From Silence to Solutions: Updated GSM Guidelines You Need to Know
What would you do if someone told you there was a medication that reduced the incidence of urinary tract infections (UTIs) by 50%, was available as a generic (making it very affordable), had minimal side effects, and was safe for nearly everyone to use? Now, what if this same medication could also improve your sex life by decreasing painful sex and improving libido, arousal and orgasm? And how pissed off would you be if someone told you that this medication has been available for years, but no one has told you about it. Well, that’s exactly what’s been going on for millions of menopausal women around the world. It is estimated that 20-84% of menopausal women experience symptoms associated with genitourinary syndrome of menopause (GSM). GSM describes the spectrum of symptoms and physical changes resulting from declining estrogen and androgen concentrations in the genitourinary tract during menopausal transition. On 4/28/25, the American Urological Association (AUA), the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU), and the American Urogynecologic Society (AUGS) finally released their official guideline on genitourinary syndrome of menopause. This guideline is further endorsed by the International Society for the Study of Women’s Sexual Health (ISSWSH) and The Menopause Society (TMS), and discusses shared decision making, screening and diagnosis, hormonal and non-hormonal interventions, energy-based interventions, and supportive data related to breast and endometrial cancers. Many menopause specialists and sex positive providers are very excited about this official guideline. With evidence-based guidelines to treat GSM, it is our hope that the silence, stigma, and misconceptions about GSM and its’ treatments can finally be dispelled.
While I won’t go through each statement that is included in the guideline, I will touch on some of those that are most important.
Key Highlights of the Updated Guidelines
Shared Decision-Making: Healthcare providers are encouraged to engage in shared decision-making with patients, considering individual preferences and treatment goals when managing GSM.
Comprehensive Evaluation: A thorough history and physical examination are essential for diagnosing GSM. Providers should actively inquire about symptoms, as many patients may not spontaneously report them.
First-Line Hormonal Therapies: Providers should offer the option of low-dose vaginal estrogen, vaginal dehydroepiandrosterone (DHEA) or oral ospemifene to patients with GSM to improve vulvovaginal dryness and/or dyspareunia. Additionally, for people with GSM and comorbid genitourinary conditions or recurrent UTI’s, providers should offer low-dose vaginal estrogen to improve symptoms and reduce the risk for future UTI’s.
Non-Hormonal Interventions: Providers should recommend the use of vaginal moisturizers and/or lubricants either alone or in combination with other therapies and counsel patients that the evidence does not support the use of alternative supplements for treatment.
Energy-Based Interventions: Providers should counsel patients that the evidence does not support the use of CO2 laser, ER:YAG laser, or radiofrequency in the treatment of GSM, however in the context of shared decision making and with disclosure that these therapies are considered experimental, these may be considered.
Breast and Endometrial Cancer: Providers should inform patients of the absence of evidence linking local low-dose vaginal estrogen, DHEA, or ospemifene to the development or increased risk for breast cancer, endometrial hyperplasia with atypia, or endometrial cancer. Furthermore, endometrial surveillance should not be performed in patients with GSM solely due to their use of these medications.
Follow-up: Providers should reassess patients after initiation of treatment to monitor response, and counsel patients that long-term treatment and follow-up may be required to manage signs and symptoms.
Despite the potentially disruptive nature of GSM, only about half of individuals with GSM symptoms report discussing these symptoms with their healthcare provider, and of those who did, most said the provider did not initiate the conversation. I am a huge proponent of education, and patients often need to advocate for themselves. The strategies defined in this GSM guideline were derived from evidence-based and consensus-based processes. If your provider is not up to date on these current guidelines, respectfully show them the guidelines and demand shared decision-making.
Final Thoughts:
The updated AUA/SUFU/AUGS guidelines provide a comprehensive framework for the management of GSM, emphasizing individualized care, thorough evaluation, and patient education. By adhering to these guidelines, healthcare providers can improve the quality of life for women affected by GSM.
If you are experiencing symptoms associated with genitourinary syndrome of menopause (GSM) and need a provider that understands, book an appointment with me. I can offer medications, education, or referrals to help alleviate your symptoms and improve your quality of life. If you would like a copy of the guidelines, email me at email@doctorpattyj.com and I will send you a printable copy.