Vaginal atrophy, or genitourinary syndrome of menopause, explained

What vaginal atrophy is.

Healthy vaginal tissue is several cell layers thick, moist and elastic, and estrogen keeps it that way. When estrogen drops, the lining gets thinner, drier, less elastic and more fragile. Blood flow falls, natural lubrication slows, and the vaginal pH tends to rise, which changes the balance of bacteria.

Vaginal atrophy and atrophic vaginitis were the old names. Mayo Clinic and the Menopause Society now use genitourinary syndrome of menopause, because the urethra and bladder have estrogen receptors too, and urinary symptoms often arrive at the same time. You will see both terms; they describe the same thing.

It is common. The Menopause Society's 2020 position statement estimates GSM affects about 27 to 84 percent of postmenopausal women, and calls it likely underdiagnosed and undertreated. Hot flashes often fade with time. GSM symptoms often do not, which is one reason it is worth treating.

Symptoms.

Mayo Clinic lists these:

• Dryness, burning or itching in the vagina.
• Thin, watery, yellow or gray discharge.
• Pain during sex from less lubrication, or light bleeding after sex.
• A frequent or urgent need to urinate, or burning when you urinate.
• Leaking urine.
• More frequent urinary tract and vaginal infections.
• Shortening and tightening of the vaginal canal.

Many people notice it first as sex that suddenly stings, or as a lube that used to be fine and now burns. That second one is often an osmolality problem, covered below.

Why it happens.

Menopause is the main cause, but anything that lowers estrogen can do it. Mayo Clinic lists perimenopause, removal of both ovaries, breastfeeding, some birth control pills, chemotherapy or pelvic radiation, and hormonal treatment for breast cancer. Smoking makes it more likely by reducing blood flow. Regular sexual activity or masturbation, with or without a partner, helps keep tissue healthier by increasing blood flow. The broader list of causes is in vaginal dryness causes, and the breastfeeding version is in postpartum dryness.

Moisturizers and lubes, first line.

The Menopause Society says nonhormone products available without a prescription give enough relief for most women with mild symptoms. Mayo Clinic suggests trying them first. They do two different jobs:

• A vaginal moisturizer is used on a schedule, every two to three days, whether or not you have sex. It holds water in the tissue and changes the day to day baseline.
• A lubricant is used during sex to cut friction for that hour.

Most people with GSM do better with both. The full comparison is in vaginal moisturizer vs lube.

Why the numbers matter more now. Osmolality is how concentrated a product is compared with the body. The WHO advises 380 mOsm/kg or under as ideal for a lubricant, with 1,200 as a ceiling. A product far above that pulls water out of cells, and thinned postmenopausal tissue has less to spare. Edwards and Panay, writing in Climacteric in 2016, argued that moisturizer and lube composition matters for exactly this group. Our osmolality explainer covers the science.

The products with the best published numbers.

Product	Type	Osmolality (mOsm/kg)	pH	Source
YES VM	Moisturizer	250	4.15	Edwards and Panay 2016
Replens	Moisturizer	1,200 to 2,011	2.5 to 3.5	FDA 510(k) filing
Revaree	Hyaluronic acid insert	Not published	Not published	None
Good Clean Love Almost Naked	Water based lube	240 to 269	4.7	Edwards and Panay 2016
Uberlube	Silicone lube	Does not apply	Does not apply	No water

• YES VM has the best numbers of any moisturizer we track: iso-osmolar and pH matched, glycerin free.
• Replens is the moisturizer clinicians name first and Mayo Clinic lists by name. Its filed osmolality is high and its pH is low. Many women use it happily; if it stings, YES VM is the swap.
• Revaree is a hormone free hyaluronic acid insert used every two to three days, for people who will not stick with a gel and applicator.
• Uberlube is a silicone lube, so osmolality does not apply. It lasts, which matters when tissue is dry. Keep it off silicone toys.
• Good Clean Love Almost Naked is a near iso-osmolar water based lube for anyone who uses silicone toys or wants something that rinses off.

Mayo Clinic also advises choosing lubes without glycerin or warming ingredients, and avoiding oil based products with latex condoms. Our menopause lube picks go deeper on lube choice, and the full ledger is in the lube index.

Prescription options to ask about.

If a moisturizer and lube used consistently for a month or two have not helped, or symptoms are moderate to severe, these are the options the Menopause Society lists as effective. They are names to bring to an appointment. We give no doses or schedules.

• Low dose vaginal estrogen, as a cream, tablet, insert or ring. Mayo Clinic notes it works at lower doses than pills and limits overall estrogen exposure.
• Vaginal DHEA (prasterone), a prescription insert.
• Ospemifene, a daily pill for painful sex caused by GSM.
• Systemic hormone therapy, usually considered when hot flashes are also a problem.

The Menopause Society notes there are not enough placebo controlled trials of laser and other energy based treatments to recommend them. It also notes that safety data for vaginal estrogen, DHEA and ospemifene in women with breast cancer are limited, so survivors should decide with their oncologist. Vaginal dilators can help when the canal has shortened or tightened; see vaginal dilators.

Daily habits that help.

Use plain water or an unscented wash on the vulva, skip douches and scented products, and choose cotton underwear. Give a new moisturizer a few weeks before judging it. Pelvic floor exercises help the leaking that can come with GSM; see best kegel weights. The longer version is how to treat vaginal dryness.

When to see a clinician.

Mayo Clinic advises an appointment for spotting or bleeding with no clear reason, unusual discharge, burning or soreness, and for painful sex that does not improve with a moisturizer or lube. Add urinary burning, urgency or repeated UTIs, which can look like GSM and need testing. Any bleeding after menopause needs a checkup. If you have had breast cancer, talk with your oncologist before starting any hormone based treatment. This page is general information, not medical advice.