Vaginal Atrophy & Dryness: The GSM Guide Nobody Gives You

Roughly half of women in perimenopause and menopause develop genitourinary syndrome of menopause (GSM). Most are never offered treatment. This is the guide nobody handed you.

What GSM actually is

As estrogen falls, the tissue of the vulva, vagina and lower urinary tract thins, dries and loses elasticity. The classic symptoms: dryness, burning, itching, painful sex, more frequent UTIs, urinary urgency, and a sense that something has changed "down there" that you can't quite name.

It's not normal — and it doesn't go away on its own

Unlike hot flushes, GSM is progressive. It tends to get worse, not better, with time post-menopause. The good news: it's also one of the most treatable parts of menopause. Treatment works for almost everyone.

The 4-tier treatment ladder

1. Hyaluronic-acid moisturisers (e.g. Hyalofemme, Replens). Non-hormonal, used 2–3x per week. Good first step for mild symptoms.
2. Vaginal estrogen (cream, pessary, ring). Tiny dose, acts only locally, almost no systemic absorption — safe for most women including many with a history of breast cancer (always discuss with your oncologist). The single most effective treatment for GSM.
3. Vaginal DHEA (prasterone). Local hormone therapy that converts to estrogen and testosterone in vaginal tissue. Useful when vaginal estrogen alone isn't enough.
4. Systemic HRT. Helps GSM modestly but is not a substitute for local treatment — many women need both.

How to ask your GP

"I'm experiencing genitourinary syndrome of menopause — vaginal dryness and pain with sex. I'd like to discuss vaginal estrogen." Naming the condition signals you've done the reading and skips the "have you tried lubricant?" detour. Bring this article if you need to.

What lubricants can and can't do

A water-based lubricant during sex helps with friction in the moment. It does nothing for the underlying tissue change — that needs a moisturiser used regularly, or a hormonal treatment. Most women need both.