In April of 2025, the American Urological Association released a new guideline on the Genitourinary Syndrome of Menopause (GSM).
Before we get to the 7 takeaways, some background information that might be useful.
What is the Genitourinary Syndrome of Menopause (GSM)?
The Genitourinary Syndrome of Menopause (GSM) is a set of symptoms related to aging and the decline in estrogen that can occur just before but mostly after the final menstrual period. This set of symptoms affects the vagina, the vulva, the urinary tract and the pelvic floor. GSM is a relatively new term and an improvement over its predecessor, vulvar vaginal atrophy (VVA). GSM encompasses a broader range of symptoms and gets rid of the unappealing word “atrophy”. For a deeper dive on GSM, see our pages on vaginal and urinary changes and pelvic floor changes pages.
What is a guideline?
Who is this GSM guideline for?
This guideline is written for clinicians — nurse practitioners, doctors, physician assistants, midwives — anyone who takes care of midlife women.
What is the goal of the GSM guideline?
This guideline aims to provide clinicians with information based on available research to identify, diagnose, counsel and treat women with Genitourinary Syndrome of Menopause to reduce the impact of symptoms and improve quality of life.
Who was involved in creating the GSM guideline?
The 2025 Guideline on the Genitourinary Syndrome of Menopause was produced by the American Urological Association in partnership with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) and the American Urogynecologic Society (AUGS) and was endorsed by the International Society for the Study of Women’s Sexual Health (ISSWSH) and The Menopause Society (TMS).
Although the guideline is written for healthcare providers, we think Table 1 in the guideline is worth scrolling to. It offers a list of the nine main (9) symptoms of GSM and the associated signs of each. If you suspect you have a symptom or symptoms associated with GSM, mention it to your healthcare provider. Research shows that too many healthcare providers don’t ask about menopause related vaginal changes. The recent enhanced attention to perimenopause and menopause and this new guideline will hopefully help to change that.
The guideline reviews many treatment options and it’s worth reading through it. We’ve highlighted the takeaways relevant for most women.
1. Vaginal estrogen should be offered for menopause related vaginal (GSM) symptoms.
- The greatest amount of evidence and experience exists for the use of local low-dose vaginal estrogen. These are products you insert into your vagina (tablet, ring, suppository or cream) or use externally (cream) on your labia and vestibule. See this diagram for an anatomy refresher.
- Healthcare providers should offer local low-dose vaginal estrogen to patients with GSM to improve discomfort/irritation, dryness, and/or pain with penetration.
- Low-dose vaginal estrogen is effective and is very safe (i.e., has a high margin of safety).
- If you have GSM and recurrent urinary tract infections (UTIs), local low-dose vaginal estrogen can reduce the risk of future urinary tract infections. Vaginal estrogen has been shown to reduce the frequency of recurrent urinary tract infections in postmenopausal women.
2. Local low-dose vaginal estrogen is not linked to breast cancer.
- There is no evidence linking local low-dose vaginal estrogen to the development of breast cancer.
- Patients with GSM who have a personal history of breast cancer, should discuss local low-dose vaginal estrogen with their team of doctors and reference this guideline.
- Importantly, if you do decide to try local low-dose vaginal estrogen, you will see a “black box warning” about associated risks on and/or in the product packaging. These risks are linked to oral estrogen from the Women’s Health Initiative study and not specifically linked to low-dose vaginal estrogen. There is a movement to remove this warning from local low-dose vaginal estrogen products. Most experts and the evidence, as noted by the first point above, suggest this warning is not warranted.
3. Local low-dose vaginal estrogen does not have negative effects on the lining of the uterus.
- Local low-dose vaginal estrogen does not increase the risk of overgrowth of the uterine lining, a condition that can lead to uterine cancer, nor with uterine cancer itself.
(Scroll to Table 2 in the guideline for details on all FDA-approved treatments for menopause related vaginal symptoms)
4. Vaginal moisturizers and/or lubricants are recommended for menopause related vaginal changes (GSM).
Vaginal moisturizers and/or lubricants, either alone or in combination with other therapies, are recommended and can improve vaginal dryness and/or pain with sex. There are many types of moisturizers and lubricants and people tend to have individual preferences so try a few if you don’t like the first one you try.
Moisturizers are absorbed into vaginal tissue and add moisture that can help relieve everyday itchiness and irritation that many women experience. You use these 2-3 times a week to maintain moisture. Hyaluronic acid is the base for most moisturizers.
Lubricants are only used to minimize friction during sex. They are not absorbed into the tissue. They come in liquid or gel and are applied to the vagina or penis. These can be water-based, oil-based or silicone-based. Only water-based or silicone-based lubricants should be used with condoms.
6. These treatments have insufficient evidence and are not recommended for treating GSM:
- vaginal and systemic testosterone
- oxytocin
- alternative supplements
- botanicals and naturally occurring organic compounds. These are not regulated by the Food and Drug Administration (FDA), and as such, the amount and quality of the active ingredients may vary.
- mixed herbal supplements. These are particularly unpredictable with respect to the balance of ingredients.
- energy-based treatments (laser)
- CO2 laser, ER:YAG laser, or radiofrequency for the treatment of GSM-related vulvovaginal dryness, vulvovaginal discomfort/irritation, painful urination or pain with penetrative sex
7. If you have GSM symptoms, the guideline suggests avoiding the following:
- excessive cleansing with soap, harsh cleansers or chemicals
- vulvovaginal irritants like soaps, cleaners, douches, spermicides, pads, and liners that can worsen the symptoms of GSM
- allergens that may include perfumes, lanolin, chlorhexidine, benzocaine, neomycin, preservatives, and latex
The guideline also covered vaginal dehydroepiandrosterone (DHEA) and ospemifene. Find more on those treatment options here.