Additional Symptoms of Genitourinary Syndrome of Menopause
While many women associate Genitourinary Syndrome of Menopause (GSM) with dryness or discomfort during intimacy, the condition can affect a wide range of tissues in the vulva, vagina, and urinary tract. As estrogen declines, the health and resilience of these tissues change, which can lead to symptoms that many women do not immediately connect to menopause.
Urinary Symptoms
Hormonal changes can affect the bladder and urinary tract, sometimes leading to symptoms such as:
• chronic urinary urgency
• increased urinary frequency
• recurrent urinary tract infections (UTIs)
• irritation or burning with urination
In some cases, women may also notice blood in the urine (hematuria). This should always be evaluated by a healthcare professional to rule out other causes.
These symptoms are often related to changes in the vaginal and urinary microbiome, again resulting from decreased estrogen. This including the reduction of protective lactobacilli bacteria and an increase in vaginal and blader pH.
Structural and Tissue Changes
Declining estrogen can also influence the structure and appearance of vulvar and vaginal tissues.
Changes may include:
• thinning or fragility of vaginal tissues, making them more prone to small fissures or tears
• narrowing of the vaginal opening (introital stenosis)
• loss of natural vaginal folds (rugae) which normally support elasticity
• labia minora resorption, where the inner labia gradually become thinner or smaller
Women may also notice changes in tissue color, including paler (pallor) or red (erythema) vaginal tissue.
Sensitivity and Vestibular Pain
The vestibule, the tissue surrounding the vaginal opening, can become more sensitive during menopause.
Some women experience:
• burning or tenderness in this area
• discomfort with sitting for long periods
• irritation when wearing tight clothing such as jeans or athletic wear
In some cases, women describe a sensation of pressure or feeling as though they are “sitting on a small ball.”
Pelvic Muscle Guarding and Vaginismus
When vaginal tissues become fragile or sensitive, the pelvic floor muscles often respond by becoming protective.
This protective response can lead to vaginismus, an involuntary tightening of the pelvic floor muscles that may make pelvic exams or intercourse painful or difficult.
Pelvic floor physical therapy can often help restore muscle relaxation and coordination when this occurs.
Recognizing the Pattern
Because GSM affects multiple tissues and systems, symptoms can appear in ways that may not immediately seem related to menopause.
Understanding the physiology behind these changes helps women recognize that these experiences are not unusual — and that effective support and treatment options are available.
Important Distinction: GSM Behaves Differently Than Many Other Menopause Symptoms
Unlike some menopausal symptoms — such as hot flashes or night sweats — that often diminish as the body gradually adapts to shifting hormone levels, Genitourinary Syndrome of Menopause typically does not improve on its own.
GSM is driven by ongoing changes in estrogen-sensitive tissues of the vulva, vagina, bladder, and surrounding pelvic structures. As estrogen levels remain low after menopause, these tissues may continue to become thinner, less elastic, and more sensitive over time.
For this reason, GSM is considered a chronic and progressive condition. Without appropriate support, symptoms may gradually worsen rather than resolve.
This is why recognizing these symptoms early is important. As discussed in Part 3 of this series, a range of supportive strategies exist — including local estrogen therapy, pelvic floor physical therapy, and other individualized approaches that can help restore tissue health and comfort.
Understanding this distinction allows women to move away from the assumption that these symptoms are something they simply have to tolerate, and instead seek the support that is available.