Not Just Dryness

The short answer

The vagina, vulva, clitoris, urethra and bladder are neighbouring tissues with estrogen and androgen receptors, shared blood supply and overlapping nerves. When estrogen remains lower, these tissues can become thinner, less elastic and more easily irritated. Vaginal moisture and blood flow may decrease, the local bacterial environment can change, and urinary symptoms may appear.

This cluster is called genitourinary syndrome of menopause, or GSM. It is not limited to vaginal dryness, and unlike many hot flashes, it often persists or progresses without treatment.

Why the name matters

Older terms such as “vaginal atrophy” described only part of the experience and could sound dismissive. GSM recognizes that menopause-related change can involve:

• Vulvar or vaginal dryness, burning, itching and irritation.
• Reduced lubrication, pain with penetration or small tears and spotting.
• Changes in arousal, genital sensation or orgasm.
• Urinary urgency, frequency, burning or repeated urinary infections.
• Discomfort with sitting, exercise, wiping or tight clothing.

Not everyone has every symptom, and similar symptoms can come from infection, a vulvar skin disorder, pelvic-floor dysfunction, medication, diabetes, cancer treatment or another condition.

What lower estrogen changes

Before menopause, estrogen supports a thicker vaginal lining rich in glycogen. Glycogen helps support lactobacilli—the bacteria that usually help maintain an acidic vaginal environment.

When estrogen declines:

1. The lining can become thinner and more fragile.
2. Glycogen decreases.
3. Lactobacilli may become less dominant and vaginal pH may rise.
4. Blood flow, elasticity and natural lubrication can decrease.
5. Friction may cause burning, pain, small tears or spotting more easily.

The urethra and bladder outlet are also hormone-responsive. Tissue and microbiome changes may contribute to urgency, painful urination and vulnerability to recurrent urinary infection. Pelvic-floor muscle tension or weakness can occur at the same time, but it is a different problem and requires its own assessment.

Sex and desire are not one hormone level

Pain predictably reduces desire. Poor sleep, relationship context, body image, stress, medication, depression and general health also influence interest and arousal.

Testosterone plays a role in sexual function, but there is no single testosterone number that explains desire. An international consensus statement supports carefully monitored testosterone therapy for one specific indication—hypoactive sexual desire disorder in appropriately assessed postmenopausal women—not as a general treatment for fatigue, mood, cognition or every sexual concern. Canadian access and approved formulations remain limited, and testosterone is a controlled drug.

Why symptoms are often missed

Many people assume dryness and urinary change are inevitable or too embarrassing to mention. Clinicians may not ask. Symptoms may then be repeatedly treated as yeast or urinary infection without confirming the diagnosis.

A useful assessment may include the exact location and quality of discomfort, triggers, urinary symptoms, sexual pain, skin changes, medication, cancer history and pelvic-floor symptoms. Examination or testing may be needed when the cause is uncertain.

Treatment is matched to the problem

For mild symptoms, non-hormonal vaginal moisturizers used regularly and lubricants used for sexual activity may be enough. Persistent moderate or severe GSM may be treated with low-dose vaginal estrogen or other prescription options after an individualized discussion.

Low-dose vaginal estrogen is different from systemic menopausal hormone therapy: it is intended to act mainly in local tissue and generally produces much lower blood levels. Current guidelines do not require progesterone with standard low-dose vaginal estrogen, although unusual bleeding still requires assessment.

Pelvic-floor physiotherapy may help when muscle tension, pain, leakage or coordination problems contribute. Simply telling every woman to do Kegels can be unhelpful—and can worsen pain when the pelvic floor is already overactive.

Energy-based vaginal laser and radiofrequency treatments have been heavily marketed. Major position statements have found insufficient high-quality evidence to establish long-term safety and effectiveness. “Non-hormonal” does not automatically mean proven or risk-free.

When to seek medical care

Arrange an assessment for persistent vulvar or vaginal pain, itching, sores, skin-colour or texture change, bleeding after sex, recurrent urinary symptoms or blood in the urine. Any vaginal bleeding after menopause should be assessed rather than attributed to fragile tissue without evaluation.

Scientific references

1. The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 genitourinary syndrome of menopause position statement. Menopause. 2020.
2. Portman DJ, Gass MLS. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy. Menopause. 2014.
3. Christmas M, et al. Clinical practice guidelines for managing genitourinary symptoms associated with menopause. Clinical Obstetrics and Gynecology. 2024.
4. Kaufman MR, et al. The AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause. Journal of Urology. 2025.
5. Davis SR, et al. Global consensus position statement on the use of testosterone therapy for women. Journal of Clinical Endocrinology & Metabolism. 2019.
6. SOGC. Intravaginal laser for genitourinary syndrome of menopause and stress urinary incontinence. Journal of Obstetrics and Gynaecology Canada. 2018.