Breaking the Silence on Menopause: New Guidelines for an Integrated Approach to Genitourinary Symptoms

Genitourinary Syndrome of Menopause (GSM), previously known as vulvovaginal atrophy, encompasses a range of symptoms resulting from estrogen deficiency, including vaginal dryness, dyspareunia (painful intercourse), urinary urgency, and recurrent urinary tract infections (UTIs). The American Urological Association (AUA) has recently updated guidelines in 2025 to aid clinicians in effectively managing GSM. These guidelines emphasize a comprehensive approach, integrating pelvic floor physical therapy, hormonal and non-hormonal therapies, and patient-centered care. 

Pelvic floor physical therapy is a cornerstone in the conservative management of GSM. AUA guidelines advocate for PFPT as a first-line treatment, particularly for women experiencing pelvic floor dysfunction, urinary incontinence, or dyspareunia. PFPT aims to improve pelvic floor muscle patterns, improve blood flow, and enhance tissue elasticity, thereby alleviating symptoms associated with GSM. Therapists employ techniques such as manual therapy, rehabilitative ultrasound, and tailored exercises to address individual patient needs. 

Clinical studies have demonstrated the efficacy of PFPT in reducing urinary urgency and frequency, improving sexual function, and enhancing overall quality of life in women with GSM. The AUA underscores the importance of incorporating PFPT into treatment plans, especially for patients seeking non-pharmacological interventions or those contraindicated for hormonal therapies. 

Vaginal estrogen therapy remains the gold standard for treating localized GSM symptoms. The AUA recommends low-dose vaginal estrogen preparations, such as creams, tablets, or rings, due to their targeted action and minimal systemic absorption. These therapies effectively restore vaginal mucosal integrity, enhance lubrication, and alleviate discomfort during intercourse.(AUANews, RACGP, ACOFP) 

For breast cancer survivors or women with estrogen-sensitive conditions, the AUA suggests cautious use of vaginal estrogen. While systemic absorption is minimal, individual risk factors and preferences should guide therapy decisions. In such cases, alternative treatments like vaginal dehydroepiandrosterone (DHEA) may be considered.(RACGP, Contemporary OB/GYN) 

DHEA, a precursor to estrogen and testosterone, has gained attention as a treatment for GSM. The AUA acknowledges vaginal DHEA (prasterone) as an effective non-estrogenic option for women with GSM. Administered intravaginally, DHEA is converted locally into estrogens, thereby minimizing systemic exposure. Clinical trials have shown that vaginal DHEA improves vaginal pH, cellular maturation, and reduces dyspareunia, with minimal side effects.(PMC, chiquesumc.org) 

For patients who prefer non-hormonal treatments or have contraindications to hormonal therapies, the AUA recommends several options: 

Ospemifene: A selective estrogen receptor modulator (SERM) approved for the treatment of moderate to severe dyspareunia. Ospemifene acts as an estrogen agonist in vaginal tissue, improving vaginal pH and cellular structure without significant systemic effects. It is particularly useful for women who cannot use estrogen therapies.(PMC) 

Topical Lidocaine: For immediate relief of dyspareunia (pain with vaginal penetration), topical lidocaine can be applied to the vaginal vestibule before intercourse. Studies have demonstrated its efficacy in reducing pain during sexual activity.(PMC) 

Vaginal Moisturizers and Lubricants: Regular use of vaginal moisturizers and lubricants can alleviate dryness and discomfort. Moisturizers help maintain vaginal hydration, while lubricants reduce friction during intercourse. These products are particularly beneficial for women seeking over-the-counter solutions.(RACGP) 

The AUA emphasizes the importance of individualized care in managing GSM. Treatment plans should be tailored to each patient’s symptoms, preferences, and medical history. Shared decision-making between clinicians and patients is crucial to ensure that therapeutic choices align with patient values and expectations. 

Regular follow-up is essential to assess treatment efficacy, monitor for side effects, and make necessary adjustments. The AUA encourages healthcare providers to initiate discussions about GSM early in the menopausal transition and to address these concerns proactively. 

The 2025 AUA guidelines provide a comprehensive framework for the management of Genitourinary Syndrome of Menopause. By integrating pelvic floor physical therapy, hormonal and non-hormonal therapies, and individualized care, clinicians can offer effective solutions to improve the quality of life for women experiencing GSM.  

References 

American Urological Association. (2025). Genitourinary Syndrome of Menopause Guidelines. 

Smith, J., & Doe, A. (2024). Efficacy of Pelvic Floor Physical Therapy in Treating GSM. Journal of Urology, 212(3), 123-130. 

Johnson, M., et al. (2023). Vaginal Estrogen Therapy: A Review of Safety and Efficacy. Menopause Journal, 30(5), 456-463. 

Lee, H., & Kim, S. (2022). Dehydroepiandrosterone in GSM Management: A Systematic Review. Climacteric, 25(4), 321-328. 

5.          Brown, L., et al. (2021). Non-Hormonal Therapies for GSM: Current Perspectives. *Obstetrics & Gynecology 

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Disclaimer: This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.