor. Often transformative for dryness, pain and recurrent UTIs within weeks. Ask for it directly.

Cream where it hurts: the opening and around the urethra. If you use a cream, ask whether to put some on the entrance (the vestibule) and around the urethra, not only inside. In a small trial, estradiol cream applied to the vestibule eased painful sex, and in a 2026 trial a fingertip of cream around the urethra prevented repeat UTIs about as well as using the applicator.

DHEA suppository (prasterone). Alternative for vaginal symptoms if local estrogen isn't right for you, sold as Intrarosa. It isn't estrogen itself: the vaginal tissue turns it into small amounts of estrogen and testosterone locally. Inserted nightly. In trials it eased painful sex and dryness.

Systemic menopausal hormone therapy (MHT) for the rest of menopause. Helps general symptoms but is usually not enough on its own for moderate-to-severe GSM, you typically still need local treatment too. Your doctor or specialist can layer them.

Vaginal moisturizers, daily, not just for sex. Different from lubricant. Used 2 to 3 times a week regardless of whether you're having sex, to keep tissue healthy. Hyaluronic-acid based and polycarbophil (bioadhesive) options are well-tolerated and widely available over the counter, ask your pharmacy for 'vaginal moisturizer, hyaluronic-acid based' and they'll know.

Outside as well as inside: a plain vulvar emollient. For the external soreness, a bland emollient (plain white petrolatum, or an unfragranced barrier ointment) used as a thin layer on the vulva, and as a soap substitute in the shower, protects a thinned skin barrier. Wash with water only, skip soaps, bubble bath, wipes, douches, 'feminine washes' and anything fragranced, they're a common cause of the itch that gets blamed on menopause. Nothing external rebuilds the tissue: that's still local estrogen or DHEA. This is comfort and barrier, not a substitute.

Be skeptical of branded 'vulva creams'. The category has exploded: intimate oils, CBD balms, 'menopause vulva serums'. The evidence is small, short and often company-funded, and mostly compares comfort scores rather than tissue change. If a product costs four times a tube of petrolatum, you're paying for the packaging. And persistent external itching, whitening, or splitting is a lichen sclerosus flag, not a moisturizer problem, treating it with cream for months is the real cost.

A serious lubricant, every time, generously. Silicone-based lasts longest and feels closest to natural. Water-based washes off easily. Stop assuming you should be wet 'naturally', that hormonal floor has shifted, lube is now a tool, not a failure.

Pelvic floor physiotherapy. Underused, often life-changing. A specialist physio can help with pain, tight pelvic floor (which painful sex often creates), incontinence, and recovering pleasure. Ask your doctor for a referral or look for one privately.

For recurrent UTIs: vaginal estrogen, then revisit antibiotics. Vaginal estrogen substantially reduces UTI frequency in postmenopausal people. Methenamine and post-coital antibiotic strategies have evidence too, but treat the underlying tissue first.