Genitourinary syndrome of menopause (GSM; also referred to as vaginal atrophy or vulvovaginal atrophy) is a syndrome that affects the lower urinary tract, the vulva, and the vagina. It is associated with low estrogen levels and thus typically affects menopausal / postmenopausal individuals. It can also occur in premenopausal patients who have low systemic estrogen levels from bilateral oophorectomy, premature ovarian failure, antiestrogenic medications, or postpartum or lactation-induced hypoestrogenism. Cigarette smoking is another risk factor because it causes relative estrogen deficiency and impairs tissue perfusion. Prevalence is below 3% in premenopausal individuals and rises to around 50% after 3 years postmenopause.

Estrogen acts on the urogenital tract, including the vaginal epithelium, vulvar tissues, urethra, and bladder. In the vaginal epithelium, estrogens induce collagen content, acid mucopolysaccharides, and hyaluronic acid, which all maintain tissue thickness, elasticity, vaginal rugae, and glycogen stores, which are a substrate for lactobacilli. Lactobacilli in turn maintain the acidic vaginal pH that promotes normal flora in the genital tract and serves as a barrier to vaginal and urinary tract infections.

Serum estradiol in postmenopausal individuals is on average 5 pg/mL compared with 40-600 pg/mL during premenopause. This drop induces many changes in urogenital tissue. The vaginal epithelium becomes thin and loses elasticity. The vaginal canal shortens and loses rugae. Loss of glycogen stores and lactobacilli colonization allow the vaginal environment to become less acidic, with pH over 5.0. Thin vaginal epithelium is more prone to damage from minor trauma, causing underlying connective tissue to become exposed and making it susceptible to inflammation and infection.

Patients often first present reporting decreased vaginal lubrication during intercourse, resulting in pain (dyspareunia). Other common symptoms include vaginal dryness, burning, or irritation, which can result in chafing and bleeding. Bladder and urethral epithelium can atrophy as well without the influence of estrogen, which can lead to urinary tract infections, dysuria, increased urinary frequency, and rarely hematuria. Symptoms generally worsen with time, even if estrogen levels remain stable.

Regular sexual activity can improve symptoms of atrophy as it promotes tissue perfusion and elasticity.