After menopause, lower estrogen makes the tissues of the vagina, vulva, urethra and bladder thinner, drier and less elastic. This can cause dryness, painful sex, urgency, leakage and recurrent urinary infections. These symptoms affect over half of postmenopausal women and tend to worsen without treatment. Moisturizers, lubricants, pelvic floor training and low-dose vaginal estrogen all help.
What is genitourinary syndrome of menopause?
Genitourinary syndrome of menopause (GSM) is the term for vaginal, vulval and urinary changes caused by low estrogen after menopause. It replaced older terms such as "vaginal atrophy," which described only part of the picture.
Estrogen receptors are found throughout the lower urinary tract, including the urethra, vagina and pelvic floor muscles and ligaments, according to the European Menopause and Andropause Society (EMAS). When estrogen falls, these tissues change.
A systematic review found GSM affects about 55% of postmenopausal women, compared with 32% in perimenopause. Many people don’t mention it, and many clinicians don’t ask. Yet it is one of the most treatable parts of menopause.
What are the symptoms?
Vaginal and vulval symptoms:
- Dryness, itching, burning or irritation
- Pain or discomfort during sex, sometimes with light bleeding afterward
- Less natural lubrication
- Changes in discharge
Urinary symptoms:
- Needing to urinate urgently or more often, including at night
- Stinging when passing urine
- Leakage when coughing, sneezing or exercising (stress incontinence), or with a sudden urge (urge incontinence)
- Recurrent urinary tract infections (UTIs)
Sexual effects:
NICE lists sexual difficulties, such as low sexual desire, among symptoms associated with menopause, and vaginal discomfort can reduce desire and arousal. See low libido.
For symptom detail, see vaginal dryness and urinary changes.
Why don’t these symptoms go away on their own?
Hot flashes relate to the brain adapting to lower estrogen, and usually fade. Vaginal and urinary tissues depend on estrogen continuously, so changes tend to persist or gradually worsen. See do menopause symptoms stop after menopause?.
What treatments are available?
Vaginal moisturizers and lubricants
- Moisturizers are used regularly, for example every few days, to keep tissues hydrated.
- Lubricants are used during sex to reduce friction and discomfort.
The 2024 international guideline on premature ovarian insufficiency notes these can be used for vaginal discomfort and painful sex, and combined with other treatments. They’re a good first step for mild symptoms.
Practical tips:
- Choose products without perfumes, flavors or warming ingredients, which can irritate sensitive tissues.
- Water-based lubricants are widely compatible with condoms and toys. Silicone-based ones last longer. Oil-based products can damage latex condoms.
- Avoid soaps, douches and scented washes on the vulva. Plain water or an emollient is gentler.
- Give moisturizers time. Regular use over several weeks usually works better than occasional use.
Low-dose vaginal estrogen
Vaginal estrogen comes as a cream, gel, tablet, pessary or ring. It treats the tissues directly.
- Effectiveness: NICE recommends offering vaginal estrogen for vaginal and urinary symptoms after menopause, including to people already using HRT.
- Duration: The Menopause Society notes it can be used at any age and for as long as needed. Symptoms may return if it’s stopped.
- Safety: Only minimal amounts are absorbed into the bloodstream. In 2025, an FDA advisory panel recommended removing or revising the boxed warning for vaginal estrogen for this reason.
If you’ve had breast cancer, NHS patient information notes that vaginal estrogen can be given to some people who can’t use HRT, after discussion with their specialist team.
Other prescription options
The Menopause Society notes that vaginal DHEA (prasterone) and oral ospemifene are other approved treatments where available. Availability varies by country.
Treatments without strong evidence
The 2024 POI guideline doesn’t recommend laser or other energy-based treatments as standard care, because trial evidence of benefit is inconclusive.
Sex after menopause
Pain or discomfort during sex is common after menopause, but it isn’t something you have to accept. Things that can help include:
- Treating dryness first, with moisturizers, lubricants or vaginal estrogen
- Allowing more time for arousal, and communicating with your partner about what feels comfortable
- Pelvic floor physiotherapy. The European Menopause and Andropause Society notes that estrogen receptors are found in the pelvic floor muscles and supporting tissues, and supervised pelvic floor training is first-line for bladder leakage. Specialist physiotherapists can also help with muscle tension and pain during sex.
- Vaginal dilators, which may help stretch tissues gently over time, especially after a period without sex or after cancer treatment
- Addressing desire and relationship factors, which may benefit from specialist support
See low libido.
How can recurrent urinary infections be prevented?
Recurrent UTIs are common after menopause, partly because changes in the vaginal environment make infection more likely.
- Vaginal estrogen. NICE advises considering vaginal estrogen for recurrent UTIs in postmenopausal women if behavioral and personal hygiene measures aren’t enough. In one trial, vaginal estrogen cream reduced recurrent infections to 16%, compared with 63% on placebo.
- Oral HRT did not significantly reduce recurrent UTIs in trials.
Discuss other prevention options with your clinician, especially if infections are frequent.
What helps bladder leakage?
- Pelvic floor muscle training. NICE recommends offering at least three months of supervised pelvic floor muscle training as the first treatment for stress or mixed incontinence. Programs include at least eight contractions, three times a day. A women’s health physiotherapist can make sure you’re doing the exercises correctly.
- Bladder training for urgency, gradually increasing the time between toilet visits.
- Reducing caffeine, which NICE suggests trying for overactive bladder.
- Adjusting fluid intake if you drink a lot or very little.
- Weight loss, which NICE advises if your BMI is over 30.
- Vaginal estrogen, which can help urinary symptoms linked to menopause.
If these don’t help, medicines, devices or surgery may be options. See a clinician for assessment.
When do symptoms need prompt checking?
Some symptoms need investigation rather than simple treatment.
Get checked promptly if you have:
- Any vaginal bleeding 12 months or more after your last period, including after sex
- Blood in your urine
- Bladder or pelvic pain that doesn’t go away
- Recurrent or persistent urinary infections that don’t respond to treatment
- A lump, sore or persistent itch on the vulva, or a change in skin color
- Constant leakage of urine
Seek urgent care for a urinary infection with fever, back or side pain, or vomiting, which can signal a kidney infection.
How to talk about it
These symptoms can feel embarrassing to raise, but they’re common and clinicians are used to discussing them. You could say: "I’ve been having vaginal dryness and discomfort during sex since menopause, and I’d like to talk about treatment." See your first menopause appointment for more questions.
Questions to ask your clinician
- Could my symptoms be genitourinary syndrome of menopause?
- Would vaginal estrogen suit me, and which form is best?
- Can I use it alongside HRT, or after breast cancer?
- Should I see a pelvic floor physiotherapist?
- What can I do to prevent recurrent urinary infections?
Frequently asked questions
Is vaginal estrogen safe long-term?
Low-dose vaginal estrogen is absorbed only minimally, and the Menopause Society notes it can be used at any age and for as long as needed. Discuss your history with your clinician.
Can I use vaginal estrogen if I’m on HRT?
Yes. NICE recommends offering vaginal estrogen to people with genitourinary symptoms, including those already using systemic HRT.
Why do I keep getting UTIs after menopause?
Changes in the vaginal and urinary tissues after menopause make infections more likely. Vaginal estrogen can significantly reduce recurrent infections.
Do pelvic floor exercises work after menopause?
Yes. Supervised pelvic floor muscle training for at least three months is the first-line treatment for stress incontinence, according to NICE.
Will vaginal dryness go away on its own?
Usually not. It tends to persist or worsen after menopause, but it responds well to moisturizers, lubricants and vaginal estrogen.
References
- Prevalence of psychosomatic and genitourinary syndrome among menopausal women: systematic review
- NICE guideline NG23: Menopause, identification and management (2024 update: genitourinary symptoms)
- EMAS: Management of urinary incontinence in postmenopausal women
- NICE guideline NG23: Menopause, identification and management
- The Menopause Charity: 2024 NICE menopause guideline (genitourinary symptoms)
- NICE NG112 evidence: Urinary tract infection (recurrent): vaginal oestrogen
- Medscape: NICE urinary incontinence in women guideline summary
- Let’s Talk Menopause: Summary of the NAMS 2022 position statement (vaginal estrogen)
- 2022 NAMS position statement summary (vaginal DHEA, ospemifene), Mayo Clinic
- Harvard Health: FDA removes menopause hormone therapy black box warnings (vaginal estrogen)
- ESHRE/ASRM/IMS: Evidence-based guideline on premature ovarian insufficiency, 2024
- Worcestershire Acute Hospitals NHS Trust: Your journey through the perimenopause and menopause (vaginal estrogen after breast cancer)
- Australasian Menopause Society: Bleeding in perimenopause, postmenopause and on MHT
Editorial status: evidence-based educational article; not individually medically reviewed. Last evidence check: September 10, 2026.
