Key points

●      GSM covers the labia, clitoris, vestibule, vagina, introitus, urethra and bladder.

●      Diagnosis is clinical. No laboratory test confirms it.

●      Five partly independent tissue systems change, at different rates in different women.

●      The consensus definition does not include loss of desire.

This review contains a proposed 5-axis framework, part of a peer-reviewed paper under revision at Oxford Academic. 

Where did the term come from?

The term was introduced in 2014 by a consensus panel of the International Society for the Study of Women's Sexual Health and the North American Menopause Society, replacing "vulvovaginal atrophy."[1]

The older term had two problems. It described tissue as withered — a word women reasonably disliked hearing about their own bodies. And it named two structures when the changes involve a third.

What does GSM include?

GSM covers changes to the labia, clitoris, vestibule, vagina, introitus, urethra and bladder, and lists among its symptoms dryness, burning, irritation, impaired lubrication, discomfort or pain with sexual activity, urgency, dysuria, and recurrent urinary tract infections.[1]

The urinary component was not appended for completeness. It was recognised as part of the same biology — which is why women with urinary symptoms and negative cultures are often experiencing something real that no urine test will find. → When Midlife Changes Feel Like a UTI

How is GSM diagnosed?

Clinically, from history and examination. No laboratory study confirms it, and routine testing has no diagnostic role except to exclude other conditions.[2]

This is why normal hormone results do not rule GSM out — a point worth carrying into an appointment.

What are the limits of the term?

GSM names a cluster of symptoms, not a mechanism. Two women can both meet criteria with entirely different underlying tissue changes.

It also omits desire. The consensus definition covers dryness, pain and urinary symptoms but not loss of desire, which many women experience alongside them and which has its own tissue-level contributors.[1] That is a genuine gap in the clinical framing. → DHEA and Libido

What changes at tissue level?

Five partly independent tissue systems change. They shift at different rates, in different orders, in different women.

Why does the same diagnosis feel so different?

Because the axis that is limiting differs between women, and that determines which interventions help.

A woman with intact vascular response and a thinned epithelium notices fragility and irritation. A woman with intact epithelium and reduced perfusion notices that arousal no longer produces the response it used to. Both have GSM. Neither has the same problem.

It also explains the commonest frustration in midlife care: a treatment addressing one axis produces partial improvement and stops. → Why Estrogen Isn't Enough

The mechanisms producing vaginal dryness are examined separately in What Causes Vaginal Dryness After Menopause?

Does GSM improve on its own?

GSM is generally considered a chronic condition. Without effective management, symptoms often persist and may worsen, although their intensity can fluctuate over time.

Surveys of postmenopausal women consistently find substantial impact on comfort, intimacy and quality of life alongside low rates of discussion with clinicians.[7] Appointments are short, the symptoms are private, and many women were told this is simply what aging is.

It isn't. It is a set of tissue changes with identifiable mechanisms.

Where should I start?

Educational note: For educational purposes only; not intended to diagnose, treat, cure or prevent any medical condition. Persistent or new symptoms should be evaluated by a qualified healthcare provider.

By Laura Kelly, DAOM, L.Ac., Dipl. O.M. A California-licensed primary care provider and nationally board-certified clinician with a clinical focus on women’s health and healthy aging. Research Scholar, Ronin Institute. ORCID: 0000-0001-6586-7308.  More about Dr. Kelly

References

1.   Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy. Menopause. 2014;21(10):1063–1068. doi:10.1097/GME.0000000000000329

2.   The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976–992. doi:10.1097/GME.0000000000001609

3.   Traish AM, Vignozzi L, Simon JA, Goldstein I, Kim NN. Role of androgens in female genitourinary tissue structure and function. Sex Med Rev. 2018;6(4):558–571. doi:10.1016/j.sxmr.2018.03.005

4.   Labrie F. Intracrinology and menopause. Menopause. 2019;26(2):220–224. doi:10.1097/GME.0000000000001177

5.   Cellai I, Di Stasi V, Comeglio P, et al. Insight on the intracrinology of menopause. Endocrinology. 2021;162(2):bqaa219. doi:10.1210/endocr/bqaa219

6.   Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. 1993;329(11):753–756. doi:10.1056/NEJM199309093291102

7.   Parish SJ, Nappi RE, Krychman ML, et al. Impact of vulvovaginal health on postmenopausal women. Int J Womens Health. 2013;5:437–447. doi:10.2147/IJWH.S44579