Sexual Wellness

Vaginal Dryness and GSM: The Condition Doctors Still Undertreat

April 2026 · 5 min read

Vaginal dryness, discomfort, burning, pain with intercourse, and recurrent urinary symptoms affect more than half of postmenopausal women and a significant fraction of perimenopausal women. The condition has a name — Genitourinary Syndrome of Menopause, or GSM — and it is one of the most underdiagnosed, undertreated, and easily addressed conditions in women's medicine.

What GSM is

GSM is the cluster of symptoms caused by declining estrogen levels affecting the tissues of the vagina, vulva, urethra, and bladder. The tissues become thinner, less elastic, less lubricated, and more prone to irritation and infection. The symptoms include vaginal dryness, burning, itching, pain with intercourse, urinary urgency, urinary frequency, and recurrent urinary tract infections.

Unlike hot flashes, which usually fade with time, GSM is progressive if untreated. The tissue changes continue to evolve years and even decades past menopause.

Why it's so undertreated

Multiple barriers. Women often don't raise it because they're embarrassed, or because they've been told it's normal, or because they didn't know it had a medical name. Providers often don't ask about it, particularly at visits focused on other concerns. And the treatments that work best — vaginal estrogen in various forms — have carried the same reputational baggage as systemic HRT, even though the safety profiles are very different.

Local estrogen

Topical vaginal estrogen is the most effective treatment for GSM and has a substantially different safety profile than systemic HRT. The doses are much lower, and systemic absorption is minimal. Studies have consistently shown that local vaginal estrogen does not raise blood estrogen levels meaningfully when used as directed.

Forms available include vaginal creams (estradiol or conjugated estrogens), vaginal tablets, vaginal rings that release estrogen continuously over three months, and suppositories. All are effective; the choice often comes down to preference and convenience.

For women with a personal history of breast cancer, vaginal estrogen is more complicated and requires individual discussion — many oncologists are comfortable with vaginal estrogen for quality-of-life concerns, but the decision is individualized.

Non-hormonal options

Vaginal moisturizers used regularly (two to three times per week, independent of sexual activity) provide meaningful symptomatic relief for women with mild GSM or women who prefer to avoid hormones. They don't reverse the underlying tissue changes but do help day-to-day comfort. Hyaluronic acid-based vaginal moisturizers have particularly good evidence.

Vaginal lubricants for use during sexual activity are a separate category. They provide immediate, temporary relief but don't address underlying tissue health.

Vaginal DHEA (prasterone) suppositories are an FDA-approved non-estrogen option for GSM. DHEA is converted locally to estrogen and androgens in vaginal tissue without significantly raising systemic hormone levels. It works particularly well for women with both dryness and pain with intercourse.

Ospemifene is an oral non-estrogen medication that acts as a selective estrogen receptor modulator. It's approved for painful intercourse due to GSM and is an option for women who prefer not to use topical treatments.

The urinary connection

Many women don't connect their urinary symptoms to vaginal health, but the tissues share estrogen sensitivity. Recurrent UTIs in postmenopausal women often respond remarkably well to vaginal estrogen — not because of the infection directly, but because the local tissue changes that promote infection are reversed. This is one of the strongest evidence-based uses of vaginal estrogen and is often life-changing for women dealing with repeat UTIs.

What to expect on treatment

Symptomatic improvement usually begins within a few weeks of starting vaginal estrogen. Tissue changes continue improving over several months. Most protocols use daily application for the first two to three weeks, then reduce to twice weekly for maintenance.

The treatment is ongoing — stopping typically means the symptoms gradually return as tissue changes reverse. This isn't a course of antibiotics that cures the problem; it's a long-term management strategy for a chronic condition.

The bottom line

GSM is common, progressive, and highly treatable. Women who suffer through it for years because they didn't know help existed — or because no one offered it — are getting a quality of care below what's currently available. If any of the symptoms in this article sound familiar, raising them with a provider who takes women's health seriously is worth doing.

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