Vaginal Dryness, Painful Sex And Recurring UTIs: The Menopause Symptom Nobody Talks About
In consultations, this is almost always the last thing a woman mentions, if she manages to mention it at all.
Vaginal dryness. Burning or itching. Sex that has become uncomfortable, then painful, then avoided altogether. Needing the toilet more urgently. A third urinary tract infection this year.
Each of these is usually treated as a separate, slightly embarrassing problem. They are not separate. They are one condition with one possible cause, and it has a name: genitourinary syndrome of menopause, or GSM.
The term was agreed in 2014 to replace the older, narrower "vulvovaginal atrophy" - partly because that phrase was difficult to say out loud, and partly because it left out the urinary half of the picture entirely. Unlike hot flushes, this does not settle down on its own. Left untreated, it tends to progress.
What counts as GSM?
The symptoms cluster across three areas, and most women have some combination rather than all of them:
Vulval and vaginal: dryness, burning, itching, irritation, discharge, reduced lubrication.
Sexual: pain during or after intercourse, discomfort with penetration, bleeding after sex, loss of desire that follows the pain rather than causing it.
Urinary: urgency, discomfort or burning on passing urine, and recurrent urinary tract infections.
That last one surprises people. Recurrent UTIs after menopause are frequently a hormonal problem rather than a hygiene one, and they are frequently treated with repeated courses of antibiotics that address the infection while leaving the underlying cause untouched.
How common is it?
Common enough that it should be a routine question in every midlife consultation, and rarely is.
The Menopause Society's 2020 position statement puts the range at roughly 27% to 84% of postmenopausal women, depending on how it is measured and asked about. In one study of over 900 women attending routine examinations, GSM was identified in 84% of those six years past menopause.
Why so few Malaysian women raise it
Partly because it is genuinely difficult to bring up. Partly because of a widespread and incorrect assumption that discomfort during sex is simply what happens after fifty, and there is nothing to be done.
And partly because women aren't asking about menopause at all. In one Malaysian study, 80% of women saw no reason to consult a doctor about their climacteric symptoms. A more recent survey of midlife women in Malaysian primary care clinics found that only about a third of those with symptoms had consulted a healthcare professional, and of those who did, only a third received any treatment.
If a woman is unlikely to raise hot flushes, she is far less likely to raise painful sex.
We'd gently suggest the opposite approach. Write it down before your appointment if saying it aloud is difficult. Doctors who work in midlife health ask about this routinely, and there is no version of this conversation they haven't already had. Our guide to Your First Consultation covers what the appointment actually looks like.
Do you need a blood test first?
No. Like menopause itself, GSM is diagnosed clinically, from your symptoms and, where appropriate, an examination. Hormone levels don't determine the treatment. We've set out the guideline positions on midlife blood tests in Do I Really Need Blood Tests in Midlife?
The one thing to take away
Hot flushes will eventually stop on their own. GSM will not.
If you have been managing dryness, discomfort or repeated urinary infections quietly for a year or two, waiting is not a neutral choice. The tissue changes tend to advance, and treatment started earlier is generally easier and more effective than treatment started late.
It is a fifteen-minute conversation. Have it.
Disclaimer: This article is for general educational purposes only and does not replace professional medical advice. It is not intended to promote any specific medicine or product. Treatment decisions should be made in consultation with a licensed healthcare professional.
Next Steps
Take our 3-minute symptom quiz to see where you are in the transition
Learn about our approach on the Hormone Health page
References
The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 Genitourinary Syndrome of Menopause Position Statement of The North American Menopause Society. Menopause. 2020;27(9):976-992.
National Institute for Health and Care Excellence (NICE). Menopause: Identification and Management (NG23). London: NICE; 2015, updated 2024.
Obstetrical & Gynaecological Society of Malaysia; Malaysian Menopause Society. Clinical Practice Guidelines: Management of Menopause in Malaysia. Kuala Lumpur: OGSM & MMS; 2022.
Portman DJ, Gass MLS; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary Syndrome of Menopause: New Terminology for Vulvovaginal Atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society. Menopause. 2014;21(10):1063-1068.
Ismael NN. A Study on the Menopause in Malaysia. Maturitas. 1994;19(3):205-209.
Manoharan A, Megat Zainal MMH, Beh HC, et al. Health-Seeking Behaviors and Treatments Received for Menopause Symptoms: A Questionnaire Survey Among Midlife Women Attending Primary Healthcare Clinics in Malaysia. J Menopausal Med. 2023;29(3):119-126.
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