Perimenopause symptoms
Intimate health
Genitourinary syndrome of menopause (GSM)
This is the area most women don't mention at the appointment. Not because it isn't affecting them. Not because they don't want help. But because there's no easy way to say it, and because somewhere along the way they've absorbed the message that these changes are just what happens — that discomfort, dryness, and a changed relationship with sex are part of getting older, not something medicine has much to offer.
That message is wrong on both counts. These symptoms have a well-understood cause. They have a name — genitourinary syndrome of menopause, or GSM — and they are among the most treatable symptoms of the menopausal transition.
Oestrogen maintains the health and suppleness of the tissues of the vagina, vulva, and urinary tract. It keeps the vaginal walls thick, elastic, and well-lubricated. It supports the mucosa of the urethra and bladder. As oestrogen levels fall during perimenopause, these tissues change: they become thinner, drier, and less elastic, and the naturally acidic vaginal environment shifts in ways that increase vulnerability to irritation and infection. Unlike vasomotor symptoms — which often improve after the transition — the physical changes caused by low oestrogen in this area tend to persist and progress over time if not addressed.
GSM symptoms are among the most prevalent of perimenopause, though reporting rates in clinical settings do not reflect that prevalence. Clinical data suggest that around 58% of perimenopausal women report vaginal dryness and approximately 39% report pain during sex. A longitudinal SWAN analysis found that women in early and late perimenopause are approximately 1.3 to 1.5 times more likely to develop monthly or more frequent urinary incontinence than premenopausal women.
A persistent dryness or reduced lubrication that may be present all the time, or more noticeable during sex. May be accompanied by itching, burning, or a general feeling of irritation in the vaginal area.
Friction, soreness, or pain during sexual intercourse that was not present before, or has significantly worsened. Research confirms it is one of the most underreported symptoms in clinical consultations.
A reduction in sexual desire, interest, or responsiveness. Local treatment for vaginal dryness and pain does not generally restore libido — the drivers of desire changes are often distinct, and both deserve attention.
A sudden, strong need to urinate that is difficult to defer. May come on without warning and be difficult to control. Caused by oestrogen-related changes in the bladder and urethral mucosa.
Needing to urinate more often than usual, including waking at night to do so. Related to the same urethral and bladder changes as urgency, and often co-occurring with it.
Involuntary loss of urine, either with urgency or with physical pressure such as coughing, sneezing, or exercise. A SWAN longitudinal study confirmed the menopausal transition itself is a significant risk factor for developing urinary incontinence.
Unlike most other perimenopause symptoms, GSM symptoms do not tend to improve on their own as the transition progresses. They are driven by persistently low oestrogen in tissues that depend on it, which means they often worsen gradually without treatment. Soap, detergents, and products used in the genital area can increase irritation in already-sensitive tissues. Infrequent sexual activity is associated with reduced vaginal elasticity and blood flow, which compounds the physical changes.
Effective treatments for vaginal dryness, pain during sex, and urinary GSM symptoms include local oestrogen therapies, non-hormonal vaginal moisturisers and lubricants, and pelvic floor physiotherapy, among others. These are not experimental or last-resort options — they are established, widely recommended first-line approaches that many women are simply never told about. If you find it difficult to raise these symptoms in conversation, it is entirely acceptable to hand your doctor a written document that lists them.
Intimate health is one of the eight domains in the Thea Klara survey. It covers vaginal dryness, discomfort during sex, changes in libido, urinary urgency, urinary frequency, and leakage — each rated by how often it happens and how much it affects you. For many women, seeing them listed in a document — named, specific, and ranked by impact — makes them easier to hand to a doctor than to say out loud.
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Kim HK et al. The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 2015.
Systematic review: prevalence and treatment of GSM-related symptoms — analysis of 27 studies. Menopause. 2021.
Leiblum S et al. Dyspareunia and reduced sexual intercourse during the climacteric: SWAN. Menopause. 2009.
StatPearls. Genitourinary Syndrome of Menopause. Updated 2024.
Nygaard I et al. Menopausal transition and urinary incontinence — SWAN cohort. Obstetrics & Gynecology. 2009.
Thea Klara provides self-advocacy tools, not medical advice. This content has been written to help you understand and describe your experience. It is not a substitute for a conversation with a qualified healthcare professional.