Menopause, GSM and hormone therapy

The transition

Perimenopause is the years of fluctuating hormones before periods stop, typically starting in the mid-forties and lasting an average of about four years, though it can be longer. Menopause is defined retrospectively as 12 consecutive months without a period; the average age is around 51 in high-income countries. Premature ovarian insufficiency, before 40, affects roughly 1 percent and requires hormone therapy until at least the average age of menopause for bone and cardiovascular protection.

Surgical menopause after bilateral oophorectomy is abrupt and typically more severe than natural menopause.

Genitourinary syndrome of menopause

GSM is the current term for the changes previously called vaginal atrophy: thinning and loss of elasticity in vulval and vaginal tissue, reduced lubrication, raised pH with a shift in the vaginal microbiome, shortening and narrowing, urinary urgency and frequency, and recurrent urinary tract infections.

Two features distinguish it from other menopausal symptoms and make it the most important thing in this article:

1. It affects roughly 50–70 percent of postmenopausal women.
2. Unlike hot flushes, it is progressive and does not resolve on its own. Untreated, it continues to worsen.

It is also drastically under-treated. Surveys consistently find most affected women never raise it and are never asked.

Treatments for GSM, with evidence

• Vaginal moisturisers used regularly, two to three times weekly, independent of sexual activity. Distinct from lubricants used at the time of sex; both are useful and they do different jobs.
• Lubricant for sex — assume it, do not ration it. Iso-osmolar, low-glycerin products cause least irritation.
• Local vaginal oestrogen — cream, pessary, tablet or ring. Cochrane review evidence supports efficacy across preparations. Systemic absorption is very low. The Menopause Society (NAMS), the British Menopause Society and ACOG have all stated that the class labelling warning derived from systemic HRT trials is not supported by the evidence for low-dose vaginal preparations, and it is used in many breast cancer survivors after discussion with their oncologist.
• Vaginal DHEA (prasterone) and oral ospemifene — alternatives with trial support.
• Vaginal moisturising plus pelvic floor physiotherapy where pelvic floor hypertonicity has developed secondary to painful sex.
• Laser and radiofrequency devices — the FDA issued a safety communication in 2018 warning that these devices are not approved for menopausal symptoms and that adverse events including burns and scarring have been reported. Subsequent sham-controlled trials, including Li et al. (2021, JAMA), found no benefit over sham. Not recommended.

Regular sexual activity or masturbation maintains tissue blood flow and is associated with less severe atrophy — a real effect, and not a substitute for treatment.

Systemic hormone therapy

Effective for vasomotor symptoms, sleep disruption, mood symptoms in perimenopause, and bone protection. It helps GSM but frequently does not resolve it, so local treatment is often needed alongside.

The 2002 Women's Health Initiative results caused a global collapse in HRT use and were substantially over-generalised. The trial's average participant was 63 and many were more than a decade past menopause. Age-stratified re-analyses (Manson et al., 2013, 2017) found a considerably more favourable risk-benefit profile for women starting therapy under 60 or within 10 years of menopause — the group who actually seek treatment.

Current position of major bodies (NAMS, BMS, NICE, IMS): for symptomatic women under 60 or within 10 years of menopause without contraindications, benefits generally outweigh risks. Transdermal oestrogen avoids the small increase in venous thromboembolism risk seen with oral. Progestogen is required alongside oestrogen for anyone with a uterus, to protect the endometrium. Breast cancer risk with combined HRT is real, small in absolute terms, duration-dependent, and comparable to or smaller than the effect of moderate alcohol intake or obesity — figures worth discussing specifically rather than in the abstract.

Testosterone

Meta-analytic evidence (Islam et al., 2019, Lancet Diabetes & Endocrinology, 36 trials, over 8,400 participants) supports transdermal testosterone for postmenopausal hypoactive sexual desire disorder: a modest but statistically and clinically meaningful improvement in desire, arousal, orgasm and satisfying sexual events. The 2019 Global Consensus Position Statement endorses it for this indication only. No female-specific preparation is licensed in most countries, so male preparations are used at a fraction of the dose with monitoring.

Beyond hormones

Desire changes at menopause are not purely hormonal. Sleep disruption from night sweats, mood changes, body image shifts, relationship length, a partner's own sexual function, and caring responsibilities for both children and parents all contribute and are all addressable. Cognitive behavioural therapy has good evidence for vasomotor symptom bother and sleep, and mindfulness-based interventions have trial support for sexual distress.

Sources

• The Menopause Society (NAMS). Position statements on hormone therapy and on GSM, current editions.
• Lethaby A et al. "Local oestrogen for vaginal atrophy in postmenopausal women." Cochrane Database of Systematic Reviews, 2016.
• Manson JE et al. "Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the WHI randomized trials." JAMA, 2017.
• Islam RM et al. "Safety and efficacy of testosterone for women: a systematic review and meta-analysis." Lancet Diabetes & Endocrinology, 2019.
• Li FG et al. "Effect of fractional carbon dioxide laser vs sham treatment on symptom severity in women with postmenopausal vaginal symptoms." JAMA, 2021.
• NICE. Guideline NG23: Menopause diagnosis and management.
• US FDA. Safety communication on energy-based devices for vaginal rejuvenation, 2018.

Last reviewed: August 2026.