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Menopause I - Genitourinary Syndrome of Menopause

Dec 21, 2022

When the word “menopause” comes to mind, people might think of hot flashes and loss of a menstrual period. Others may relate to this time as a period of brain fog, mood swings or insomnia. This is because menopause affects all women differently. To add another layer, menopause is more often a process, rather than a brief phase. Menopause is defined as reaching one full year without a period.

Perimenopause, however, is a period of fluctuating hormone levels, which can begin as early as age 35 and last up to 10-12 years prior to the last menstrual period. This means a variety symptoms can present at different times, and hormonal changes may not always be considered as a cause.

There is so much that we are just not told about menopause, so let’s make the next three blog posts all about it! Better yet, let’s start by addressing one of the more taboo topics not listed above: Genitourinary Syndrome of Menopause. 


Prior to menopause, estrogen made primarily by the ovaries is abundant. This estrogen, known as estradiol or E2, is also the most potent form. Following menopause, estrogen mainly comes from fat cells, and is overall less beneficial in the same way as E2. Estrogen makes skin smooth, soft and improves its blood flow. Estrogen also helps feed our good vaginal bacteria, which helps keep the vaginal environment healthy and prevent infection.

Along with the vagina, our bladder and urethra are also rich in estrogen receptors. This helps decrease bladder sensitivity, allowing it to fill sufficiently, so that we only feel the need to urinate when full. Additionally, estrogen has a strong influence on our soft tissues, including the tissue surrounding our urethra.


Without sufficient estrogen available to interact with the tissues of our urinary and genital systems, we can experience what is known as Genitourinary Syndrome of Menopause (GSM). Symptoms may include vaginal dryness, dyspareunia (painful intercourse), bleeding and discomfort following intercourse, burning or itching sensations.

Additionally, the tissues surrounding our genital area, known as the vulva, often lose their pink, puffy appearance, which is another sign of decreased blood flow and estrogen to the area. The entry to our vagina can become smaller in size and begin to feel tight, resulting in pain on penetration. As blood flow toward our clitoris declines, nearby tissues can become less mobile and sometimes result in difficulty achieving orgasm.

Lack of estrogen causes tissues to become thinner and less supportive due to collagen and elastin changes, which can result in pelvic pressure or prolapse. Women also become more predisposed to urinary incontinence, bladder urgency and urinary tract infections following menopause. 


If considering all this makes estrogen seem like a wonder hormone, that’s because it is! It is important to emphasize that hormone treatment (HT) is much safer than once thought. Women should not be afraid to reach out to an expert to help decide if HT is appropriate for them.

The best way to find knowledgable, up to date experts on HT is to go to to find a NAMS (North American Menopause Society) certified provider. Your Pelvic Floor Physical Therapist (PT) can help you retrain your bladder and muscles of the pelvic floor to eliminate leakage, urinary urgency and frequency.

PTs also help instruct in techniques to improve pressure management, desensitize and mobilize the tissues of your vulva and pelvic floor. This may entail internal and external manual techniques, breathing and dilator therapy. Menopause affects multiple systems, and therefore may require more than a single provider. Your Pelvic Health Physical Therapist is one provider who wants to help you build a plan and connect with other experts in your community to get you back to living your life unbothered by GSM.

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