Genitourinary syndrome of menopause (GSM) occurs during perimenopause and after menopause due to decreased estrogen levels. Patients with GSM may experience vulvovaginal (dryness, burning, irritation), urinary (urgency, frequency, dysuria, urinary tract infections), and sexual symptoms (dyspareunia, bleeding with intercouse, and reduced libido, arousal, orgasm). GSM is usually diagnosed based on symptoms and physical findings after other causes have been ruled out.
GSM is an underdiagnosed condition with estimates of prevalence varying widely. There are many treatment options available for GSM from traditional lubricants and moisturizers to hormonal and complementary therapies.
In this Guidelines Side-by-Side, we have compared the latest treatment guidelines from the American Urological Association (AUA), North American Menopause Society (NAMS), and the Endocrine Society (ENDO) on genitourinary syndrome of menopause.
Guidelines of Comparison
- Treatment of Symptoms of the Menopause
- ENDO (2015)
- Summary
- Pocket Guide
- Full-text
| Intervention(s) | AUA/AUGS/SUFU (2025) | NAMS (2020, 2022) | ENDO (2015) |
|---|---|---|---|
| Low-Dose Vaginal Estrogen | Yes | Yes, if lubricants/moisturizers were not successful | Yes, if lubricants/moisturizers were not successful |
| Vaginal Dehydroepiandrosterone (DHEA) | Yes | Yes, if lubricants/moisturizers were not successful | Guideline does not address |
| Ospemifene | Yes | Yes, if lubricants/moisturizers were not successful | Yes, as a trial for those with moderate/severe symptoms |
| Vaginal Moisturizers and/or Lubricants | Yes, alone or in combination with other interventions | Yes, as first line intervention | Yes, as a trial using at least 2x weekly |
| Alternative Supplements | NOT recommended | Guideline does not address | Guideline does not address |
| Vulvovaginal Cleansers | NOT recommended | Guideline does not address | Guideline does not address |
| CO2 Laser | NOT recommended for most patients, but may be considered after shared decision making if other interventions are contraindicated or ineffective | More long-term data is needed before it can be recommended | Guideline does not address |
| ER:YAG Laser | NOT recommended | More long-term data is needed before it can be recommended | Guideline does not address |
| Radiofrequency | NOT recommended | More long-term data is needed before it can be recommended | Guideline does not address |
| Progestogen | Guideline does not address | NOT recommended (for most women) | NOT recommended |
Key Takeaways
- Vaginal moisturizers/lubricants, vaginal estrogen, and ospemifene
- All three guidelines agree that vaginal moisturizers and lubricants, low-dose vaginal estrogen, and ospemifene may be considered to treat GSM. NAMS and ENDO both recommend vaginal moisturizers and/or lubricants before moving on to vaginal estrogen or ospemifene.
- Vaginal Dehydroepiandrosterone (DHEA)
- Both the AUA and NAMS recommend DHEA for the treatment of GSM, but NAMS specifies that patients should trial vaginal moisturizers/lubricants before using DHEA.
- CO2 Laser
- The use of CO2 lasers for GSM is not recommended for most patients, but AUA states it may be considered if other interventions have not been effective or are contraindicated. NAMS suggests more research is needed to draw a conclusion on the use of CO2 laser for the treatment of GSM.
- Progestogen
- The use of progestogen is not addressed by the AUA, but is not recommended by ENDO and is not recommended for most women according to NAMS.
- Alternative Supplements, Vulvovaginal Cleansers, ER:YAG Laser, and Radiofrequency
- AUA does not recommend alternative supplements, vulvovaginal cleansers, ER:YAG lasers, and radiofrequency for the treatment of GSM. NAMS suggests that more research is needed to draw a conclusion on these therapies.
This concludes our Guidelines Side-by-Side on genitourinary syndrome of menopause. Don’t forget to sign up for alerts to stay informed on the latest published guidelines and articles.
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