Genitourinary Syndrome of Menopause

In 2014, experts recommended the term genitourinary syndrome of menopause (GSM) to more accurately describe the broad spectrum of genital, sexual, and urinary changes associated with the hypoestrogenic state that develops after menopause. Adoption of this terminology replaced older, more limited descriptors, eg, vulvovaginal atrophy and atrophic vaginitis, reflecting a broader understanding that estrogen deficiency affects multiple structures throughout the lower genitourinary tract rather than the vagina alone. GSM encompasses vulvovaginal atrophy, urogenital atrophy, and atrophic vaginitis, involving the vagina, labia, urethra, and bladder as a consequence of diminished estrogenic stimulation. Reported prevalence ranges from 14% to 87% among postmenopausal women, making GSM one of the most common chronic conditions associated with menopause. Reduced estrogen exposure serves as the primary underlying cause of GSM in postmenopausal individuals and in patients of any age who experience prolonged hypoestrogenism, including those who are lactating, have hypothalamic amenorrhea, or receive antiestrogen therapies for conditions, eg, breast cancer, uterine fibroids, or endometriosis. Progressive estrogen deficiency produces structural and functional changes throughout the urogenital tract, altering tissue integrity, vascularity, lubrication, elasticity, and the vaginal microbiome. Clinical manifestations frequently resemble those of urinary tract infections, vulvovaginal infections, and other genitourinary disorders, creating diagnostic uncertainty that may delay recognition and appropriate treatment.  Without timely intervention, ongoing anatomic and physiologic changes often lead to progressive symptoms, diminished quality of life, recurrent urinary complications, and sexual dysfunction. Effective management, therefore, requires an individualized, evidence-based approach that may incorporate nonhormonal therapies, local or systemic hormonal treatment, or other emerging therapeutic options based on symptom severity, patient preferences, and underlying comorbidities.