The Menopause Symptom I've Watched Women Suffer With for 25 Years

Long before I started focusing on perimenopause and menopause, I spent many years caring for older women in the hospital who were admitted with acute illnesses on top of their chronic medical conditions. One thing I saw over and over again was recurrent UTIs. So many times, a UTI would become part of an already complicated hospital stay, and I would hear from the patient or her family, “Oh, she gets UTIs all the time,” or, “It seems like she’s on antibiotics for them throughout the year.”

Sometimes these infections were no longer simple to treat. Women who had been exposed to antibiotics over and over could develop infections with multidrug-resistant organisms necessitating the need for Infectious Disease to help determine how to treat them. Oftentimes, a UTI can become much more serious and can progress to urosepsis, a life-threatening response to an infection that starts in the urinary tract.

It was so common that it almost seemed like an expected part of getting older. Knowing what I know now about every menopause symptom and GSM, I look at that clinical picture very differently. When I started focusing more closely on menopause care and really understanding Genitourinary Syndrome of Menopause, or GSM, so many of those experiences came full circle for me. For recurrent UTIs in perimenopausal and postmenopausal women, there is often an underlying reason that we aren't addressing.

Asking these questions is part of my intake form, along with sleep, hot flashes, mood, and periods. How is your vaginal and bladder health? Any dryness? Burning? Pain with sex? Feeling like you have to pee all the time? UTIs that keep coming back? Women aren't necessarily too embarrassed to talk about these symptoms. For most, no one has ever asked them.

Currently, there isn't even full agreement in medicine on exactly which symptoms count as GSM. Estimates of how many women it affects range widely, anywhere from about 13 to 87 percent of menopausal women, depending on the study and how symptoms were measured. GSM is common, underdiagnosed, and undertreated. Part of the problem is that these symptoms are often dismissed as a normal part of aging. Another big piece is education. Many clinicians simply haven't received enough education or training around GSM or how to treat it. I know because I was one of them. Despite years of caring for women, this was not something I had been adequately taught either.

From "Atrophy" to GSM

Before it was called GSM, this whole picture used to go by a different name: vaginal atrophy. You may still hear that term used, sometimes even by clinicians.

I think that is a pretty awful term because "atrophy" means wasting away, shrinking, deteriorating. It's a word we use for muscle that hasn't been used in months, or tissue that's dying off. Calling what's happening to a woman's body "atrophy" makes it sound like decline, like something is failing, like it's just one more thing wearing out with age. It also puts the focus on one tissue, the vagina, when what's actually happening involves the vulva, urethra, and bladder too.

GSM is a better name because it describes what's actually going on: a syndrome, a pattern of related changes that are driven by a hormonal shif and not a body falling apart. Women already hear enough messaging that their bodies are failing them as they age. This is tissue responding exactly the way estrogen-sensitive tissue is supposed to respond when estrogen drops. 

What's Actually Happening

Estrogen does a lot more in the body than regulate your menstrual cycle. This area of the body,  the vulva, vagina, urethra, and bladder is loaded with estrogen and androgen receptors, more concentrated here than in many other parts of the body. That's part of why this tissue is so sensitive to hormonal changes. As estrogen declines during the menopause transition, these tissues change too.

The vaginal and vulvar tissues can become thinner, drier, less elastic, and more fragile. Blood flow changes. The vaginal environment and microbiome change, which means that the protective, acidic environment that normally keeps harmful bacteria out starts to shift. The tissues around the urethra and bladder are affected as well.

That's why GSM isn't just about vaginal dryness. It can show up as vaginal dryness, burning, or irritation, pain or discomfort with sex, bleeding or spotting with sex, vulvar discomfort, urinary urgency, frequency, or leakage (including with coughing, sneezing, or laughing), burning with urination, and recurrent UTIs. Reduced blood flow and tissue changes can also affect clitoral sensitivity, sexual desire, and the ability to reach orgasm, which is something women rarely connect back to menopause. In some women, it can also involve clitoral atrophy or vaginal prolapse. Sometimes it's one menopause symptom, and sometimes it's several. This often starts in perimenopause, so you don't have to be completely through menopause for these changes to begin.

Why I Don't Only Talk About This as a "Menopause" Condition

GSM is not only a menopause condition, and I try not to talk about it that way. At its core, GSM is about low estrogen, and low estrogen can happen for a lot of reasons that have nothing to do with age or the menopause transition.

This includes women who've had surgical menopause, women with premature ovarian insufficiency, postpartum and breastfeeding women, and women on medications that suppress estrogen, like aromatase inhibitors or tamoxifen for breast cancer treatment, or GnRH agonists. It can also include women taking certain oral contraceptive pills.

Combined oral contraceptives work in part by suppressing your body's natural estrogen production and replacing it with a synthetic, lower-potency version. In some women, especially with longer-term use, this can lead to the same kind of vulvovaginal changes we see in GSM: dryness, thinning tissue, irritation, and sometimes bladder symptoms, even in women who are decades away from menopause. The research here is smaller and less established than what we have on postmenopausal GSM, but it's a real and recognized phenomenon, and it's exactly why I don't want this condition boxed in as something that only happens after your periods stop. If you're on the pill and dealing with dryness, discomfort, or recurrent UTIs, it is important to discuss with a provider as a possible reason, regardless of your age or menopause status.

The UTI Piece Is a Big One

In postmenopausal women, estrogen loss is a major part of the answer to why UTIs keep coming back. As estrogen declines, the vaginal and urinary environment changes in ways that can make some women more susceptible to recurrent infections. This is part of our urinary health too, and it can become a real safety issue. If you're cycling through antibiotics for UTI after UTI, that's exactly the conversation worth having with your provider, whether vaginal estrogen might be right for you. This conversation is protective of their long-term health.

One of the earliest trials on this, back in the 1990s, followed postmenopausal women with a history of recurrent UTIs. At four months, 95 percent of the women using vaginal estrogen were UTI-free, compared to just 30 percent of the women on placebo. By the end of the study, the women on estrogen were averaging half a UTI per year. The placebo group averaged almost six.

The American Urological Association, along with the Canadian Urological Association and SUFU, updated their recurrent UTI guidelines in 2025 and actually strengthened their recommendations on this topic. Their current guidance: in perimenopausal and postmenopausal women with recurrent UTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs, as long as there's no contraindication. It's a standard, evidence-backed part of national urology guidelines, and it's still one of the most underused tools we have.

What Happens to the Labia

There's been a lot of conversation online lately about what actually happens to the labia during menopause. You do not actually lose your labia, but the tissue does go through real, visible changes. Estrogen is responsible for maintaining the structure, elasticity, pigmentation, and moisture of the labia, just like it is for the rest of the vaginal and vulvar tissue. When estrogen drops after menopause, this tissue can thin, lose volume, and become drier. The labia majora can lose some of their fullness and firmness, a process related to fat loss in the area. The labia minora may resorb, shrink or flatten. Skin color and hair distribution shifts too. None of this is about vanity. It is the same underlying process driving the rest of GSM but we can see it.  

And Then There's Sex

Another thing I hear all the time is, "Sex just isn't comfortable anymore." Sometimes women think that's simply what happens as they get older. They start avoiding sex because they know it's going to hurt.

Painful sex isn't something you should just accept as part of aging. When the vaginal tissues become thinner, drier, and less elastic, intercourse can become uncomfortable or painful. Sometimes women begin anticipating that pain, which can cause the pelvic floor muscles to tense up in response, and that tension can end up making the pain worse. It becomes a cycle, and it's one more reason treating this early matters.

Why GSM Doesn't Get Better on Its Own

Unlike some symptoms of menopause, GSM tends to persist and gets worse the longer it goes untreated. The tissue keeps thinning, keeps drying out, keeps losing elasticity. This is exactly why I don't want women waiting until sex has become so painful they've stopped having it altogether, or until they've had four UTIs in a year, before someone finally asks about their vaginal and urinary health. We should be talking about this much earlier, because the sooner we treat it, the more resilience the tissue still has.

Who This Affects

GSM is most commonly linked to natural menopause, but it isn't limited to that. It can affect anyone in a lower estrogen state, including women who've had surgical menopause, women with premature ovarian insufficiency, postpartum and breastfeeding women, and women on medications that suppress estrogen, like aromatase inhibitors or tamoxifen for breast cancer treatment, or GnRH agonists.

How We Diagnose It

GSM is a clinical diagnosis, meaning it's based on your symptoms and history, not bloodwork or imaging. Current guidelines recommend a detailed medical, sexual, and psychosocial history for any patient with GSM symptoms or risk factors. A genitourinary exam can be part of a full workup, and if you haven't had one recently, I'll often recommend you see your gynecologist for one, especially if we need to rule out other causes or confirm what's going on with the tissue itself.

But in my own visits, the most valuable diagnostic tool I have is the conversation. If a woman describes dryness, burning, painful sex, urinary urgency, or recurrent UTIs, and she's in or around menopause, that symptom pattern alone is usually enough to point us toward GSM and start treatment. I also believe in prevention as well. We know this is inevitable. 

GSM often doesn't show up alone. It's common to have more than one issue going on at once, for example vaginal irritation alongside pelvic floor dysfunction, which is one more reason a clear diagnosis matters, it's rarely just one thing happening in isolation. Honestly, the most valuable diagnostic tool I have is the conversation itself.

If any of this sounds familiar, whether it's dryness, burning, painful sex, urinary changes, or recurrent UTIs, please hear this: none of it is something you have to just accept, and none of it means your body is failing you. It means your tissue is responding exactly the way estrogen-sensitive tissue responds when estrogen goes away. 

In Part 2, I'll walk through exactly how we treat GSM, what actually works, what the current medical guidelines recommend, and how this gets handled a little differently depending on your health history.