Genitourinary Syndrome of Lactation: Patient-Reported Survey of Symptom Burden, Care Gaps, and Treatment Utilization in the Postpartum Period

Objective : To evaluate treatment practises for postpartum individuals with genitourinary symptoms. Design : Cross-sectional survey. Setting : Online survey disseminated through postpartum/parenting groups and social media (March to May 2025). Population or Sample : Postpartum individuals within 24 months of delivery. Exclusion criteria included nulliparity, current pregnancy, prior genitourinary disorders, and incomplete responses. Methods : A 30-item questionnaire assessed demographics, lactation status, genitourinary symptoms, treatments offered and utilized, and quality of life (QoL; 0–100). Participants were stratified into exclusive lactation, non-exclusive lactation, and non-lactating groups. Quantitative data were analyzed with descriptive statistics, chi-square tests, and multinomial logistic regression (α = 0.05). Qualitative data underwent thematic analysis. Main Outcome Measures : Provider interaction/treatment practices for genitourinary symptoms. Results : Of 1,446 respondents (median age 36 years), 47.65% were exclusively lactating, 14.66% mixed feeding, and 37.69% non-lactating. Vaginal dryness was the most common symptom (exclusive: 100%; non-exclusive: 100%; non-lactating: 78.72%), followed by dyspareunia (57.04%, 50.00%, 36.33%). Functional impairments were prevalent with 76.34% of exclusively lactating participants reporting difficulty with sexual activity. Despite symptom burden, 63.81% were never asked about genitourinary concerns, and only 28.42% were offered treatment. Awareness of lactation-compatible therapies was limited (60.03% unaware). Vaginal estrogen and pelvic floor physiotherapy were most commonly recommended, but to fewer than 30% of symptomatic individuals. Lactation status was significantly associated with symptom presence and treatment patterns (p < 0.001). Themes highlighted severe pain, disrupted intimacy, and lack of provider support. Conclusions : Genitourinary symptoms during lactation are common yet inadequately managed. Care models should incorporate routine screening, provider education on lactation-safe therapies, and improved access to multidisciplinary interventions.

In the United States, 83.2% of mothers begin breastfeeding at birth, with the percentage of breastfeeding by 6 months postpartum dropping to 55.8%. 1 Challenges leading to breastfeeding cessation include inadequate social support, lactation difficulties, employment demands, and personal health issues. 2 However, it has only recently been appreciated that many lactating individuals may struggle with a constellation of symptoms known as Genitourinary Syndrome of Lactation (GSL). Introduced in 2024, the term GSL describes the genital and urinary symptoms that arise in response to the hypoestrogenic and hypoandrogenic state induced by lactation. 3 Since its inception, the term GSL has appeared in multiple publications, reflecting growing interest in this underappreciated phenomenon. 4–7 Physiologically, GSL is driven by the lactation-related hyperprolactinemia, which suppresses the hypothalamic-pituitary-gonadal axis and results in decreased ovarian production of estrogen and androgens. 8 This hormonal environment can lead to a range of symptoms, including vaginal dryness, dyspareunia, urinary urgency, urinary tract infections, and sexual dysfunction. 9–11 GSL remains largely overlooked in both research and clinical settings despite the large population at risk. Many patients and healthcare providers are unaware of its presentation and available treatment options. This knowledge gap not only delays diagnosis and treatment but also contributes to the significant quality-of-life burden that these symptoms can impose. As such, there is a pressing need to better understand the clinical landscape of GSL and barriers to care. This study aimed to assess the genitourinary symptoms experienced by postpartum lactating individuals and explore the barriers they face in seeking and receiving effective treatment.

An online survey was distributed via social media, postpartum/breastfeeding/mom facebook groups, newsletters, and email to various post-partum mom affinity and parenting groups from March 17th, 2025 to May 5th, 2025. Eligibility criteria included individuals who have experienced the postpartum period and who were willing to disclose lactation patterns, contraceptive methods, and genitourinary symptoms. Exclusion criteria were applied after responses were received and included nulliparity, current pregnancy, being more than 24 months postpartum, pre-existing hormonal or genitourinary conditions diagnosed prior to pregnancy (interstitial cystitis, chronic vulvodynia), systemic hormone therapy used unrelated to postpartum care, and incomplete survey response. Participants were informed that survey submission was voluntary and were given the option to opt out of the survey at any time. This study was granted IRB exemption per Georgetown University (IRB: STUDY00008312). The 30-item survey was developed de novo through interdisciplinary meetings with obstetricians, gynecologists, urologists, researchers, patients and patient advocates. Content validity was maximized by beta testing by our research team, with feedback incorporated into survey revisions. We collected and managed data using Qualtrics, a secure, web-based software platform designed for survey administration and data capture in research settings. The primary outcome of interest was the provider interaction/treatment practices for genitourinary symptoms. This included assessing the treatments offered and the treatments used. The presence of symptoms was assessed. Functional impairments associated with symptoms were also assessed on a scale from 0-100 (100 = most affected, 0 = not affected). Key variables included lactation pattern, menstrual return, genitourinary symptoms, treatments offered and received, and functional impairments associated with symptoms/quality of life. Additional factors analyzed included demographic information and prior medical history relevant to genitourinary health. For the purposes of this study, “impaired vaginal/perineal wound healing” was defined based on self-reported symptoms suggestive of delayed or problematic healing at the site of a vaginal tear, episiotomy, or perineal repair. Participants were instructed to consider symptoms such as persistent pain, separation of sutures, prolonged bleeding, infection, or continued sensitivity beyond the expected healing window (typically >6 weeks postpartum). This category was included as a binary (yes/no) variable based on participant interpretation and experience. In addition, we acknowledge that “breastfeeding” is not inclusive of all experiences nor inclusive of the act of pumping. In this paper we will therefore use the term “lactating” as a categorization revolving around infant feeding choices. Statistical Analysis Quantitative Data Analysis Data were analyzed using descriptive statistics in Microsoft Excel and used to compare variables across reported patient characteristics, symptom severity, and treatment status. Categorical variables were analyzed using Pearson’s chi-square test. Contraceptive methods were stratified based on their likelihood to suppress ovulation. Contraceptives categorized as ovulation suppressive included combined oral contraceptives (COCs), the patch, the vaginal ring, the implant, and depot medroxyprogesterone acetate (Depo-Provera). In contrast, non-hormonal methods (copper IUDs, barrier methods) and progestin-only options like the minipill or hormonal IUDs were categorized as consistently inhibiting ovulation. Multinomial logistic regression was performed to assess the correlation between patient characteristics, symptom presence, and treatment patterns. Statistical analyses were conducted using Prism and Python (α = 0.05). Qualitative Data Analysis We performed a descriptive thematic analysis of the free-text responses from the survey’s optional, open-ended prompt: “Anything else you would like to tell us?”. Narrative responses were analyzed using the clinical-qualitative method for content analysis. 12 Full-text responses were tabulated, and authors independently reviewed responses. The collated data were then categorized in relation to the research question, ensuring categories were exhaustive and mutually exclusive.

Of 1509 survey responses, responses were eliminated for never having delivered a child (13 surveys), duplication (4 surveys), and lack of any responses (46 surveys). In total, 1446 patients (95.83%) completed the survey in part or in full (median [interquartile range] age, 36 [8] years). The overall response rate could not be calculated given the wide distribution of the survey on social media and the inability to determine the total number of individuals who had access to the survey link. Participants represented an international population, with the majority residing in the United States (69.29%), followed by the United Kingdom (12.66%), Australia (11.55%), Canada (5.74%), Europe (0.62%), and Asia (0.14%). The majority of participants (47.65%) exclusively lactated, 14.66% used a combination of lactation and formula-feeding, and 37.69% of participants did not lactate. The most common length of time lactating was >1 year (30.01%), followed by 6 months - 1 year (29.46%) and 3-6 months (20.08%). Most participants (65.01%) were not using any form of contraception. Patients’ characteristics are shown in Table 1. Onset of Menstruation The return of menstruation varied notably by lactation status, with delayed resumption most common among exclusively lactating individuals. At the time of analysis, menstruation had not yet resumed in 64.73% of exclusively lactating participants, compared to 50.00% of those who were non-exclusively lactating, and only 5.87% of non-lactating participants (Table 2). Early return of menstruation (<1–3 months postpartum) was most frequently reported among non-lactating individuals (29.36%), compared to 13.68% of non-exclusive and 11.90% of exclusively lactating individuals. By 4–6 months postpartum, menstruation had resumed in 21.36% of non-lactating individuals, 11.79% of non-exclusive lactators, and 9.58% of exclusive lactators. A similar trend continued at 10–12 months (22.94% non-lactating, 14.62% non-exclusive, 7.11% exclusive), illustrating a dose-dependent relationship between lactation intensity and prolonged postpartum amenorrhea. Correlation analysis revealed that lactation status was significantly associated with the timing of menstrual resumption (Χ²(12, N=1446) =468.2, p<0.001). Exclusive lactation was associated with a longer delay in menstruation resumption (r =-0.42), whereas non-lactation was correlated with earlier menstruation return (r=0.47). Duration of lactation was also positively correlated with delay in menstruation (r=0.42). Return of menstruation was significantly associated with the presence of GSL symptoms (Χ²(4, N=1446) =85.57, p=0.0001), although not with symptom severity (Χ²(16, N=1446) = 9.57, p > 0.05) or symptom type (Χ²(16, N=1446) =9.57, Contraceptive Use and Ovulatory Suppression Participants reported a range of contraceptive methods. The most common response was no contraception (65.01%), followed by hormonal IUD (13.62%), barrier methods (8.30%), and oral contraceptives (3.32%). A minority reported using the minipill (3.04%), implant (0.83%), injection (0.07%), patch (0.14%), or vaginal ring (0.22%) (Supplementary Table 1). There was no statistically significant association between type of contraception (ovulatory suppression vs non-ovulatory suppression) and onset of menstruation (Χ²(20, N = 1446) = [value], p > 0.05). GSL Symptoms GSL symptoms were common across all groups, with vaginal dryness reported by nearly all participants in the exclusive (100%) and non-exclusive (100%) lactation groups, and 78.72% of those not lactating. Pain with intercourse was also frequently reported (57.04% exclusive, 50.00% non-exclusive, 36.33% non-lactating), followed by urinary incontinence (34.69% exclusive, 32.55% non-exclusive, 28.99% non-lactating) and impaired vaginal/perineal wound healing (18.87% exclusive, 14.62% non-exclusive, 12.29% non-lactating). The presence of GSL symptoms varied significantly by lactation status (Χ²(2, N=1446) =137.4, p0.05). When asked to identify their most distressing symptom, dyspareunia was the most frequently reported across all groups (46.44% exclusive, 41.04% non-exclusive, 30.64% non-lactating). Vaginal dryness was also commonly reported as most distressing, particularly among non-lactating individuals (40.18%), compared to 27.83% of non-exclusively lactating and 19.59% of exclusively lactating participants. Details are shown in Table 2. Functional impairments and quality of life GSL symptoms negatively impacted functional impairments in several domains. Among exclusively lactating individuals, 76.34% reported difficulty engaging in sexual activity, followed by increased discomfort in daily activities (57.18%), and mental health impacts (38.75%). These trends were consistent across groups, though the prevalence of reported difficulty was highest in the exclusive lactation group for most categories (Table 3). When impact scores were assessed on a scale from 0 to 100 (with 100 indicating greatest impact), exclusively lactating individuals reported the highest mean impact on sexual activity (63.83), followed closely by non-exclusive (60.85) and non-lactating participants (59.91). General mental health was most affected among non-lactating individuals (53.23), compared to non-exclusive (46.97) and exclusively lactating individuals (24.24) (Table 3). Provider Interaction and Treatment Practices The majority of participants had the opportunity to interact with health care professionals, through 6-weeks postpartum checkups (87.8%), or annual visits (42.3%). The majority (63.81%) of participants reported that their healthcare provider did not ask about genital or urinary symptoms, and over half (53.87%) did not initiate bringing up these concerns themselves. Comfort levels of patients discussing these symptoms varied, with only 35.62% reporting that they “definitively felt comfortable” doing so, while a combined 16.59% felt “probably” or “definitely uncomfortable”. Among those who raised the topic, only 28.42% were offered treatment. Furthermore, awareness of available treatment options during lactation was extremely limited; 60.03% were unaware that such treatments exist. When treatments were offered, pelvic floor physiotherapy (20.75%) and vaginal estrogen (16.73%) were most commonly recommended. However, a comparison of the treatment offered versus treatment used revealed notable discrepancies (Figure 1). While 43.25% of participants were offered no treatment, only 18.60% reported using none, suggesting many sought treatments independently or through alternate means. Several treatment modalities showed higher usage than their offer rates; pelvic floor physiotherapy (20.75% offered vs 29.94%, used) and vaginal moisturizers (12.03% offered vs 25.24% used)– both nearly doubling in usage compared to offer rates. Similarly, the ”Other” category showed a higher uptake (7.40%) than the offer rate (3.80%), suggesting that patients may have explored alternative or complementary therapies not routinely provided by clinicians. In contrast, vaginal estrogen (16.73% offered vs. 13.76% used) showed relatively comparable offer-to-use ratios, indicating alignment between clinical recommendations and patient behavior. Use of other topical hormones (2.00%) and oral hormones (1.18%) was low. Survey responses are detailed in Supplementary Table 2. Participants’ treatment experiences were significantly associated with lactation status. Whether treatment was offered (Χ²(16, N=1446) =93.32, p<0.0001), the type of treatment used (Χ²(16, N=1446) =140.4, p<0.0001), and whether treatment was used (Χ²(2, N=1446) =72.13, p<0.0001) were all statistically associated with lactation status. Patients offered a select few treatments were likely to use the treatment offered, including vaginal estrogen (r=0.63), PFPT (r=0.45), and oral medications (r=0.54), vaginal moisturizers (r=0.36), topical hormones (r=0.30), and oral hormones (r=0.34). Those not offered treatment were still likely to use some form of therapy (r=-0.39). Free text quotation analysis Participants provided a total of 143 free-text quotations. The most common themes patients reported were related to pain. Among these quotations, patient emphasis was often on the severity of pain experienced, and lack of resources to help mitigate this pain (30 quotations), which patients often attributed to vaginal dryness (23 quotations). Frustration also included difficulty with exercise (18 quotations) and incontinence (11 quotations). Regardless of patient experience, there were 15 quotations of gratefulness towards clinicians and the pursuit of this research.

To our knowledge, this survey study provides the first large-scale characterization of genitourinary and sexual symptoms associated with lactation, collectively referred to as Genitourinary Syndrome of Lactation (GSL). We found that GSL symptoms were highly prevalent across all lactation statuses; 92% of participants reported vaginal dryness– making it the most prevalent symptom; almost 50% reported pain with intercourse and about one-third of participants reported urinary incontinence. Notably, exclusively lactating individuals reported the highest symptom burden: with all experiencing vaginal dryness, over half dyspareunia, and one-third noting urinary incontinence. Pain with intercourse was consistently identified as the most distressing symptom regardless of lactation statuses and functional impairments measures were significantly impacted. The notable impact on all domains of functional impairment highlight both the high prevalence and multidimensional impact of genital and urinary symptoms in the postpartum period, with differences in symptom experience and severity depending on lactation status. Awareness of safe therapeutic options during lactation was limited. These findings underscore a critical gap in postpartum care and highlight the need for routine screening and education about GSL, especially for lactating individuals. Our findings support and expand upon existing literature regarding postpartum vulvovaginal health 3,6,13 . Despite a physiological basis, our data reveal a striking gap between symptom burden and clinical engagement. Over 60% of participants reported that their healthcare provider did not inquire about genitourinary symptoms, and only a third felt fully comfortable raising these concerns themselves. This gap is consistent with prior research showing low rates of provider-initiated discussions about postpartum sexual health and urogenital function 14,15 . Moreover, among those in our study who did disclose symptoms, treatment offerings were limited. Vaginal estrogen and PFPT were the most commonly recommended interventions yet were offered to fewer than 30% of symptomatic individuals. There is limited published guidance on how clinicians manage postpartum genitourinary symptoms, particularly in lactating patients. Existing data suggests variability in clinical approaches, including the use of vaginal estrogen and PFPT, but there is no standardized care pathway. 16,17 Topical vaginal estrogen has been proven effective in relieving hypoestrogenic symptoms, including vaginal dryness and dyspareunia in hypoestrogenic states, but remains underutilized in the postpartum population. 13,18 Therapeutic regimens such as 2 grams of conjugated estrogen cream twice weekly or daily 0.1% estriol cream applied to the vestibule have led to substantial symptom improvement in small trials. 16,19 Yet over 60% of this study’s respondents were unaware that such treatments exist, highlighting a significant education gap. Notably, utilization remained low among participants who were offered estrogen therapy. In our survey 16.73% of respondents were offered vaginal estrogen, but only 13.76% reported using it. This discrepancy likely reflects both provider hesitancy and patient concerns around hormone safety during lactation despite studies showing low-dose vaginal estrogen is considered safe during lactation, with minimal systemic absorption and negligible effects on milk production or infant exposure. 20–23 Prior literature suggests that patient misconceptions and provider uncertainty both contribute to this underutilization. 16,24,25 PFPT was the most commonly utilized intervention, with 20.75% being offered it by a healthcare provider, and even more, 29.94% of respondents reporting use. PFPT has demonstrated efficacy in managing postpartum pelvic pain, dyspareunia, and urinary symptoms—particularly when scar tissue, pelvic floor laxity, or neuromuscular dysfunction are present. 13,26 Importantly, however, the mechanisms addressed by PFPT differ from those addressed by local hormonal therapies. Insertional dyspareunia related to hypoestrogenism and atrophic epithelial changes is more likely to respond to topical estrogen or other local therapies, whereas deep dyspareunia and pelvic pain associated with musculoskeletal dysfunction may benefit from PFPT. To date, no published studies to our knowledge have directly evaluated PFPT in the context of GSL, and there is limited evidence to suggest that hypoestrogenism itself directly contributes to pelvic floor musculoskeletal dysfunction, although indirect effects through pain, disuse, or connective tissue changes are possible. The modest referral rate overserved in our study may reflect provider under-recognition of PFPT’s targeted role, as well as patient barriers related to cost, geographic access, and awareness. These data illustrate a pattern in which patients utilize treatments that are not specifically recommended by a healthcare provider, particularly non-hormonal and non-prescription options, highlighting communication gaps between postpartum patients and healthcare providers. In contrast, PFPT is more widely integrated into postpartum care in several European countries. For instance, in France, the national health system routinely covers up to ten sessions of postpartum pelvic floor rehabilitation (rééducation périnéale) for all women, regardless of symptoms. 27,28 In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends pelvic floor muscle training be offered to all postpartum women, particularly to those at increased risk of pelvic floor dysfunction. 29,30 These international practices reflect a more proactive, preventive approach to postpartum pelvic health, underscoring potential gaps in access and standardization in other settings. Together, these findings emphasize the need for improved postpartum education in the United States, provider training on GSL management, and system-level support to increase access to evidence-based, lactation-safe treatments—both topical and rehabilitative—for genitourinary symptoms. Free-text responses from participants further highlight the emotional and physical toll of untreated GSL symptoms. Many respondents described severe pain, disruptions to intimate relationships, and frustration with the lack of available support. These findings are consistent with qualitative research documenting postpartum women’s feelings of isolation and invalidation when experiencing sexual and genitourinary symptoms. 31,32 Addressing this gap requires not only clinical awareness but also system-level changes in postpartum care models that explicitly include genitourinary health as part of routine screening and education. While many postpartum issues are multifactorial, GSL is one contributing factor that is both treatable and often overlooked. Addressing a single modifiable component may empower a sense of agency during the postpartum recovery process. Although not evaluated in the present study, postpartum depression affects approximately 10–20% of new mothers and is strongly associated with physical discomfort and sexual dysfunction. 33,34 Integrating management of GSL into a broader biopsychosocial model of postpartum care may therefore enhance both physical and psychological outcomes.

Several limitations must be acknowledged. The anonymous nature of the survey design does not prevent a participant from completing the survey multiple times. Although the survey was accessible nationwide, the sample may overrepresent certain groups—particularly insured, healthcare-seeking individuals, and was only offered in English, limiting generalizability. The questionnaire was also non-validated and some questions for subjective in nature. Relatedly, nonresponse bias may also be present, as individuals with stronger interest or more significant symptoms may have been more inclined to complete the survey. The inclusion window, up to 24 months postpartum, is wide and could have implications for the findings since some symptoms may be time dependent. Additionally, the retrospective nature of the study introduces the potential for recall bias, and response bias is possible due to the phrasing of questions and the structure of response options.

The widespread occurrence of genitourinary symptoms during lactation—especially among individuals who are exclusively lactating—calls for increased clinical awareness and more structured approaches to care. Incorporating routine evaluation of these symptoms into postpartum visits, equipping healthcare providers with up-to-date knowledge on safe and effective treatment options and improving access to multidisciplinary support services are important strategies to address this unmet need. In parallel, creating clear, supportive educational materials can help postpartum individuals identify symptoms early and feel empowered to seek care, ultimately improving comfort, function, and quality of life during the lactation period. Declarations Author Contribution: Sara Perelmuter (Conceptualization [lead], Data curation [lead], Formal analysis [equal], Investigation [equal], Methodology [lead], Project administration [lead], Resources [equal], Supervision [lead], Writing- original draft [equal], Writing- review & editing [lead]); Alexandra Drian (Data curation [equal], Formal analysis [equal], Investigation [equal], Resources [equal], Writing- original draft [equal], Writing- review & editing [equal]); Sasha Vereecken (Data curation [equal], Formal analysis [equal], Investigation [equal], Resources [equal], Writing- original draft [equal]); Melissa Davide (Data curation [equal], Formal analysis [equal], Investigation [equal], Resources [equal], Writing- original draft [equal]); Jayden Berdugo (Data curation [equal], Formal analysis [equal], Investigation [equal], Resources [equal], Writing- original draft [equal]); Cameron Stokes (Data curation [equal], Formal analysis [equal], Investigation [equal], Writing- original draft [equal]); Claire B Sandler (Data curation [equal], Formal analysis [equal], Investigation [equal], Writing- original draft [equal]); Daniel Krutz (Data curation [equal], Formal analysis [lead], Methodology [equal], Resources [equal], Software [lead], Visualization [equal]); Breanna Thomas (Data curation [equal], Writing- original draft [equal]); Temiloluwa Faokunla (Data curation [equal], Writing- original draft [equal]); Madeeha N Malik (Data curation [equal], Writing- original draft [equal]); Alexandra Payne (Project administration [supportive]); Rachael Sussman (Project administration [supportive]); Jill Krapf (Writing- review & editing [supporting]); Rachel Rubin (Writing- review & editing [supporting]). Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Acknowledgements: We would like to acknowledge the Sexual Medicine Research Team (SMRT) for their help and support in this project. Ethics Statement: This study was granted IRB exemption per Georgetown University (IRB: STUDY00008312) on Feb 14, 2025.

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Comparison of Treatment Offered versus Treatment Used Supplementary Material File (tables.docx) - Download - 21.44 KB Information & Authors Information Version history Peer review timeline Published The Journal of Sexual Medicine Version of Record7 Apr 2026Published Copyright This work is licensed under a Non Exclusive No Reuse License.

Authors Metrics & Citations Metrics Article Usage 476views 158downloads Citations Download citation Sara Perelmuter, Alexandra Drian, Sasha Vereecken J, et al. Genitourinary Syndrome of Lactation: Patient-Reported Survey of Symptom Burden, Care Gaps, and Treatment Utilization in the Postpartum Period. Authorea. 05 November 2025. DOI: https://doi.org/10.22541/au.176231889.99282947/v1 DOI: https://doi.org/10.22541/au.176231889.99282947/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.