Vaginal Dryness & Painful Sex After Menopause: GSM

“Sex has become painful. I have started avoiding it. I feel embarrassed even bringing this up, like it is something I just have to live with now.”

If you have thought some version of this, please hear this clearly: you do not have to live with it, and you are far from alone.

Vaginal dryness, burning, irritation, and pain with intercourse are among the most common symptoms of the menopause transition. Yet they are also among the least discussed. In fact, many women never mention them to a provider at all, often out of embarrassment or the mistaken belief that nothing can be done.

However, something can be done. This is a well-understood, well-researched condition with a name and a range of evidence-based treatment options. And understanding what is actually happening is the first step toward finding relief.

This article builds on our related overview of why menopause symptoms happen by going deeper into one of the most undertreated areas of menopause care.

What is happening?

The condition behind these symptoms is called genitourinary syndrome of menopause, or GSM. Providers use this term to describe a collection of symptoms that develop from declining estrogen’s effect on the vaginal, vulvar, and urinary tissues.

Here is what that means in plain language.

Specifically, estrogen plays an important role in maintaining the thickness, elasticity, lubrication, and blood flow of vaginal tissue. It also supports the health of the urinary tract lining. As estrogen declines during perimenopause and menopause, these tissues can become thinner, drier, and less elastic.

As a result, those tissue-level changes can lead to a range of symptoms, including:

Vaginal dryness
Burning or irritation
Pain with intercourse (medically called dyspareunia)
Decreased lubrication during sexual activity
Urinary urgency or frequency
Recurrent urinary tract infections (UTIs)
A general sense of vaginal or vulvar discomfort

The International Society for the Study of Women’s Sexual Health and The Menopause Society introduced the term GSM in 2014 to replace the older term “vulvovaginal atrophy.” This updated name matters because it reflects the full scope of the condition, including urinary symptoms that many women do not realize are connected.

Pain, dryness, and low libido are not the same thing

That said, pain, dryness, and low libido are distinct experiences, though they can certainly overlap. GSM is a physical, tissue-level condition. By contrast, changes in sexual desire can have separate hormonal, psychological, and relational contributors. Understanding which one you are experiencing matters, because the right approach may be different for each. We explore this distinction further in our related content on [the difference between pain, dryness, and low libido].

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Why this happens during midlife

GSM is driven primarily by declining estrogen. However, several factors can influence its severity and how you experience it.

Hormones. Estrogen decline is the primary driver of GSM. Unlike hot flashes, which for many women improve over time, GSM symptoms often persist or even progress without treatment. This is because the underlying tissue changes tend to continue as estrogen remains low. Research suggests GSM symptoms affect approximately 45% to 77% of postmenopausal women, and they generally worsen over time without intervention.

Aging physiology. Vaginal and urinary tissues, like skin elsewhere in the body, undergo some degree of change with age generally. Consequently, these age-related changes can compound the estrogen-related effects.

How sleep, stress, and lifestyle contribute

Sleep and stress. While not direct causes of GSM, poor sleep and chronic stress can affect overall well-being, comfort, and interest in intimacy. For this reason, they may compound the experience of these symptoms even when the underlying tissue changes are the primary driver.

Nutrition and lifestyle. In addition, hydration, certain medications (including some antihistamines and blood pressure medications), and smoking can all influence vaginal dryness and tissue health to varying degrees.

Medical contributors. Certain medical treatments, including some breast cancer treatments, aromatase inhibitors, and other medications that lower estrogen, can cause or worsen GSM symptoms. Because treatment options may differ depending on your medical history, these are worth discussing directly with your care team.

The recurrent UTI connection

This one deserves particular attention. Because declining estrogen thins the urinary tract lining and can alter the vaginal microbiome by reducing protective Lactobacillus species, postmenopausal women are more likely to experience recurrent UTIs than they were earlier in life. Unfortunately, this connection is often missed when recurrent UTIs are treated repeatedly with antibiotics alone, without addressing the underlying tissue changes. Notably, the 2025 AUA/SUFU/AUGS guideline on GSM specifically recommends local low-dose vaginal estrogen to reduce the risk of future urinary tract infections in women with GSM and recurrent UTIs.

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What does the evidence show?

Research indicates that GSM affects a substantial proportion of postmenopausal women, yet it remains significantly underreported and undertreated. In part, this is because many women do not realize it is a recognized medical condition. Additionally, many providers do not routinely ask about it.

A 2023 JAMA review noted that GSM symptoms affect approximately 45% to 77% of women, generally worsen over time, and may persist indefinitely. Unlike vasomotor symptoms, which tend to improve for many women over years, GSM often does not resolve on its own.

Importantly, the evidence for treatment is genuinely reassuring.

Vaginal estrogen

Vaginal estrogen is supported by strong evidence as an effective treatment for GSM symptoms. For example, a 2023 JAMA review reported that low-dose vaginal estrogen is associated with subjective improvement in GSM symptom severity by approximately 60% to 80%. Because vaginal estrogen acts locally with minimal systemic absorption, research indicates it carries a different, generally more favorable safety profile compared to systemic hormone therapy.

Is vaginal estrogen safe without a progestogen?

This is one of the most common questions in GSM care. The short answer: the evidence is reassuring.

Low-dose vaginal estrogen acts locally, with minimal absorption into the rest of the body. That means its safety profile is meaningfully different from systemic hormone therapy.

Generally, a progestogen is not needed. The WHI Observational Study followed over 45,000 women for a median of 7.2 years and found no increased risk of endometrial cancer with vaginal estrogen use. Similarly, a 2019 systematic review of 38 studies reached the same conclusion. More recently, a 2026 cohort study confirmed that endometrial cancer rates among vaginal estrogen users were comparable to women using estrogen-plus-progestogen therapy.

The 2025 AUA/SUFU/AUGS guideline puts it directly: clinicians should counsel patients that local low-dose vaginal estrogen does not increase endometrial risk.

No long-term randomized trials have studied endometrial cancer as a primary outcome with vaginal estrogen. But the available data, extending beyond seven years, is consistently reassuring. Regardless of treatment, any postmenopausal bleeding should always be evaluated.

Non-estrogen prescription options

Vaginal DHEA (prasterone) is a non-estrogen hormonal option that converts to active hormones locally within vaginal tissue. According to a 2023 JAMA review, it is associated with improvement in GSM symptom severity by approximately 40% to 80%. The FDA approved it specifically for severe dyspareunia (pain with intercourse) due to menopause, and some research suggests it may improve sexual function more than low-dose vaginal estrogen alone.

Ospemifene is an oral selective estrogen receptor modulator (SERM) that the FDA approved for the treatment of moderate to severe dyspareunia and vaginal dryness due to menopause. Based on a 2023 JAMA review, it is associated with improvement in GSM symptom severity by approximately 30% to 50%. Notably, it is the only oral (non-vaginal) prescription treatment specifically approved for GSM, which some women may prefer. The most common side effect is an increase in hot flashes, which tends to diminish after the first month.

Non-hormonal options

Vaginal moisturizers and lubricants are supported by evidence as helpful for symptom relief. For instance, a 2024 systematic review in the Annals of Internal Medicine found that vaginal moisturizers may improve dryness compared with placebo. That said, moisturizers and lubricants generally address symptoms rather than the underlying tissue changes the way hormonal treatments can.

For women who prefer non-hormonal approaches or who are not candidates for hormonal treatment, these remain a reasonable starting point. Furthermore, they can also be used alongside hormonal treatments for additional comfort.

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Myth vs. fact: what women are often told about vaginal dryness

Myth: Vaginal dryness is just a normal part of aging that you have to accept.

Fact: GSM is a recognized medical condition with effective, evidence-based treatments. While the tissue changes are related to declining estrogen, the symptoms are treatable, not inevitable.

Myth: Vaginal estrogen is the same as systemic hormone therapy and carries the same risks.

Fact: Low-dose vaginal estrogen acts locally with minimal systemic absorption. As a result, its safety profile differs meaningfully from oral or transdermal systemic hormone therapy.

Myth: You need to take a progestogen if you use vaginal estrogen.

Fact: Low-dose vaginal estrogen acts locally and has not been linked to increased endometrial risk in studies extending beyond seven years. Accordingly, the 2025 AUA/SUFU/AUGS guideline states that a progestogen is generally not needed.

More common misconceptions

Myth: Pain with sex and low libido are the same thing.

Fact: They are distinct experiences with potentially different causes. GSM is a physical, tissue-level condition, while changes in desire can have separate hormonal, psychological, and relational contributors. For this reason, the right approach may differ for each.

Myth: Recurrent UTIs after menopause are just bad luck.

Fact: Declining estrogen thins the urinary tract lining and alters the vaginal microbiome, which increases susceptibility to UTIs. Therefore, addressing the underlying tissue changes with vaginal estrogen may reduce recurrence.

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What women should know

These are the key takeaways worth remembering:

– GSM is a common, recognized medical condition, not a sign that something is wrong with you, and not something you have to simply accept.

– Unlike some menopause symptoms, GSM often does not improve on its own over time without treatment. In fact, it tends to progress.

– Pain with sex, dryness, and low libido are distinct experiences that may have different causes and may need different approaches.

When it comes to getting help

– Recurrent UTIs after menopause may be connected to GSM, not just unrelated infections. For this reason, it is worth mentioning them to your provider.

– You do not need to wait until symptoms are severe. Similarly, you do not need to feel embarrassed bringing this up. This is a routine, common topic in women’s health.

– Treatment is personalized. There is no single right answer for every woman, which is exactly why an individualized evaluation matters.

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What can help?

Treatment for GSM is not one-size-fits-all. You can use these options alone or in combination depending on your symptoms, preferences, and health history.

Vaginal moisturizers. Used regularly (not just around sexual activity), these can help maintain tissue hydration and comfort day to day. As a result, they are a reasonable starting point for many women, including those who prefer to avoid hormonal treatment. Think of them like a daily moisturizer for your skin, applied to vaginal tissue instead.

Lubricants. Used at the time of sexual activity specifically to reduce friction and discomfort. Because lubricants address the moment rather than the underlying tissue changes, they are often used alongside other treatments rather than as a stand-alone solution for significant symptoms.

Prescription treatment options

Vaginal estrogen. Available as a cream, tablet, ring, or insert, low-dose vaginal estrogen directly addresses the tissue changes underlying GSM. It is supported by strong evidence for symptom improvement, with a localized safety profile that differs meaningfully from systemic hormone therapy. Multiple formulations exist, and the right one depends on your preference and comfort.

Vaginal DHEA (prasterone). This non-estrogen hormonal option, available as a vaginal insert, was approved by the FDA for pain with intercourse due to menopause. It may be appropriate for women seeking an alternative to estrogen-based treatment, or for those who want a hormonal option that works through a different mechanism.

Ospemifene. This oral medication (taken by mouth, not vaginally) was approved by the FDA for moderate to severe vaginal dryness and pain with intercourse due to menopause. It may be a good option for women who prefer not to use a vaginal product. However, the most common side effect is an increase in hot flashes early in treatment, which tends to improve.

Other approaches worth discussing

Pelvic floor physical therapy. When pelvic floor tension, guarding, or pain contributes to discomfort with intercourse, pelvic floor physical therapy can be an important part of treatment. Specifically, ACOG notes that women with dyspareunia due to pelvic floor dysfunction may benefit from pelvic floor physical therapy, which can include internal soft-tissue work, biofeedback, and home exercises. Providers often recommend this alongside other GSM treatments rather than as a replacement.

Systemic hormone therapy. If you have other menopause symptoms alongside GSM, such as hot flashes, night sweats, or mood changes, systemic hormone therapy may address multiple symptoms at once. That said, some women on systemic hormones still need additional vaginal therapy for GSM symptoms specifically. We discuss this in more depth in our related article on menopause hormone therapy.

Whichever path makes sense for you, the underlying message is the same: effective, evidence-based options exist. You do not have to choose between suffering in silence and settling for a treatment that does not fit your needs or preferences.

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When should someone seek evaluation?

While GSM is a reasonable topic to raise with any provider, certain situations make an evaluation especially worthwhile:

– Persistent vaginal dryness, burning, or irritation that affects daily comfort

– Pain with intercourse that has developed or worsened over time

– Recurrent urinary tract infections, especially if they have increased in frequency around the menopause transition

– New or unusual vaginal bleeding, discharge, or lesions, which should always be evaluated to rule out other causes

– Uncertainty about whether vaginal estrogen or other hormonal treatments are safe for you, particularly if you have a personal history of hormone-sensitive conditions

– Simply wanting a clearer explanation of what is happening and what your options are

In other words, none of these symptoms need to reach a breaking point before they are worth discussing. Many women wait years before raising this topic. That is time you do not have to spend uncomfortable or avoiding intimacy.

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Frequently asked questions about vaginal dryness and GSM

Is vaginal dryness a normal part of menopause?

Vaginal dryness is common during and after menopause, but “common” does not mean you have to accept it. GSM is a recognized medical condition with effective treatments. Because the tissue changes are related to declining estrogen, they are treatable rather than inevitable.

What is the difference between GSM and vulvovaginal atrophy?

They describe the same condition. GSM is the updated term, introduced in 2014, because it better captures the full range of symptoms, including urinary symptoms like urgency and recurrent UTIs, not just vaginal changes.

Is vaginal estrogen safe?

Low-dose vaginal estrogen acts locally with minimal absorption into the body. Consequently, its safety profile differs from systemic hormone therapy. Observational data extending beyond seven years, including the WHI study of over 45,000 women, has not shown increased endometrial risk. The 2025 AUA/SUFU/AUGS guideline recommends counseling patients that it does not increase endometrial risk. Generally, a progestogen is not needed. If you have a history of hormone-sensitive cancer, however, decisions should involve your oncologist.

Can I use vaginal estrogen if I am on systemic hormone therapy?

Yes. Some women on systemic hormone therapy still need additional vaginal estrogen for GSM symptoms specifically. In fact, this is a common and well-recognized approach.

What is vaginal DHEA, and how is it different from vaginal estrogen?

Vaginal DHEA (prasterone) is a non-estrogen hormonal option that converts to active hormones locally within vaginal tissue. The FDA approved it for pain with intercourse due to menopause, and it works through a different mechanism than vaginal estrogen.

Looking at the whole picture

GSM is a real, common, treatable condition. It is not an inevitable or untreatable part of aging.

A thoughtful evaluation considers your specific symptoms, your health history, your preferences around hormonal versus non-hormonal treatment, and how these symptoms are affecting your daily life and relationships. From there, it builds a plan around all of it together.

You do not have to accept vaginal dryness, discomfort, or pain with intimacy as simply part of this life stage.

If these symptoms sound familiar, book a consultation to talk through what is happening and what may help.

(Telehealth appointments are currently available for patients located in Arizona and New York.)

Schedule a Consultation

This information is educational and not a substitute for personalized medical care.

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