Genitourinary syndrome of menopause (GSM)

Genitourinary syndrome of menopause, GSM for short, covers the changes that come to the vulva, the vagina and the bladder as estrogen falls. In plain words: vaginal dryness, burning or irritation, pain during sex, and bladder symptoms such as needing to go more often, needing to go urgently, or stinging when you pass urine.

You may also see it called vaginal atrophy or atrophic vaginitis. The Pakistan Menopause Society's recommendations say GSM replaced those older names.

The PMS recommendations place GSM in the first few years after the menopause. Women's Health Concern notes that some women notice dryness before then. It is common: the European Menopause and Andropause Society (EMAS) says it affects around half of women after the menopause.

Women's Health Concern, the patient arm of the British Menopause Society, lists more than dryness and pain during sex: discomfort when sitting, standing, exercising or passing urine, whether or not you are having sex at all. A smear test that has become harder to get through. Discharge that turns more watery, or irritation and burning that feels like thrush.

The factsheet warns that treating it as thrush with remedies bought over the counter can make it much worse. It also says only a quarter of affected women seek treatment.

In Urdu there is barely an everyday word for any of this. Most women manage to say khushki, dryness, or takleef, discomfort, and leave the rest unsaid.

The PMS recommendations describe GSM as the set of changes linked to a fall in estrogen and other sex hormones. Women's Health Concern explains what that does to the tissue: without estrogen, the skin of the vulva and vagina becomes thinner and less elastic, makes less moisture, and is more easily damaged, so even gentle friction can hurt.

NICE NG23 sets out the options in order:

• Vaginal estrogen is the first thing NICE recommends offering, including to women already on HRT (1.5.5). It comes as a cream, a gel, a tablet, a pessary or a ring, and NICE asks doctors to choose the form together with the woman (1.5.7). See vaginal estrogen.
• NICE asks doctors to explain that "serious adverse effects are very rare", that the estrogen acts locally with only a minimal amount absorbed into the bloodstream, and that symptoms often come back when it is stopped, though it can be restarted (1.5.6).
• EMAS adds that vaginal estrogen may help prevent urine infections that keep coming back. NICE covers that use in its separate guideline on recurrent urinary tract infection (1.5.13).
• Moisturisers and lubricants can be used with vaginal estrogen or on their own, including by women who cannot or would rather not use a hormone (1.5.8 and 1.5.9). The British Menopause Society's statement on GSM also gives both as options, with moisturisers used regularly whether or not you are having sex.
• If those have not worked or are not tolerated, NICE lists vaginal prasterone, and ospemifene as a tablet for women who find a locally applied treatment impractical, for example because of disability (1.5.10 and 1.5.11).
• On lasers, NICE is direct: "Do not offer vaginal laser treatment for genitourinary symptoms associated with menopause unless as part of a randomised controlled trial" (1.5.20).

Women who have had breast cancer have a separate set of NICE recommendations, starting with non-hormonal treatments, and involving a breast cancer specialist for women on aromatase inhibitors.

If dryness, pain or bladder changes get in the way of sex, sleep, prayer or sitting comfortably, that is reason enough. Women's Health Concern suggests writing your symptoms down and handing the note over if saying them out loud feels impossible.

The PMS recommendations ask doctors to look further for persistent pain, urine infections that keep coming back or do not respond to treatment, blood in the urine, a prolapse, or leaking that affects your daily life (Table 4). Bleeding after sex, or any bleeding after your periods have stopped, is on its list of red flags that need checking (2.3).

Women's Health Concern names the strain this can put on a marriage, especially when a woman feels unable to explain why she is pulling away from intimacy. Knowing it is common, and has a name and a treatment, can make the conversation with a husband easier as well as the one with a doctor.

Women also ask whether a vaginal treatment affects their fast in Ramadan, or their ghusl and prayer. Those questions belong with a qualified scholar. When to use the treatment around sehri and iftar is a question for whoever prescribes it.