Vaginal dryness and urinary symptoms

Summary

Hot flashes pass with time; vaginal dryness does not — it progresses. More than half of postmenopausal women experience dryness, burning, itching, painful sex, frequent urination or recurrent urinary tract infections; yet the great majority never mention it to their doctor and accept it as "just my age". In fact this group of symptoms has a name (the genitourinary syndrome of menopause, GSM), a clear cause (estrogen deficiency) and an effective solution that is among the safest of the hormonal treatments.

What is happening?

The vagina, vulva, urethra and base of the bladder are all estrogen-sensitive tissues. When estrogen falls:

• The vaginal wall thins, blood flow drops, and natural moisture and elasticity decline. The tissue is easily irritated, and small tears and bleeding can occur.

• The vaginal environment changes: The protective lactobacilli decrease and the pH rises, making infection more likely.

• The urethra and bladder undergo the same loss of estrogen: frequent urination, urgency, burning and recurrent urinary tract infections are all part of GSM.

• Sex: Dryness and thinning make intercourse painful; the fear of pain reduces desire; and as sex becomes less frequent, the tissue loses more of its elasticity.

In 2014 the term "vaginal atrophy" was replaced by GSM, which also covers the urinary symptoms and is less stigmatizing ⁵.

What do we know?

• The symptom is progressive and does not improve without treatment: Unlike vasomotor symptoms, GSM worsens over time; recognizing it early limits the changes in the tissue ¹.

• Moisturizers and lubricants are the first step: Vaginal moisturizers used regularly (a few times a week) and lubricants during sex are effective for mild symptoms and contain no hormones. Water- or silicone-based products, matched to vaginal pH and free of fragrance, are preferred ^{2 1}.

• Vaginal estrogen is effective and safe: In a Cochrane review, vaginal estrogen (cream, pessary, ring) significantly improved dryness and painful sex compared with placebo ³. Very little passes into the blood; it does not thicken the lining of the womb; no progestogen needs to be added; and there is no limit on how long it can be used ^{1 7}. In some women taking systemic HRT, vaginal symptoms persist and additional vaginal treatment may be needed. In November 2025 the US FDA removed the systemic risk warnings from low-dose vaginal estrogen products ⁶.

• Women with a history of breast cancer: The Menopause Society and NICE state that where non-hormonal methods are not enough, low-dose vaginal estrogen may be considered in consultation with the oncologist; the decision is made more cautiously in women taking an aromatase inhibitor ^{1 2}.

• Other prescription options: Vaginal DHEA (prasterone) and oral ospemifene are approved alternatives for painful sex; availability varies by country ¹.

• Vaginal laser is not recommended: In a sham-controlled randomized trial (VeLVET), fractional CO2 laser made no difference to symptoms compared with a sham procedure; regulators have warned that these devices are unproven and costly for GSM ⁴.

• Recurrent urinary tract infection: Vaginal estrogen has been shown to reduce the frequency of recurrent infections in postmenopausal women ¹.

What does this give you?

• Say it: Doctors may not routinely ask about this symptom, so raise it yourself. "Sex is painful", "there's a constant burning", "I've had three urinary infections" — sentences like these start the assessment.

• You can take the first step today: Using a fragrance-free, pH-matched vaginal moisturizer regularly needs no prescription. Avoid soap, perfumed products and douching; they irritate the tissue further.

• Don't refuse vaginal treatment out of fear of systemic risks: Vaginal estrogen sits outside the breast and clot risk discussion around systemic HRT; it acts only on the tissue where it is applied.

• Sexual activity protects the tissue: Regular sexual stimulation (with a partner or alone) helps preserve blood flow and elasticity; if there is pain, the pain needs dealing with first.

• Pelvic floor physiotherapy: An evidence-based option for painful sex and urinary leakage; your doctor can refer you.

Sources

1. The Menopause Society. The 2020 Genitourinary Syndrome of Menopause Position Statement. Menopause. 2020;27(9):976-992.
2. NICE. Menopause: identification and management (NG23). 2015; updated November 2024.
3. Lethaby A, et al. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2016;(8):CD001500.
4. Li FG, et al. Effect of fractional carbon dioxide laser vs sham treatment on symptom severity in women with postmenopausal vaginal symptoms. JAMA. 2021;326(14):1381-1389.
5. Portman DJ, Gass ML. Genitourinary syndrome of menopause: new terminology. Menopause. 2014;21(10):1063-1068.
6. Makary MA, et al. Updated labeling for menopausal hormone therapy. JAMA. 2025; doi:10.1001/jama.2025.22259. FDA press release, 10 November 2025.
7. Panay N, et al. International Menopause Society (IMS) recommendations and key messages on women's midlife health and menopause. Climacteric. 2025;28(6):634-656.

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