Peeing should be a simple process: You feel the urge to go, you empty your bladder quickly and painlessly, and you wipe comfortably. Then you go about your day until you need to pee again, hours later.

But for many women in perimenopause and menopause, peeing isn’t simple anymore. It’s become a constant battle of frequency, urgency, and sometimes lack of control. And even with extra-gentle wiping, toilet paper feels like sandpaper.  

This ongoing urinary discomfort comes to you courtesy of GSM. The initials stand for “genitourinary syndrome of menopause,” an ugly name for an unpleasant condition.  

What is GSM?

The name genitourinary syndrome of menopause was first introduced in 2014, but previously used terms were horrible too: urogenital atrophy, atrophic vaginitis, and vulvovaginal atrophy. Ugh! Because these older terms focused only on the vaginal symptoms, experts changed the official medical term to GSM to include the urinary aspects.

GSM is a chronic, progressive condition that affects a woman’s genital and urinary tracts. It can involve changes in the vagina, labia, clitoris, and urethra, and it affects an estimated 60% of menopausal women.

Decreased estrogen is one of the causes of GSM, so it may show up in perimenopause and menopause. Women with low estrogen for other reasons (like medications, surgical removal of the ovaries, or treatments affecting the ovaries) can also experience GSM symptoms.

The vaginal symptoms of GSM

Estrogen helps keep the vagina well-lubricated and pliable. As the estrogen receptors in vaginal tissues receive less and less estrogen, vaginal health deteriorates. The vaginal and vulvar tissues become thin, weak, and stiff, while lubrication lessens. In some women, the vagina shortens and vaginal opening becomes smaller. It’s like a beautiful flower shriveling due to lack of moisture and structure.  

The vaginal dryness may cause irritation, itching, and pain. And the fragile tissues may bleed when anything is inserted, whether during sex or a gyn exam. For many perimenopausal and menopausal women, the fear of painful sex is real and may contribute to low (or nonexistent) sex drive and loss of intimacy with a partner.

The urinary symptoms of GSM

While some women have heard about the vaginal symptoms of perimenopause and menopause, the urinary complications aren’t talked about as much. With GSM, you may have any of the following urinary symptoms:

• Increased frequency

• Urgency or not making it to the bathroom

• Postvoid or uncontrolled dribbling

• Getting up at night to pee

• Peeing a little when you cough or sneeze

• Burning or pain  

• Recurrent urinary tract infections (UTIs)

The “why” behind the symptoms is that estrogen loss may weaken urinary tract health in several ways:

Drier, thinner tissues:  
Like the vagina, the urethral and bladder linings also have estrogen receptors, so declining estrogen makes these urinary tissues dry out and become thinner. Dry tissues aren’t as healthy, so bacteria can gain a foothold more easily.

Weaker muscles:  
Lack of estrogen weakens the muscles that hold the urethra closed, so bacteria can get in more easily and urine can leak out.  

Pelvic floor muscles can also be weakened by loss of estrogen. Less support from those muscles can allow the bladder to drop (prolapse) into the vagina. This makes fully emptying your bladder more difficult, so you have urinary retention and may feel the urge to go again soon after peeing. Retention can contribute to UTIs because when urine sits in the bladder, it allows bacteria to multiply.

Bacterial changes:
When estrogen drops, so does the level of Lactobacillus bacteria in your vaginal and urinary tracts. These good critters normally help regulate the vaginal pH and fight off the bad bacteria that cause infections, like bacterial vaginosis or a UTI. Without that line of defense, bad bacteria can take hold—including E. coli, a common culprit in UTIs.

Is it a UTI, GSM symptoms, or something else?

Let’s say you have burning and urgency and you’re urinating often. That symptom combo seems like a UTI, right? But it could just be GSM. How do you know which you’re dealing with?

This is where you need your doctor’s help to test your urine for bacteria. If the test is positive, you have a UTI. But if you have a negative urine test coupled with symptoms that mimic a UTI, you may be dealing with GSM instead.

And if you do get a UTI, know that UTIs in menopause are rarely your fault. (You already follow the standard prevention advice: pee right after sex and wipe from front to back.) These UTIs can be caused by loss of estrogen, so there is no reason to blame yourself for doing anything to cause them.

Self-care for urinary symptoms of GSM  

One thing no one talks about is the effect urinary symptoms of GSM can have on your quality of life. The irritation and burning can make it difficult to find pants that are comfortable in the crotch area. Even just sitting in a chair can be excruciating sometimes. And forget about riding a bike!  

Ladies, putting up with urinary symptoms and discomfort is no way to live. What can be done to relieve symptoms?

There are a number of lifestyle approaches for GSM self-care. Here’s the short list:

Avoid irritating products. Ingredients in douches, flushable wipes, scented soaps, laundry detergents, fabric softeners, and dryer sheets can be irritating and make burning and itching worse. Choose unscented products. The fewer chemical substances used down there, the better.

Wear 100% cotton underwear. Synthetic underwear may be irritating to the vulvovaginal area, including the urethral opening. Loose-fitting slacks may help avoid rubbing and constriction. Consider wearing no undies at night for even less irritation.

Stay hydrated. It may seem counterintuitive, especially if you have urinary frequency. Drinking more water, and therefore peeing often, may help reduce recurrent UTIs by flushing out bad bacteria hanging around in your urinary tract.

Pelvic floor physical therapy. Ask your doctor for a referral to a physical therapist who specializes in helping strengthen the pelvic floor muscles. Kegels can help, but there are lifestyle techniques and more advanced exercises to improve pelvic floor health.

Urinary incontinence devices. If you’re really struggling with bladder control incontinence, you may want to consider a prevention device, like a pessary.

Another way to care for yourself is to be evaluated by a doctor. Chronic urinary symptoms can also be related to another underlying health condition, such as type 2 diabetes or a sexually transmitted disease, which may require medical treatment.

Hormonal solutions for GSM

Bioidentical hormones delivered right to the vulvovaginal area can help replace estrogen to keep the estrogen receptors in the vagina and urethra happy. Called the “gold standard” solution for GSM by some experts, vaginal estrogen targets GSM symptoms right at the source.

Vaginal estrogen comes in several forms, like creams, gels, vaginal suppositories, or dissolvable vaginal tablets. If you’re struggling with GSM symptoms, ask your doctor if you would be a good candidate for compounded vaginal estriol, estradiol, or a combination to address your urinary health. Because you deserve to pee normally.