It’s Not You, It’s Your Estrogen: Why Your UTIs, IC, and Pain with Sex Might Actually Be Genitourinary Syndrome of Menopause

You know what nobody talks about? The fact that menopause can sneak into your bladder and vagina like a hormonal ninja, quietly wreaking havoc—burning, itching, leaking, and messing with your sex life—until you’re left wondering if it’s all in your head - IT'S NOT

Let’s talk about Genitourinary Syndrome of Menopause (GSM)—a condition that affects nearly half of all peri and postmenopausal women, but is still wildly underdiagnosed, misdiagnosed, or dismissed altogether.

Misdiagnosed as IC, UTIs, or “Just Aging”

GSM often flies under the radar because it doesn’t look like a textbook menopause symptom. Instead, it masquerades as:

• Interstitial cystitis (IC) or “painful bladder syndrome”

• Recurrent urinary tract infections (sometimes with negative cultures)

• Burning with urination, urgency, frequency—despite a “normal” urinalysis

• Painful sex, vulvar irritation, or exam findings labeled as “normal aging”

  
  

The problem? If providers don’t recognize GSM, women get stuck in a cycle of antibiotics, unnecessary procedures, or being told to “just drink more water” while their quality of life tanks.

What Genitourinary Syndrome of Menopause Actually Is

GSM is the clinical name for a collection of genital, sexual, and urinary symptoms that result from estrogen deficiency during the menopause transition and beyond.

Estrogen is crucial to maintaining the health of the vulva, vagina, urethra, bladder, and vestibule. When levels drop, these tissues become:

• Thinner

• Dryer

• Less elastic

• More fragile

• More vulnerable to irritation, inflammation, and infection

  
  

Yes, your vestibule—that tender area just inside the labia minora—is affected too. Lined with urethelial cells, just like the bladder, it’s highly estrogen-dependent. When estrogen declines, the vestibule loses moisture, elasticity, and its ability to buffer against irritation. Even gentle touch or penetration can start to feel like sandpaper.

During a pelvic exam, when the vestibule is lightly palpated—especially with a cotton swab—many patients immediately recognize the sensation, often saying, “That’s the pain I always think is a UTI.”

Common Symptoms of GSM

GSM symptoms can range from mild to debilitating and may include:

• Vaginal dryness, burning, or irritation

• Pain with sex (dyspareunia)

• Loss of lubrication and arousal

• Urinary urgency or frequency

• Burning with urination (without infection)

• Recurrent UTIs

• Painful pelvic exams or difficulty tolerating a speculum

• Loss of vulvar tissue, clitoral hood fusion (the hood of the clitoris "seals off" over the clitoris making stimulation more difficult), or “disappearing labia”

  
  

These aren’t just physical annoyances. They impact intimacy, relationships, confidence, and mental health. And they don’t get better without treatment—because GSM is chronic and progressive.

The Good News? It's Very Treatable

Despite the alarm bells, GSM is very manageable with the right treatment. And it doesn’t require overhauling your entire life—just giving your estrogen-deprived tissues the local TLC they need.

First-line options:

• Vaginal moisturizers (used regularly to maintain hydration)

• Lubricants (used during sex to reduce friction)

  
  

These may be enough for mild symptoms—but for most women, local estrogen therapy is the gold standard.

Low-dose vaginal estrogen:

• Comes in creams, tablets, rings, and softgel inserts

• Has minimal systemic (whole body) absorption

• Does not require progestogen even if you have a uterus

• Can be used indefinitely for symptom relief and tissue restoration

  
  

Other FDA-approved options include DHEA vaginal inserts (prasterone) and ospemifene (an oral non-hormonal medication).

“But I Have a History of Breast Cancer…”

If that’s the case, don’t panic—and definitely don’t suffer in silence. GSM treatment can still be on the table, even with a history of hormone-sensitive cancers.

• Non-hormonal options like moisturizers and ospemifene may be appropriate

• For severe symptoms, vaginal estrogen may be considered in consultation with your oncologist

• The Menopause Society official position statement supports individualized, shared decision-making

“How Long Do I Have to Use It?”

Forever, if you want symptom relief.

GSM isn’t temporary—it’s a progressive condition driven by the loss of estrogen. That means stopping treatment will lead to the return of symptoms. The good news? Low-dose vaginal therapies are safe for long-term use and are generally well tolerated. In fact, low-dose vaginal estrogen has also been shown to reduce the risk of recurrent UTIs in older women—and may even lower the risk of hospitalization related to those infections.

The Takeaway

GSM isn’t just a “dry vagina” problem. It’s a whole lower urinary and genital tract condition that:

• Mimics IC

• Disguises itself as UTIs

• Dramatically impacts sex, confidence, and quality of life

But with the right treatment, you can feel like yourself again.