How We Treat GSM (And What Actually Works)

In my last post, I discussed what Genitourinary Syndrome of Menopause, or GSM, actually is, the vaginal, vulvar, and bladder changes that come with declining estrogen, why it's so common, and why it doesn't get better on its own. If you missed it, I suggest going back and reading that first. Here I want to go over what we can actually do about it.

GSM responds well to treatment. There's more than one path depending on your symptoms and what you're comfortable with, and it is absolutely not something you should just have to live with.

Vaginal Estrogen: The Gold Standard

For most women, low dose vaginal estrogen is the most effective treatment we have for GSM. As estrogen declines, the vaginal and vulvar tissues become thinner, drier, and less elastic, and the urinary tract changes too. Those changes don't get better on their own. They tend to progress with time.

Because of that, I feel strongly that vaginal estrogen is something we should be talking about with all women as they move through menopause, even before symptoms become significant. Why wait until sex hurts, the tissue has changed, or you're dealing with recurrent UTIs if we have a safe, effective treatment that can help maintain the health of these tissues in the first place? In 2025, the American Urological Association and several of the major medical organizations specializing in urinary and pelvic health released a comprehensive guideline reviewing the best available evidence and formally recognizing the safety and importance of vaginal estrogen therapy for GSM. This means that the broader medical community, not just menopause specialists, is starting to treat this as a legitimate, undertreated condition rather than something cosmetic or optional.

Low dose vaginal estrogen comes in a few different forms, so we can usually find an option that works well for you. There are creams, vaginal tablets or suppositories, and a vaginal ring that stays in place for three months. I tend to recommend and prescribe the cream often, because it allows us to treat both the vaginal tissue and the external vulvar tissue.

Some women feel that the tablets and suppositories are a little less messy and prefer the convenience. The ring is another great option because you can put it in and forget about it for three months, but it is currently brand name, so it tends to be more expensive. They are all effective, so a lot of the decision comes down to preference, symptoms, and cost.

I also recommend vaginal moisturizers and lubricants along with vaginal estrogen. I don't really think of these as either or treatments because they do different things. As urologist Kelly Casperson says, I like to describe moisturizers as "skin care down there." Just like we moisturize the skin on our face and body regularly, the vulvar and vaginal tissues benefit from regular moisture too. Vaginal moisturizers are meant to be used consistently, not just when you're having sex. Lubricants are different. That's what I recommend using with sex to decrease friction, irritation, and discomfort.

My approach is vaginal estrogen to treat the underlying estrogen loss and help maintain healthy tissue, a moisturizer used regularly as part of your routine, and lubricant with sex. They work together, and for many women, that combination provides much better support than relying on any one of them alone.

Vaginal Estrogen Is Not the Same as Systemic Hormone Therapy

Low-dose vaginal estrogen treats the vaginal and urinary tissues locally, and systemic absorption is very low if at all. When a woman tells me, "I was told I couldn't use estrogen," I don't automatically assume vaginal estrogen is off the table. We talk about why she was told that, what her history actually is, and what the evidence says.

Prior to July 2025, these products carried the same FDA boxed warning as full-body hormone therapy, and I understand why that's alarming to see on the box. That warning reflects regulatory labeling as a class (which was also incorrect by the way) rather than the actual risk at these very low, localized doses, and this is exactly the kind of thing worth talking through with a menopause-knowledgeable clinician.

Other Prescription Options

There are also non-estrogen prescription treatments, including vaginal DHEA (prasterone) and oral ospemifene, an oral SERM. These can be helpful alternatives, but both are brand-name only right now, which means they can be expensive depending on your insurance.

Vaginal estrogen, by contrast, is available in generic forms, which makes it more accessible for most women. Vaginal DHEA is often a good option specifically for women on aromatase inhibitors for breast cancer, which is worth discussing with your oncology team.

Pelvic Floor Physical Therapy

More women should know about this, because it's not just for postpartum recovery. A pelvic floor PT is trained to evaluate and treat the muscles supporting your bladder, bowel, uterus, and vagina.

When painful sex leads a woman to brace or tense in anticipation of pain, that tension ends up making things worse. A pelvic floor therapist is specifically trained to help with that pattern. They can assess whether your muscles are too tight, too weak, or some combination, and build a plan around it, which might include manual therapy, targeted stretching, biofeedback, and exercises for both strength and coordination. Because the same muscles support your rectum, pelvic floor PT can also help with bowel problems, such as constipation with straining or difficulty emptying. The same techniques, muscle retraining, biofeedback, and learning to coordinate and relax these muscles, apply here too. So if you're dealing with rectal or bowel symptoms alongside the vaginal and urinary changes, this is what a pelvic floor therapist can address.

I often recommend using pelvic floor therapy and vaginal estrogen together. The vaginal estrogen helps improve the health of the tissue, while pelvic floor therapy helps relax and retrain the muscles and address any pain that may have developed.

Lifestyle Habits and Supplements

A few lifestyle habits help alongside medical treatment: staying well hydrated, urinating after sex, and limiting caffeine and alcohol if urinary urgency is an issue.Guidelines also specifically recommend avoiding vaginal washes, deodorants, and cleansing products, since these can irritate and dry the tissue further. None of these habits replace treatment, but they support it.

You may also see vitamin D, vitamin E, phytoestrogens, or probiotics mentioned for GSM. There is no scientific evidence supplements address GSM. I encourage some of them to consider it as part of an overall healthy routine, but not specific to GSM. 

What About Vaginal Laser Therapy?

You may have seen vaginal laser treatments advertised for GSM which is a non-hormonal, in-office procedure that uses laser energy to stimulate the tissue to rebuild itself. 

The problem is that we just don't have strong enough evidence yet to say that vaginal laser or radiofrequency treatments are effective treatments for GSM. They are also not FDA approved or cleared for the treatment of GSM and can be very expensive, often costing thousands of dollars out of pocket.

For me, vaginal estrogen remains the first choice. We have decades of evidence supporting its safety and effectiveness, it treats the underlying estrogen loss that is causing these tissue changes, and generic options make it affordable for most women.

That's not to say lasers may never have a role. For a woman who truly cannot or does not want to use vaginal hormones, it may be something to discuss. But at this point, I would consider it an alternative or experimental option rather than a first line treatment.

What If You're Already on Hormone Therapy?

Many women and even providers don’t know that you can be using an estrogen patch, gel, or other systemic hormone therapy and still have GSM symptoms. Systemic estrogen may help, but it doesn't always deliver enough estrogen locally to fully resolve GSM. Current guidelines specifically recommend that women already on systemic estrogen still be offered low-dose vaginal estrogen or vaginal DHEA, especially if having symptoms..  

A Special Note for Cancer Survivors

Women on aromatase inhibitors or other anti-estrogen cancer treatments are at especially high risk for severe GSM, and understandably have questions about whether any absorbed estrogen could interfere with treatment. This is not just about breast cancer. Women treated for gynecologic cancers, endometrial, ovarian, cervical, vulvar, and vaginal, are often hit especially hard, because surgery, radiation, and chemotherapy can cause sudden menopause overnight. Going from normal hormone levels to zero in weeks rather than years tends to produce earlier and more intense symptoms.

For women with a history of cervical, vulvar, or vaginal cancer, low dose vaginal estrogen is generally considered safe because these cancers are typically not driven by estrogen. For women with early stage, low risk endometrial cancer, the evidence is also reassuring and has not shown an increased risk of recurrence with local vaginal estrogen. Ovarian cancer is a little more complicated because there are different types, so that conversation needs to be individualized.

A history of breast cancer does not automatically mean vaginal estrogen is off the table. Current guidelines support an individualized discussion about low dose vaginal estrogen based on the type of breast cancer, treatment history, current medications, and severity of GSM symptoms. Non-hormonal options are important too. Like other women, I recommend regular vaginal moisturizers, lubricant with sex, pelvic floor therapy when needed, and vaginal dilators for some women.

The biggest thing I want cancer survivors to know is that a history of cancer does not mean you have to live with GSM. Too many women are simply told, "You can't use estrogen," without any discussion about the type of cancer they had or the very important difference between systemic estrogen and low dose local vaginal estrogen. There is much more nuance to this conversation, and every woman deserves to understand her options so she can make an informed decision with her healthcare team.

Follow-Up Matters

GSM treatment isn't a one-and-done conversation. Current guidelines recommend ongoing follow-up, since symptoms and needs shift over time. That's why I keep asking at every visit, not just the first one.

The Bottom Line

GSM is common, it's treatable, and it is absolutely not something you should just have to live with. I've spent over two decades watching women suffer through this quietly, cycling through antibiotics for infections that could have been prevented, avoiding intimacy because it hurts, assuming nothing could be done.

If you've noticed changes to your labia, your vaginal tissue, or your bladder around menopause, these changes are real, they're rooted in hormone loss, and they're treatable. If you're experiencing vaginal dryness, burning, painful sex, urinary urgency, recurrent UTIs, or just a sense that something down there has changed, bring it up. And if your provider doesn't ask, ask them yourself.

Because you deserve better than "this is just what happens now."