Medically reviewed by
Betsy Greenleaf, DO
Board-Certified OB/GYN & Urogynecologist; Empire Director of Anti-Aging Vaginal dryness is not a cosmetic complaint or an inevitable part of aging that patients must simply accept. It is the most visible symptom of a well-defined, treatable medical condition: genitourinary syndrome of menopause (GSM). For clinicians, the challenge is rarely that effective treatments do not exist — they do, and several are highly effective. The challenge is that the condition is underreported, underdiagnosed, and often left out of routine visits because both patients and providers find it awkward to raise.
This guide situates vaginal dryness within the broader field of sexual health and dysfunction and is written for clinicians who want an accurate, practical overview. It is clinical education, not medical advice, and nothing here should be read as a treatment recommendation, protocol, or substitute for current product labeling and individualized judgment.
What is GSM?
As Dr. Betsy Greenleaf teaches in Empire's sexual dysfunction curriculum, what was historically called atrophic vaginitis — the drying, thinning, and inflammation of the vaginal walls — is now more accurately described as genitourinary syndrome of menopause. The terminology changed for a clinically meaningful reason: the older labels described only the vagina, but the same estrogen loss that thins vaginal tissue also affects the urethra, bladder, and surrounding urinary structures. GSM names the whole picture.
The hallmark of GSM is that it presents as a constellation, not a single symptom. Patients may describe any combination of the following, and the mix varies from one woman to the next:
- Vaginal dryness — the most commonly reported symptom, ranging from mild to severe.
- Irritation, itching, and burning of the vulvar and vaginal tissue.
- Dyspareunia — pain during intercourse, driven by thinned, less elastic, less lubricated tissue.
- Urinary symptoms — urgency, frequency, discomfort, and a tendency toward recurrent urinary tract infections.
This is genuinely common. Across studies, the prevalence of vaginal dryness in postmenopausal women has been reported anywhere from roughly 20% to over 90%, climbing with each advancing stage of menopause. Notably, even among women with no prior diagnosis of vaginal atrophy, the great majority report genital symptoms when actually asked — a reminder that the condition is frequently present but rarely volunteered.
Why GSM happens
The primary driver of GSM is straightforward: a decline in estrogen production. Estrogen maintains the thickness, elasticity, blood flow, and natural lubrication of vaginal and vulvar tissue, and it supports the healthy, slightly acidic vaginal environment that protects against infection. When estrogen falls, the tissue thins, loses its moisture, becomes more fragile, and is more easily irritated.
The most common setting for that decline is menopause, when the ovaries stop producing estrogen. But it is not the only setting. Estrogen also drops during the perimenopausal years leading up to menopause, in younger women who are breastfeeding, and as a result of medical interventions — including cancer treatment such as chemotherapy or pelvic radiation, and anti-estrogen medications like tamoxifen. Conditions such as diabetes and Sjögren's disease can contribute as well. Recognizing these alternative causes matters, because a 30-something woman with dryness after cancer therapy needs the same physiologic understanding as a 60-something woman years past menopause.
Because GSM is fundamentally a hormonal phenomenon, it connects directly to the wider conversation about menopausal hormone management. Providers who want to understand the systemic side of estrogen loss should review the companion material on estrogen replacement therapy and bioidentical hormone therapy for women in the hormone cluster. Local genitourinary treatment and systemic hormone therapy are distinct decisions, but they share the same underlying biology.
Symptoms and impact
The downstream effect of GSM reaches well beyond physical discomfort. Painful intercourse can lead to avoidance, which strains intimacy and relationships; chronic irritation affects daily comfort; and recurrent urinary tract infections create a cycle of antibiotics and anxiety. In Dr. Greenleaf's framing of sexual health more broadly, the brain and the relationship are central — and unaddressed physical discomfort feeds directly into reduced desire and arousal, so a tissue problem becomes a whole-experience problem.
Unlike hot flashes, which tend to fade over time, GSM is progressive when untreated: the tissue does not spontaneously recover because the estrogen that maintained it is gone. This is an important counseling point. Patients often assume dryness will pass on its own; in reality it typically persists or worsens, which is exactly why identifying and treating it carries lasting value rather than offering only temporary relief.
The clinical takeaway is to ask the question. Because patients so rarely raise these symptoms unprompted — out of embarrassment or the belief that nothing can be done — a brief, matter-of-fact inquiry during relevant visits surfaces a condition that responds well to treatment.
Evaluation
Evaluation begins, as with all sexual health concerns, by building rapport and creating a comfortable, non-judgmental environment with assurance of confidentiality — a foundation Dr. Greenleaf emphasizes throughout the course because patients will not disclose what they do not feel safe disclosing. A focused history characterizes the symptoms: onset, duration, severity, what aggravates or relieves them, and the impact on comfort, urinary function, and intimacy.
A focused pelvic examination is central. Estrogen-deficient tissue has a characteristic appearance — pale, thin, smooth, and less elastic — and the exam helps confirm GSM while screening for other causes of vulvovaginal symptoms such as infection or dermatologic conditions. The clinician also evaluates for tenderness and for signs that point toward overlapping diagnoses, since dryness, pain, and urinary symptoms are not always a single problem.
Crucially, GSM should not be diagnosed in isolation. Dr. Greenleaf's consistent message is to take a whole-body approach and look for contributors outside the pelvis — medications, systemic conditions, and the patient's overall hormonal status. Laboratory testing is directed by the clinical picture rather than ordered reflexively. The specific examination technique and the structured intake she uses are taught in depth in Empire's course.
Treatment options
GSM treatment is best understood as a ladder, matched to symptom severity, patient history, and preference. The science behind each rung is summarized below; the specific product selection, dosing, and how to sequence these options for an individual patient are taught in Empire's training.
Vaginal moisturizers and lubricants
The first and least invasive layer is non-hormonal. Lubricants reduce friction during intercourse and are used at the time of activity. Vaginal moisturizers — typically containing ingredients such as hyaluronic acid, which retains moisture — are applied on a regular schedule (often every few days) to maintain hydration rather than just at the moment of need. Two product characteristics matter clinically: pH and osmolality. The healthy vaginal pH is roughly 3.5 to 4.5, and the World Health Organization advises choosing products within or near that range and with osmolality at or below 1200 (ideally lower), because high-osmolality products can draw water out of vaginal cells and worsen irritation. For mild dryness, this layer alone can be enough.
Local vaginal estrogen — the mainstay
For moderate to severe GSM, local vaginal estrogen is the mainstay of treatment. It is available as creams, tablets, and rings, and it works by restoring the vaginal mucosa directly — rebuilding tissue thickness, elasticity, and lubrication at the source. Its defining advantage is the favorable systemic profile: because it is delivered locally at low doses, far less estrogen enters the bloodstream than with oral or transdermal therapy, which is why it can relieve dryness, irritation, and painful intercourse, and reduce recurrent urinary tract infections, with comparatively low systemic exposure. Considerations include local irritation from some formulations, attention to prolonged use, and caution in women with a history of estrogen-sensitive cancer, where the decision is individualized in coordination with the patient's broader care. Specific formulations, starting and maintenance dosing, and patient selection are covered in the course.
DHEA
Vaginal DHEA is a further option that works locally to improve the symptoms of atrophy — dryness, irritation, and painful intercourse — and has shown benefit across domains of sexual function. Because it is converted to hormones within the tissue, it can raise local DHEA and testosterone activity while keeping circulating levels within the normal postmenopausal range at appropriate doses, limiting systemic effect. It is a useful alternative for patients who prefer or require a non-estrogen approach.
The O-Shot and PRP
Regenerative approaches use platelet-rich plasma (PRP) — a concentrate from the patient's own blood, rich in growth factors — injected into vulvovaginal and clitoral tissue to stimulate the body's own healing and collagen production. Placed in a specific anterior-wall location, this is the basis of what is popularly marketed as the O-Shot. Evidence honesty matters here: PRP for genitourinary and sexual concerns is still emerging, with small studies, heterogeneous protocols, and long-term efficacy that remains under evaluation. It is a legitimate area of interest, particularly for menopausal women with atrophy, but it should be presented to patients as developing rather than established. The science and technique are detailed in our overview of PRP for sexual health.
Energy-based devices
A range of energy-based devices — vaginal laser, radiofrequency, and red-light therapy — aim to stimulate collagen and improve tissue quality. They are worth discussing honestly: the proposed mechanisms are plausible, many patients report satisfaction, and the procedures are generally low-downtime, but robust long-term efficacy and safety data are limited, and the FDA has previously raised concerns about marketing claims made for some of these devices for vaginal “rejuvenation.” The responsible framing for patients is cautious optimism grounded in the current evidence, not overstatement.
The hormone connection
GSM sits at the intersection of sexual health and endocrinology, and treating it well means understanding that intersection. As Dr. Greenleaf reminds clinicians, hormones are a tool, not the answer — vaginal estrogen can restore the tissue beautifully, but if a patient's broader picture involves unaddressed stress, relationship strain, or the natural shift in desire that accompanies long-term relationships and aging, the tissue fix alone will not resolve the whole experience. Local genitourinary therapy and the brain-and-relationship side of sexual response work together, not in isolation.
This is why GSM connects naturally to the larger discussion of hormones and sexual function, and to systemic menopausal management through estrogen replacement therapy. A clinician comfortable with both the local and systemic levers — and clear on which problem each one solves — is positioned to actually resolve a complaint that too often gets a dismissive answer.
Treat menopausal sexual health with confidence
Empire Medical Training's Sexual Dysfunction Training, developed by board-certified OB/GYN and urogynecologist Dr. Betsy Greenleaf, teaches the evaluation and treatment of GSM and the full range of female and male sexual health concerns — including local vaginal estrogen, DHEA, PRP, and how to add these services responsibly to your practice. CME-accredited and available in person and via livestream.
Enroll in the Sexual Dysfunction Training →Training to treat GSM
For a provider, GSM is an unusually high-value clinical opportunity: the condition is extremely common, frequently undertreated, and responds well to interventions that range from simple counseling to in-office procedures. Treating it competently requires understanding menopausal physiology, performing a focused evaluation, knowing how to choose among moisturizers, lubricants, local vaginal estrogen, DHEA, and the emerging regenerative options — and, just as importantly, how to raise and discuss these topics in a way that puts patients at ease.
Empire's curriculum is built around exactly this kind of practical, respectful, evidence-honest judgment, taught by a physician who pioneered female sexual medicine and directs Empire's anti-aging education. The course connects GSM to the broader sexual health field and to the hormone and regenerative skills that support it.
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