The Best Treatments for Genitourinary Syndrome of Menopause

Peter Kovacs, MD, PhD


March 15, 2017

Genitourinary Syndrome of Menopause: An Overview of Clinical Manifestations, Pathophysiology, Etiology, Evaluation, and Management

Gandhi J, Chen A, Dagur G, et al
Am J Obstet Gynecol. 2016;215:704-711


The cessation of regular follicular development brings significant hormonal changes. Estradiol synthesis decreases, and the number of estrogen receptors decrease in the urogenital tissues, which results in estrogen deficiency.[1] Estrogen improves blood flow in the urogenital tissues and increases transudation and gland secretion, which are responsible for lubrication. Estrogen also induces epithelial proliferation and maintains adequate elastin/collagen content in these tissues. As estrogen levels decline, these functions become less effective, resulting in epithelial thinning, decreased lubrication, and decreased tissue support. This leads to symptoms associated with genitourinary syndrome of menopause (GSM).[2] The symptoms affect the vagina (dryness, irritation, pain, epithelial thinning, bleeding due to tissue friability/atrophy, pH changes), the urinary bladder (urinary frequency, incontinence, cystocele/rectocele, prolapse), and sexual life.[3]


GSM describes the physical findings and symptoms that are due to decreased estrogen secretion. Estrogen is the most effective therapy for moderate/severe conditions because it rapidly restores lubrication and pH in the vagina. Local and systemic administration work equally well. The lowest effective dose for the shortest duration is recommended. For women with other menopause-related problems such as vasomotor symptoms and osteoporosis, systemic therapy is recommended. When genitourinary symptoms dominate, local therapy is sufficient. This approach is not associated with systemic effects and requires no progestin for endometrial protection.

Other options include:

  • Selective estrogen receptor modulators (SERMs; eg, ospemifene) for vulvovaginal atrophy and dyspareunia;

  • Tissue-specific estrogen complex (combination of SERM and estrogen), which is well-tolerated and effective for symptom relief;

  • Laser therapy, which has been shown to improve elasticity, vascularity, and epithelial proliferation;

  • Tibolone, a steroid product that improves sexual life and urinary symptoms;

  • Local application of oxytocin gel to improve epithelial function;

  • Local use of androgens to increase epithelial thickness and secretions; and

  • Lubricants or moisturizers for symptom relief.


Treatment has to be individualized; the presence or absence of systemic symptoms and comorbidities has to be considered:

  • For mild symptoms that are mostly sexual in nature, the use of lubricants may be sufficient.

  • When local genitourinary symptoms predominate, local estrogen therapy seems to be the most effective.

  • For women affected by vasomotor symptoms or osteoporosis as well as systemic estrogen-progestin deficiency, SERM, tibolone, or SERM + estrogen may be best. The full benefits of laser therapy and other locally administered products need to be studied further.



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