Understanding the 2025 AUA Guidelines on Genitourinary Syndrome of Menopause (GSM): What midlife women need to know

Navigating the menopausal transition can bring about various changes, some of which may affect your quality of life. One such condition is Genitourinary Syndrome of Menopause (GSM), a collection of symptoms resulting from decreased estrogen and androgen levels affecting the genitourinary tract. Recognizing the impact of GSM, the American Urological Association (AUA) in collaboration with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) and the American Urogynecologic Society (AUGS), released comprehensive guidelines in April 2025 to outline the most effective management of GSM. 

What is Genitourinary Syndrome of Menopause (GSM)?

GSM encompasses a range of symptoms affecting the genital and urinary systems due to hormonal changes during menopause. Common symptoms include:

• vaginal dryness and irritation
• pain during intercourse (dyspareunia)
• urinary urgency and frequency
• recurrent urinary tract infections
• decreased lubrication and sexual discomfort

These symptoms can significantly impact daily activities, sexual health, and overall wellbeing.

Highlights from the 2025 AUA GSM Guidelines

The updated guidelines provide a structured approach to the diagnosis and management of GSM:

1. Symptom-Based Diagnosis

Medical clinicians are encouraged to diagnose GSM based on patient-reported symptoms rather than relying solely on physical signs or hormone levels. This approach acknowledges the variability of GSM manifestations and emphasizes the importance of patient experiences. 

2. Shared Decision-Making

A cornerstone of the guidelines is the emphasis on shared decision-making. Clinicians should collaborate with patients, considering their preferences, values and treatment goals to develop individualized care plans. I love this principle of working with the patient. In many guidelines, it is rare that your input matters so in my opinion, this is very progressive!

3. Treatment Options

• Local Low Dose Vaginal Estrogen: Recommended as the first-line therapy for GSM symptoms such as vaginal dryness and dyspareunia. It have a very favourable safety profile and is effective in symptom relief. This is huge for all women to know as historically, the use of menopause hormone therapy (MHT) was jaded by the poor interpretation and media of the very large Women's Health Initiative study. 
• Non-hormonal Therapies: Vulvo-vaginal moisturizers and lubricants can be used alone or alongside hormonal treatments to alleviate symptoms. So for you ladies out there who can't used MHT or would like to try the non-hormonal route of treatment prior to trying hormones, this is KEY! Check out some of the lubricants and moisturizers in our store.
• Alternative Hormonal Options: Vaginal dehydroepiandrosterone (DHEA) and oral ospemifene are additional options, particularly for those who cannot use estrogen therapies. 
• Energy Based Therapies: The AUA guidelines advise caution with treatments like CO2 lasers (eg. MonaLisa laser), as current evidence does not support their efficacy in GSM management.

4. Safety Considerations

To mitigate false information being spread online, the guidelines clearly state that local low-dose vaginal estrogen does not increase the risk of breast or endometrial cancer. This helps to alleviate many concerns that women have considering this therapy. 

5. Ongoing Management

GSM is a chronic condition so regular follow-ups are essential to assess treatment efficacy and make necessary adjustments as required.

The Role of Pelvic Floor Physiotherapy in Managing GSM

Pelvic floor physiotherapy plays a vital role in the non-hormonal management of GSM symptoms. Specialized physiotherapists can help with:

• Strengthening Pelvic Floor Muscles: Improving muscle tone, strength and endurance can alleviate urinary symptoms and enhance sexual function
• Enhancing Blood Flow and Tissue Health: Manual techniques and other modalities can help increase circulation and improve vaginal tissue elasticity and lubrication
• Education and Empowerment: Providing you with knowledge and exercises to manage symptoms effectively is vital since ongoing maintenance and management of GSM is essential.

If you are experiencing symptoms of GSM, it's important to consult with your healthcare provider. Have an open discussion about hormonal and non-hormonal treatment options, including the potential benefits of pelvic floor physiotherapy. Early intervention can significantly improve quality of life and your overall wellbeing.