06Genitourinary Syndrome of Menopause
Progressive, under-reported, highly treatable — and almost never asked about.
Key takeaways
- —Up to 80% of postmenopausal women have GSM; fewer than a quarter raise it unprompted, so you must ask.
- —Local oestrogen produces serum levels within the postmenopausal range and does not require a progestogen for endometrial protection.
- —Vaginal oestrogen reduces recurrent UTI recurrence substantially — a hard clinical endpoint, not a comfort measure.
- —Treatment is indefinite: symptoms return within weeks to months of stopping because the underlying atrophy returns.
- —Energy-based vaginal devices have not demonstrated benefit over sham in the better trials, and regulators have issued safety warnings.
Graded claims
Low-dose vaginal oestrogen relieves GSM symptoms
Established — RCT / guideline-gradeMultiple RCTs and Cochrane review.
Vaginal oestrogen reduces recurrent UTI in postmenopausal women
Established — RCT / guideline-gradeRCT evidence (Raz & Stamm) plus guideline endorsement.
Vaginal oestrogen requires added progestogen for endometrial protection
Refuted or actively misleadingNot required at licensed low doses in women with an intact uterus.
Prasterone improves dyspareunia
Supported in defined populationsLicensed on RCT evidence for moderate-severe dyspareunia.
Fractional CO2 laser is superior to sham for GSM
Popular, weak or conflicting supportBest-quality sham-controlled trials show no difference; FDA safety communication issued.
Vaginal oestrogen is absolutely contraindicated after breast cancer
Popular, weak or conflicting supportMost guidelines permit it after non-hormonal failure, with oncology input.
Supporting references
- The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society — Menopause 2020 https://pubmed.ncbi.nlm.nih.gov/32852449/
- A controlled trial of intravaginal estriol in postmenopausal women with recurrent UTI — Raz & Stamm, NEJM 1993 https://pubmed.ncbi.nlm.nih.gov/8350884/
- FDA Safety Communication: Energy-based devices for vaginal 'rejuvenation' — FDA https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic