New guideline outlines best practices for managing genitourinary syndrome of menopause
New guidelines on GSM recommends symptom-based diagnosis, shared decision-making, and local estrogen as first-line therapy to improve quality of life.
New guideline outlines best practices for managing genitourinary syndrome of menopause |Image Credit: © InsideCreativeHouse - stock.adobe.com.
The American Urological Association (AUA), Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), and American Urogynecologic Society (AUGS) have published a new guideline with evidence-based recommendations for the diagnosis and treatment of Genitourinary syndrome of menopause (GSM).1
Diagnosis is based on patient-reported symptoms, including dryness, irritation, dyspareunia, and urinary complaints such as dysuria, urgency, and recurrent urinary tract infections. Physical signs—such as labial atrophy, introital stenosis, or changes in vaginal pH—may support the diagnosis but are not required. Clinicians are advised not to rely on hormone levels for diagnosis or management decisions.
Shared decision-making is emphasized
The guideline emphasizes shared decision-making (SDM) that considers patient preferences and goals. Clinicians should screen patients using a focused history, perform a genitourinary exam, and assess for coexisting conditions. Referrals to pelvic floor physical therapy or sex therapy may be appropriate, particularly when symptoms affect psychosocial or sexual well-being.
Local low-dose vaginal estrogen is first-line therapy
Vaginal estrogen is recommended to improve vulvovaginal dryness, irritation, and dyspareunia. This therapy may be administered as a cream, insert, tablet, or ring. Although evidence quality was low, it consistently showed improvement in symptoms with a favorable safety profile. Patients with recurrent urinary tract infections should also be offered local estrogen, which has moderate-level evidence supporting its use in reducing infection risk.
Other hormonal options available
Vaginal dehydroepiandrosterone (DHEA) may improve dryness and dyspareunia and is considered a moderate-strength recommendation. Oral ospemifene is also an option for these symptoms but carries a conditional recommendation due to limited evidence. For patients already on systemic estrogen therapy, additional local estrogen or DHEA may be offered. None of these treatments are associated with an increased risk of breast or endometrial cancer based on available evidence.
Non-hormonal and energy-based therapies
Moisturizers and lubricants are recommended alone or in combination with other treatments. The guideline advises against using alternative supplements or vaginal irritants. Evidence does not support energy-based therapies such as CO₂ or Er:YAG laser, or radiofrequency devices. These interventions are considered experimental and may be discussed only in the context of SDM for patients ineligible for FDA-approved options.
No surveillance required for endometrial changes
The guideline states that patients using local estrogen, vaginal DHEA, or ospemifene do not require endometrial surveillance. Limited data suggest these treatments do not increase the risk of endometrial hyperplasia or cancer.
Reevaluation is necessary
The guideline recommends that clinicians reassess patients to monitor symptom response and discuss the potential need for long-term treatment. GSM is a chronic condition, and ongoing therapy may be needed to maintain symptom relief and quality of life.
"What we've come up with are pragmatic statements that can be rapidly implemented. I do believe we're going to be transformational, both to engage urologists to treat these patients, as well as improve these patients' outcomes in a very global sense," said Melissa R. Kaufman, MD, PhD, FACS, guideline chair, Patricia and Rodes Hart professor in urologic surgery, and professor of urology and chief of the Division of reconstructive urology and pelvic health at Vanderbilt University Medical Center in Nashville, Tennessee.2
References
1. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 0(0). doi:10.1097/JU.0000000000004589. https://www.auajournals.org/doi/10.1097/JU.0000000000004589
2. Kaufman M. Speaking of Urology: Melissa Kaufman, MD, on AUA’s new guideline on genitourinary syndrome of menopause. Urology Times. April 28, 2025. Accessed April 29, 2025. https://www.urologytimes.com/view/speaking-of-urology-melissa-kaufman-md-on-aua-s-new-guideline-on-genitourinary-syndrome-of-menopause
