This probably isn’t the best way to start a conversation, but do you have an itchy, dry vagina? Do you have more frequent urinary tract infections or thrush-like symptoms more often? Do you pee when you sneeze, laugh or jump? Or has sex become painful?

If you’re heading toward menopause, or are menopausal, and you answer yes to any of these questions, there’s a chance you have what is now called GSM – or Genitourinary Syndrome of Menopause.

The term has actually been around since 2014. Previously it was called either vulvovaginal atrophy or atrophic vaginitis but those terms didn’t include the urinary symptoms, and in the case of vaginitis, they were slightly misleading as it implies inflammation or infection. So, the name was changed to encompass the myriad of symptoms women may experience.

What is it that causes this plethora of rather uncomfortable symptoms? Oestrogen – or the lack of it – to be more precise. As we age our oestrogen levels drop, and because we have oestrogen receptors all around our body – including our brains, skin and reproductive regions – they suffer from the loss.

In the brain many women experience ‘brain fog’, loss of concentration, mood swings. Some even describe it as a loss of interest in life or feeling low.

The skin becomes dryer, thinner, and sometime itchier – and the same thing happens to the vulva and vaginal walls.

As the walls thin, urinary stress incontinence – that unwanted peeing – can become an issue for many women. In addition, the vagina produces less lubrication and as a result the acid balance or pH can change, which leads to increased infections. And with less lubrication sex can go from being an enjoyable experience to a painful one.

When does this happen? Well, stress incontinence can start before menopause and is often a result pelvic floor issues or the stresses of childbirth. But it can be an issue for women in the lead up to menopause – the peri-menopausal, as it’s know.

The average age for menopause in the UK is 51 but often the dryness, itchiness and painful sex present 3-4 years after the last period – just when you may have thought you were through the worst of it!

So, what can be done?

According to NICE guidelines, the first-line treatment that should be offered to women is Hormone Replacement Therapy or HRT. These days the vast majority of HRT used in the UK comes from yams and soy and are what’s called ‘body identical’ or sometimes ‘bio-identical’. Those that came from horse urine are rarely used in Europe or the UK these days.

According to the Menopause and PMS Service at the Chelsea and Westminster Hospital, it is “more accurate to describe these hormones as body identical rather that bio-identical as they resemble hormones produced within the body. Oestradiol, progesterone and testosterone are all available as body identical hormones.”

The reason why its preferable to call them body identical rather than bio-identical is that they may be confused with compounded versions of bio-identical hormones. These are versions of HRT that are advertised as being ‘tailored’ to your needs based on a saliva or blood test.

The British Menopause Society does not recommend these as they are not regulated. The tablets are put together by a local pharmacy or the company offering the tests but there is no control over what goes into them, so you would never be sure of exactly what you were getting. It’s a view supported by American Gynaecologists and Obstetricians as well.

In addition, according to Gynaecologist and menopause expert, Vikram Talaulikar, co-founder of the Menopause Clinic London on Harley Street, “these compounds are not regulated or tested, so there is no safety data on them and no one knows what the long term effects could be.”

So, the best option is the conventional HRT. Alongside those are creams, gels, oestrogen secreting rings or vaginal pessaries that can be used in and around the vagina.

But both of these measures may not always do the trick. And if they don’t, then PRP or energy-based non-invasive treatments are an option.

According to GP and women’s health doctor, Unnati Desai, PRP or Platelet Rich Plasma, when injected into the vagina, clitoris and external genitalia, can help improve sensitivity and lubrication. It can help relieve the symptoms of Lichen Sclerosus. And, there’s no downtime. She explains the PRP, which is full of stem cells and growth factors, can help improve blood supply to the region, and with a better blood supply, you get better function. The common name for this treatment is the O-Shot.

The energy-based treatments include laser, radiofrequency or ultrasound. Dr. Desai says laser treatments such as the Femilift treatment she offers, “good for vaginal atrophy, dryness, infections, GSM, stress incontinence and Lichen Sclerosus.”

“I offer a combination of treatments as they work in different ways to improve tissue quality, ” she says. The energy-based treatments work in a similar fashion to the skin tightening/rejuvenation treatments that are frequently used on the face or neck. In the vagina they target the deeper layers of the vaginal wall, creating heat and micro-trauma which causes them to tighten up. It also sparks a healing response that encourages new collagen production and better blood flow. This can help strengthen the vaginal walls, helping to reduce stress incontinence. It also has the added bonus of improving the mucosa and in turn, lubrication.

To have a laser treatment you must have a normal smear on your last cervical smear, no active infection and will need a pelvic exam.

Dr Desai believes we need to start thinking about vaginal atrophy much earlier than we currently do. It starts as soon as our oestrogen levels start declining, which is why it’s important to seek help for the symptoms of menopause when they start.

And if you’ve left it until your periods have stopped, then “evidence from the States suggests that the optimal time is to start is before a woman is 3 years post-menopausal,” she says.

But that doesn’t mean there’s nothing that can be done. “After that, it may take more treatments to get a good result,” she says, but there can always be an improvement.

If you are affected by these issues, please make an appointment without women’s health/menopause experts. You can find them here:

womens health menopause

If you want to learn more about GSM and vaginal symptoms please download Jane Lewis’s leaflet on GSM here: https://www.mymenopausalvagina.co.uk/downloads

Jane is the author of “Me and My Menopause Vagina” and an active campaigner for education on vaginal atrophy. You can find her on Instagram @my_menopausal_vagina