Reignite Passion: How To Manage Genitourinary Syndrome Of Menopause (GSM)

Treatment options

YES! There are many treatment options.

The most important takeaway? Do not suffer in silence!

Like many of the symptoms women experience during the menopause journey, your doctor may not ask if you are having this problem, and some women+ find it awkward and uncomfortable to discuss GSM.

However, vaginal atrophy is a progressive condition, so the longer you wait, the worse things can get and the longer you suffer unnecessarily.

So, what can be done? 

Many women+ ask if vaginal atrophy can be reversed, but the thing to remember is that the primary goal of treatment is to relieve your symptoms, whether those are in your vagina, vulva, pelvis, urinary tract or you experience them during sex.

OTC lubricants and moisturizers for a dry vagina

If your symptoms are mild to moderate, there are a wide range of non-hormonal over-the-counter vaginal lubricants (reduce friction; used in the moment when engaging in sexual activity), which are a good place to start.

Just like you apply moisturizer to your body, if you have dry, itchy skin during the hormonal transition, you’ll also want to apply a vaginal moisturizer to your vagina. Your healthcare provider may recommend a long-acting vaginal moisturizer to hydrate cells and tissue. It is meant to be used consistently (like your face) up to 7 days a week.

When applied regularly, over-the-counter (OTC) products can help to alleviate the issues created by vaginal dryness, both as you go through your day and at the time of sexual activity.

As always, pay attention to labels and follow all instructions. Although you can use these products externally, these options are meant to be used inside the vagina to achieve their results. So, make sure you don’t find yourself picking up something labeled as a moisturizer but intended for external use only.

When it comes to lubricants, water-based are usually a better option, although silicone-based also works. However, silicone may cause sex toys made of silicone to break down.

Products such as petroleum jelly and mineral oil are NOT suitable and may worsen your symptoms or increase the risk of infection.

And if you are in the perimenopause stage of the journey, remember you can still get pregnant. Petroleum jelly and oils can also cause latex condoms to break. That means the effectiveness of condoms in preventing pregnancy and sexually transmitted infections (STIs) would be reduced.

Prescription medication for GSM

In addition to over-the-counter moisturizers and lubricants, there are several medications to treat GSM. Like treating other symptoms during the hormonal transition, some products have hormones and others are non-hormonal.

Some women+ have concerns and even fears regarding hormone therapy. There are indeed risks in its use that some women+ may not want to take. Others should not use HT, or certain HT formulations, due to prior or underlying medical conditions like breast and uterine cancer or blood clots.

It’s your body and you can choose a hormone-free product or one with hormones, depending on your personal situation. Connect with your healthcare practitioner to get guidance based on your particular health status.

Researchers are also testing other medications like vaginal tamoxifen capsules. The capsule DARE-VVA1 does not have hormones and helped post-menopausal women+ with thinning and dryness in a clinical study. Adverse side effects were mild to moderate.

Ospemifene (OSPHENA®)

Ospemifene is an oral, non-hormonal treatment approved by the FDA for moderate-to-severe vaginal dryness and/or moderate-to-severe painful intercourse. It also addresses symptoms due to changes in and around your vagina related to the menopause journey. It reduces the pH of the vagina and also changes the number of certain types of vaginal cells.

Ospemifene should not be used by everyone, e.g., those with unusual vaginal bleeding, a history of stroke, heart attack, blood clots, severe liver disease, and certain cancers. It can also increase the risk of uterine cancer. Potential side effects include stroke, blood clots, vasomotor symptoms like hot flashes and night sweats, headache, and heavy vaginal bleeding.

Prasterone DHEA vaginal inserts  (INTRAROSA®)

INTRAROSA® is FDA-approved vaginal insert for use in post-menopausal women. It can treat painful sexual intercourse due to vaginal changes caused by menopause. 

The insert is made of prasterone, a man-made form of DHEA.

Dehydroepiandrosterone (DHEA) is a hormone made in the adrenal glands. Those are located on top of each kidney and make hormones that help control functions like heart rate and blood pressure.

While it is advertised as a non-estrogen, it is converted to sex hormones such as estrogen, progestin, and testosterone in the body. DHEA is used by the body to produce those other hormones and, as such, is considered what is known as a precursor.

The inserts should not be used if you have abnormal vaginal bleeding, which needs to be investigated, and certain types of cancer. Potential side effects include abnormal Pap smear results and vaginal discharge.

Hormone therapy: pills, estrogen cream, and vaginal rings

There are a variety of formulations and ways to take hormones (e.g., creams, rings, tablets), and understanding the array of hormone therapy medication options can be challenging.

For example, some women may take hormones orally because they have several menopausal symptoms, for which systemic HT is a good option, like hot flashes and night sweats.

However, if your main menopause symptom is vaginal dryness, then estrogen cream used locally may be all you need, rather than a pill which results in the distribution in the bloodstream throughout the body.

Estrogen cream can help to relieve vaginal dryness as well as itching, inflammation, or soreness of the vulva. For some women+, it may be the best solution, especially if GSM symptoms are severe.

Low-dose estradiol or estriol vaginal rings have also been found to be effective for persistent GSM symptoms.

A new (2023) phase 2 study also found 15 mg of estetrol (E4) helps with hot flashes and GSM. It decreased signs of vaginal atrophy. The women+ reported a 41% reduction in vaginal dryness and 50% reduction in pain.

Vaginal stretching exercises and dilators

In addition to medication and over-the-counter moisturizers, anecdotally, some women have reported benefiting from gentle and regular vaginal stretching exercises, although there are no clinical trials to support this.

The muscles around your vagina, like any muscle in your body, can get tight or stiff. Gentle stretching may help alleviate muscle tension and discomfort.

A good option for women+ with severe GSM may be a vaginal dilator for those who engage in penetrative sex. It can be especially helpful if intercourse is not possible because your vagina has become too short or narrow.

Vaginal dilators can stretch and enlarge your vagina slowly as part of sexual activity alone or with a partner.

If you are considering vaginal exercises or dilators, please consult with your GYN, who may refer you to a pelvic floor physical therapist to offer specific guidance tailored to your needs.

Kegel exercises to strengthen your pelvis

These are not just for a postpartum body! They’re important during the menopause journey too.

Kegel exercises were developed in the 1940s by the gynecologist, Dr. Arnold H. Kegel.

They are a nonsurgical technique you perform that strengthens pelvic floor muscles and reduces the likelihood of leakage of urine.

On the other hand, “reverse Kegel” exercises can help release pelvic pain and tightness. It is important to learn how to tighten and release your pelvic floor.

A hypertonic pelvic floor (overactive) can cause as many disorders as a relaxed one but is often harder to diagnose.

Your healthcare provider can help you find a pelvic floor physical therapist to help you strengthen your pelvis as well as teach you additional pelvic floor exercises.