Update on the Management of Genitourinary Syndrome of Menopause

Dr. Colleen Stockdale presented information that dermatologists should know about genitourinary syndrome of menopause (GSM), including epidemiology, clinical presentation, differential diagnosis, and treatment options. GSM is an umbrella term describing the signs and symptoms of the female genitourinary tract caused by estrogen deficiency; it includes what was formerly called vaginal atrophy and atrophic vaginitis. Dermatologists may encounter GSM in their patients, especially if they ask about vulvovaginal symptoms.

Colleen Stockdale, MD, MS, clinical professor of obstetrics and gynecology at the University of Iowa

First, Stockdale discussed the prevalence and epidemiology of GSM. An estimated 84% of postmenopausal women experience GSM symptoms; 25% of those who use systemic hormone therapy will experience urogenital atrophy despite improvement in other menopausal symptoms. GSM can occur in younger women who are estrogen deficient, including those who are postpartum and lactating, receiving estrogen-depleting therapy for breast cancer, or receiving anti-estrogen acne treatment. Vaginal dryness and irritation occur in 2–3% of premenopausal women and 50% of women in early menopause. Unlike vasomotor symptoms of menopause, which generally improve with time, GSM progressively worsens without treatment.

Second, Stockdale described the clinical presentation of GSM. GSM signs and symptoms include vulvovaginal irritation, soreness, dryness, and lower urinary tract problems. Patients typically complain of vaginal dryness, burning, and painful sex. Diagnostic features include diminished vaginal rugae; vaginal tissue thinning; introitus narrowing; mucosal defects including petechiae, micro-fissures, and inflammation; diminished vaginal maturation index; and increased vaginal pH (>5.0).

Third, Stockdale discussed GSM diagnosis and treatment. The differential diagnosis of GSM includes yeast infection, contact irritant, vaginosis/vaginitis, including desquamative inflammatory vaginitis, lichen planus, and lichen sclerosis. GSM is not mutually exclusive to other skin conditions treated by dermatologists. Stockdale urged dermatologists to consider GSM in patients with lichen planus who complain of vaginal dryness or burning and those with yeast infection symptoms who do not improve with antifungal treatment.

The American Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, and the American Urogynecologic Society released updated guidelines for GSM treatment in 2025. The guidelines emphasize shared decision-making with a patient-centered, step-wise approach. The primary management goal is symptom relief. In mild-to-moderate cases, consider nonhormonal lubricants and topical barrier creams. Iso-osmolar and silicone-based lubricants are better than water-based gels because they cause less irritation. Patients should avoid irritants and allergens, including propylene glycol, parabens, lanolin, and formaldehyde (found in toilet paper).

In severe cases, vaginal estrogen therapy is the gold standard treatment. Stockdale emphasized that vaginal estrogen therapy is safe and effective. The FDA removed the Black Box Warning from all estrogen formulations in November 2025. Use of low-dose vaginal estrogens does not result in sustained serum estrogen levels exceeding the normal menopausal range. There is no increased risk of venous thromboembolism, endometrial proliferation, or hyperplasia with local estrogen therapy. Small studies showed no increased risk of breast cancer with local estrogen therapy and no breast cancer recurrence in patients on tamoxifen or aromatase inhibitors. Additional progesterone is not needed.

Vaginal estrogen therapy options include:

• Estradiol vaginal ring: worn in the vagina and changed every 3 months
• Estradiol vaginal insert: tablet or softgel inserted into the vagina 2–3 nights/week. The treatment goes to the top of the vagina and may miss the vestibule and vulva. For more severe cases, Stockdale recommends estrogen cream over inserts.
• Estradiol or conjugated estrogen creams: applied to the vagina and vestibule 2–3 times/week. The tube comes with several applicators that patients must wash after each use. The instructions say to use the whole tube but that is unnecessary. Stockdale recommends applying a toothpaste-sized amount with a finger.

If vaginal estrogen therapy is contraindicated, other treatment options include dehydroepiandrosterone (DHEA) and ospemifene. DHEA is a daily vaginal insert that can be used in patients who do not want estrogen therapy. Ospemifene is a daily pill that Stockdale prescribes to patients who struggle with vaginal insertion. It is contraindicated with fluconazole and not covered by insurance.

Finally, Stockdale emphasized that dermatologists could treat patients with GSM symptoms. Patients with postmenopausal bleeding should be referred to their gynecologist or primary care physician for evaluation. Laser treatment has not been evaluated or recommended by any medical society and should be avoided. Patients should be treated for as long as symptoms last.

Mark your calendar: The DF Clinical Symposium returns January 27–31, 2027.