GSM, a topic even more taboo than hot flashes

Genitourinary syndrome of menopause (GSM) is the second major pillar of climacteric symptoms, after hot flashes. The bladder, vaginal mucosa, and perineum all have estrogen receptors: when these disappear, these areas suffer, but it takes time tend to appear later, unlike hot flashes which occur early on. Women almost never bring it up spontaneously, so it is up to the healthcare professional to ask about it in a relaxed, open manner.

Vaginal dryness: in reality, it is primarily vulvar

What is referred to as "vaginal dryness" is felt mainly in the vestibule, the area between the labia minora at the entrance to the vagina (the vagina itself cannot be "felt" as dry). This dryness manifests almost exclusively during intercourse, and rarely in daily life, except in very advanced menopause.

Be careful not to blame everything on menopause

If a woman complains of vulvar dryness or pain in daily life (not just during intercourse), especially with itching at night, do not jump to the conclusion that it is menopause: it could be vulvar lichen sclerosus, a little-known but common dermatological condition where the labia minora can almost disappear. Many women are mistakenly treated with estrogen creams without any improvement. The treatment for lichen sclerosus is a long-term cortisone ointment, which is different from hormone therapy. Odile encourages women to explicitly ask their doctor to examine the vulva if there is any doubt.

Solutions for dryness

A lubricant for intercourse: normal and necessary, even when on hormone therapy. Local estrogens : vaginal cream or capsules, or vulvar cream, which can be combined with a soothing moisturizing balm for daily use. Hyaluronic acid injections in cases of atrophy or fissures. Radiofrequency or endovaginal laser, more expensive options that require multiple sessions.

"Use it or lose it"

Regular mechanical stimulation of the vaginal mucosa (through intercourse, sexual play, or toys, whether alone or with a partner) plays an active role in maintaining its health, complementing estrogen treatments. Both approaches—medical and mechanical—work together: estrogen alone is not enough without regular stimulation.

It affects every woman, sooner or later

Few women are affected at the very beginning of menopause, but after a few years, all women are, just as skin inevitably ages. Some women don't complain about it simply because they are no longer sexually active. Women who maintain regular sexual activity without hormones may have a healthier mucosa.

The urinary aspect: recurrent infections

The bladder is less effective at defending itself against infections during menopause. The first-line treatment is vaginal estrogen (the vaginal wall is adjacent to the bladder wall, so the estrogen also reaches the bladder). Basic tips: urinate after intercourse, stay well hydrated, do not hold your urine for too long (but don't urinate too frequently either, as this can lead to urgency), and above all, treat constipation, an often-overlooked factor, even though the bacteria originate in the gut.

The urinary aspect: leakage and overactive bladder

Menopause exacerbates pelvic organ prolapse (already predisposed by childbirth), which weakens the bladder sphincter and can cause stress incontinence. Pelvic floor physical therapy, which is essential for prevention postpartum, becomes necessary during menopause to treat existing leakage (it is never "too late" to start, it just requires a bit more effort). The other side of this isurgency : an overactive bladder that creates a sudden, intense need to urinate, with a risk of leakage if a restroom is not immediately available.

The vicious cycle of dryness

Dryness → less pleasant foreplay → reduced arousal → less natural lubrication → less enjoyable intercourse → less desire to repeat → less frequent intercourse → even drier mucosa. Breaking this cycle requires the use of lubricants and maintaining regular sexual activity, whether alone or with a partner.

The vagina is the opposite of a battery: it only wears out if you don't use it.