Genitourinary Issues in Midlife: What Women Should Know

As women move through midlife, hormonal changes can bring a variety of symptoms. One particularly common and under-recognised condition is genitourinary syndrome of menopause (GSM), which affects the vaginal and urinary systems due to the natural decline in oestrogen.

Despite how widespread GSM is, the prevailing attitude is often that these symptoms are just a normal, unavoidable part of ageing. This belief can lead to underdiagnosis and undertreatment, leaving many women to suffer in silence, making the condition worse over time.

What Is GSM?

GSM encompasses a range of symptoms related to low oestrogen levels in the vaginal and lower urinary tract tissues. These include:

• Vaginal dryness, burning, or irritation

• Pain or discomfort during sex

• Recurrent urinary tract infections (UTIs)

• Urinary urgency or frequency

• Vulval discomfort or itching

Unlike many other menopause-related symptoms, GSM does not improve spontaneously. In fact, it tends to worsen over time if left untreated — but the good news is that it is both manageable and treatable.

Treatment Options: Safe, Effective, and Individualised

According to NICE menopause guidance, GSM should be actively managed with evidence-based treatments tailored to each woman’s needs. Treatments are usually safe, effective, and cost-efficient. Yet awareness and access remain barriers for many.

Vaginal Oestrogen

One of the most effective treatment options for GSM is vaginal oestrogen. It is:

• Body-identical — the same as the oestrogen naturally produced by the body

• Locally applied — via tablet, cream, pessary, or ring, delivering low doses directly to vaginal tissues

• Safe — it does not increase the risk of breast cancer, and is safe for long-term use in most women

• Effective — it helps:

  • Restore vaginal tissue thickness and elasticity

  • Increase vaginal blood flow

  • Lower vaginal pH to healthier levels

  • Support beneficial vaginal bacteria

  • Improve natural lubrication

  • Strengthen urethral and bladder tissues

Common Forms and Brands (UK)

Vaginal oestrogen is available in several forms, allowing women to choose what suits them best. These include:

• Vaginal tablets, such as Vagifem® 10 micrograms and its generic version Vagirux®. These are small pessaries inserted into the vagina, used daily for the first two weeks and then reduced to twice weekly for ongoing maintenance.

• Vaginal creams, such as Ovestin® cream (containing estriol) and Imvaggis®, an ultra-low dose estriol formulation. These are applied directly into the vagina using an applicator. They are typically used daily to start, then reduced to twice weekly.

• Vaginal rings, such as Estring®. This is a soft, flexible ring inserted into the vagina, releasing a low dose of oestrogen continuously over 90 days. It is replaced every three months and can be a convenient, low-maintenance option.

• Vaginal pessaries (soft capsules), such as Intrarosa®, which contains prasterone (DHEA). Although not technically an oestrogen, it is converted in the vaginal tissues to active sex hormones and works in a similar way. It is used once daily and can be an alternative for certain women.

Each option has different advantages depending on individual preference, ease of use, lifestyle, and medical history. Your practitioner can help guide the choice that’s right for you.

Non-Hormonal Support

Non-hormonal options, such as vaginal moisturisers and lubricants, can also play an important role. Moisturisers used regularly help maintain hydration, while lubricants can reduce friction and discomfort during sex. These can be used alongside vaginal oestrogen for added relief.

Common Questions and Concerns

• Duration of treatment: Unlike systemic hormone therapy, vaginal oestrogen can be used indefinitely as long as symptoms persist — there is no fixed time limit.

• When to expect results: Some improvement may be noticed within days, but optimal results typically take 4–12 weeks.

• Stopping treatment: Symptoms often return if treatment is stopped, as the underlying hormonal deficiency remains.

• Using with moisturisers and lubricants: Vaginal oestrogen treats the root cause but does not act as a lubricant. Water-based lubricants can be used during sex, and regular moisturisers help maintain comfort day to day.

Why Early Intervention Matters

GSM can affect physical comfort, sexual wellbeing, and overall quality of life. For many women, it begins in early perimenopause — even when periods are still regular — which can occur in the 40s or even 30s. If left unaddressed, symptoms typically worsen over time.

Women deserve clear information, compassionate care, and personalised treatment that prioritises comfort, confidence, and long-term health.

If you are experiencing any symptoms of GSM, don’t ignore them. You are not alone — and support is available. Midlife changes aren’t limited to genitourinary symptoms, either. This is often the time to seek evidence-based, individualised care to support your overall wellbeing through midlife and beyond — the kind of care we provide at our clinic.

Get Help at Marina Danilova Clinic

If you’re experiencing symptoms of GSM or other midlife changes, we’re here to help with holistic care.

To get started, please complete our New Patient Form.