The Symptom No One Warned You About
When most women picture menopause, they picture hot flashes. Maybe night sweats. Maybe the dramatic, fan-yourself-at-dinner kind of moment that gets joked about in movies.
What they often don't picture is this: a creeping, quiet kind of discomfort. Dryness that makes sitting through a workday harder than it should be. Burning or itching that you'd never bring up casually. Pain with intimacy that starts to feel personal — even though it isn't. A urinary tract infection that keeps coming back without a clear reason.
If any of that sounds familiar, you are not imagining it, you are not alone, and you are not "just getting older." There is a name for this collection of symptoms — Genitourinary Syndrome of Menopause, or GSM — and there are real options to help you feel like yourself again.
At LeFave Pharmacy in Alpena, we talk with women in northern Michigan about this every week. Many of them tell us the same thing: I didn't know I was allowed to ask about this. So let's start there. You are. And here is what we want you to know.
What Is Genitourinary Syndrome of Menopause (GSM)?
GSM is the medical term for a group of changes that can happen in the vaginal, vulvar, and urinary tissues during perimenopause and menopause. It used to be called vulvovaginal atrophy or atrophic vaginitis, but the newer term — adopted by the North American Menopause Society and the International Society for the Study of Women's Sexual Health — is broader and more accurate, because the changes affect more than just vaginal tissue.
GSM happens because estrogen levels drop as ovarian function slows down. Estrogen helps keep the tissues of the vagina, vulva, urethra, and bladder thick, elastic, well-lubricated, and pH-balanced. When estrogen falls, those tissues can become thinner, drier, less elastic, and more sensitive — which can show up as a wide range of symptoms.
GSM is common. Research suggests that roughly half of postmenopausal women experience GSM symptoms, though many studies put that figure higher because the condition is so under-reported. And unlike hot flashes, which often improve over time, GSM tends to be progressive — meaning symptoms can persist or worsen the longer estrogen stays low, unless something is done to support the tissue.
That last part is important: GSM rarely "just goes away." But it is very treatable.
Symptoms of GSM: It's Not Just Vaginal Dryness
One of the reasons GSM goes undiagnosed is that the symptoms vary so much from person to person. You may have one or two of these — or several. Common symptoms include:
Vulvovaginal symptoms
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Vaginal dryness
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Burning, itching, or irritation
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A sensation of tightness or pressure
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Pain or discomfort during intercourse (sometimes called dyspareunia)
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Light spotting after intimacy
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Decreased sexual sensation or arousal
Urinary symptoms
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Urgency (the "I have to go right now" feeling)
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More frequent trips to the bathroom
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Painful or burning urination
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Recurrent urinary tract infections (UTIs)
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Mild stress incontinence
If you have been living with any of these and chalking them up to stress, age, or "the way it is now" — please know that there is a reason these things may be happening, and there are options worth exploring with a knowledgeable provider.
Why GSM Is So Underdiagnosed
A few reasons. First, GSM symptoms tend to overlap with other things — UTIs, yeast infections, skin sensitivity, even normal day-to-day discomfort — which makes it easy to dismiss. Second, many women never bring it up. A widely-cited international survey by the North American Menopause Society found that only a fraction of women with GSM symptoms actually discuss them with their healthcare provider, often because they feel embarrassed or assume nothing can be done.
And third, GSM is genuinely under-taught. Hot flashes and night sweats get most of the airtime in menopause conversations. Vaginal and urinary symptoms — even though they affect quality of life, intimacy, sleep, and confidence — get far less.
You don't have to keep quiet about it. And you don't have to live with it.
How GSM Is Treated: An Overview of Your Options
There is no single "right" treatment for GSM. The best plan depends on your symptoms, your health history, your other menopausal changes, and what you and your healthcare provider decide together. Many women benefit from a combination of approaches.
Here is a plain-language overview of what is generally available.
1. Non-hormonal options
For mild symptoms, or for women who can't or prefer not to use hormones, non-hormonal approaches may help:
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Vaginal moisturizers — applied regularly (not just before intimacy) to support tissue hydration over time.
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Personal lubricants — used as needed to reduce friction and discomfort during intimacy. Water- and silicone-based options are generally well tolerated.
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Pelvic floor physical therapy — can help when pain, tightness, or urinary symptoms are part of the picture.
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Lifestyle support — staying hydrated, avoiding harsh soaps and irritants, and gentle, consistent intimacy or pelvic stimulation can all help maintain tissue health.
These approaches don't replace estrogen, but for some women they are enough — or they pair well with other treatments.
2. Local (vaginal) estrogen therapy
For moderate to severe GSM, local vaginal estrogen is one of the most studied and supported treatments. It delivers a small dose of estrogen directly to the affected tissues, with very limited absorption into the rest of the body. Major medical organizations — including the North American Menopause Society and the American College of Obstetricians and Gynecologists — recognize low-dose vaginal estrogen as a first-line option for GSM in appropriate candidates.
Vaginal estrogen is available in several FDA-approved commercial forms (creams, tablets, rings) and may also be available as a compounded preparation when a custom strength, base, or delivery form is needed for an individual patient.
3. Compounded estrogen creams and inserts
This is where compounding pharmacies come in. Some women — and their prescribers — find that commercially available products don't quite fit their needs. Maybe the dose is too high or too low. Maybe the base ingredients cause irritation. Maybe a different application form (a cream, a suppository, a gel, a ring base) would be easier to use consistently.
A compounding pharmacy such as LeFave Pharmacy and Compounding, can prepare a patient-specific compounded estrogen cream or related preparation based on a prescription written by your healthcare provider. Common compounded options for GSM may include:
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Estradiol vaginal cream in custom strengths
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Estriol vaginal cream
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Testosterone is often an excellent added option
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Combination preparations (for example, estradiol + estriol, sometimes called "Bi-Est" formulations)
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Vaginal suppositories or inserts in custom bases
Compounded medications are not FDA-approved drugs — they are prescription preparations made for an individual patient. At LeFave Pharmacy, every compounded preparation is made in our 503A pharmacy in Alpena, as prescribed by your healthcare provider, and tailored to the dose and form that fits your prescription.
If you'd like to learn more about how this works, our Custom Compounding page walks through the process.
4. Systemic BHRT (bioidentical hormone replacement therapy)
Some women have GSM along with other significant menopausal symptoms — hot flashes, sleep disruption, mood changes, low libido, brain fog. In those cases, systemic bioidentical hormone replacement therapy (BHRT) may be considered, in addition to or instead of local treatment.
BHRT uses hormones that are structurally identical to the ones your body naturally produces (such as estradiol and progesterone). It can be delivered in several forms — creams, capsules, troches, or other preparations — and the goal is to support whole-body symptom relief, not just local tissue health.
BHRT isn't right for everyone, and it's a conversation that involves your full health history, your goals, and your healthcare provider's clinical judgment. Many patients in northern Michigan come to LeFave for a pharmacist consultation about BHRT as a complement to working with their provider.
Why Compounding Can Make a Difference for GSM
For many GSM patients, the right dose, in the right form, in the right base is what actually makes a treatment work — or stop working. Compounded preparations can be useful when:
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A patient is sensitive to a preservative, dye, or filler in a commercial product
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A lower (or higher) strength is clinically appropriate
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A different delivery form would improve comfort or consistency
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A combination of hormones in a single preparation is prescribed
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The ability to use and add Testosterone or DHEA as an additional option
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A specific base — soothing, hypoallergenic, or fragrance-free — is needed
Compounding doesn't replace commercial products — it complements them. As a 503A compounding pharmacy, our role at LeFave is to prepare patient-specific medications based on a prescription from your healthcare provider, with the precision and personal attention that's hard to get in a one-size-fits-all setting.
The Role of Hormone Testing
Hormone testing isn't required to begin treatment for GSM — clinical symptoms are usually enough for a healthcare provider to make a treatment plan. But for some women, comprehensive hormone testing can add helpful context, especially when symptoms are confusing, when treatment isn't working as expected, or when a more complete picture of hormone health is wanted before considering systemic BHRT.
LeFave offers comprehensive hormone panel options and pharmacist-led review of results. We work alongside your healthcare provider — not in place of them — so the picture stays complete.
What to Expect at a Pharmacist Consultation
If you're not sure where to start, a bioidentical hormone replacement consultation at LeFave Pharmacy is a good first step. It is not a sales pitch and it is not a substitute for your provider — it's a conversation.
Here's what a typical consultation looks like:
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You share what's going on. Your symptoms, what you've tried, what's working, what isn't.
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We listen and educate. Dr. Spicer or one of our pharmacists walks through what GSM and broader hormone changes can look like, what the treatment options are, and what may make sense in your situation.
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We coordinate with your provider. If a compounded preparation or BHRT plan looks like a fit, we partner with your prescribing healthcare provider on the specifics. They write the prescription; we prepare it.
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We follow up. Treatment for GSM is rarely "set it and forget it." We check in, adjust as needed in coordination with your provider, and answer questions as they come up.
Many patients tell us that the relief of simply being heard — and given clear, honest information — is half the battle.
Frequently Asked Questions About GSM
Is GSM the same as vaginal atrophy? GSM is a broader, updated term that includes vaginal atrophy plus the urinary and vulvar changes that often go along with it. Many providers and patients still use the older terms interchangeably.
Does GSM only happen after menopause? No. GSM symptoms can begin during perimenopause, the years leading up to menopause, when estrogen levels start to fluctuate. They can also occur in younger women after certain medical treatments that lower estrogen.
Will GSM go away on its own? For most women, no. Unlike hot flashes, GSM tends to be progressive when left untreated, because the underlying tissue change continues as long as estrogen stays low. The good news is that it usually responds well to treatment.
Is vaginal estrogen safe? Low-dose vaginal estrogen is recognized as a first-line option for GSM by major medical societies, with very limited absorption into the rest of the body. As with any prescription, it should be evaluated based on your individual health history with your healthcare provider.
What's the difference between bioidentical and synthetic hormones? Bioidentical hormones are structurally identical to the hormones your body produces. Synthetic hormones are similar but not identical in structure. Both have a place in care — the right choice depends on your situation, preferences, and your provider's clinical recommendation.
Do I need a prescription for compounded estrogen cream? Yes. Compounded medications are prepared based on a prescription written by your healthcare provider for you, individually. They are not available over the counter.
How long does it take to feel better? Many patients report initial improvement in tissue comfort and dryness within a few weeks of consistent use, with continued improvement over several months. Individual responses vary.
Can GSM affect my urinary symptoms or recurrent UTIs? Yes. Because the urinary tract tissues are also estrogen-sensitive, GSM can contribute to urgency, frequency, discomfort, and recurrent UTIs in some women. Local estrogen therapy is sometimes part of the plan in those cases.
You Deserve to Feel Like Yourself Again
Hot flashes get the headlines, but for a lot of women, GSM is the symptom that quietly affects daily life the most — and it's the one we're most likely to suffer in silence about.
You don't have to. Whether it's a non-hormonal moisturizer, a low-dose vaginal estrogen prescription, a compounded preparation tailored to you, or a broader BHRT conversation, there are real, evidence-informed options worth exploring.
If you're in Alpena or anywhere in northern Michigan and want to talk through what might fit your situation, we're here.
Schedule a consultation with LeFave Pharmacy →
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About the Reviewer
This article was reviewed by Dr. Kristine Spicer, PharmD, owner and lead pharmacist at LeFave Pharmacy & Compounding in Alpena, Michigan. Dr. Spicer specializes in bioidentical hormone replacement therapy, custom compounding, and personalized hormone support for women in northern Michigan.
Disclaimer
This content is for informational purposes only and does not constitute medical advice. Compounded medications are prepared based on individual patient prescriptions and are not FDA-approved drugs. Please consult with your healthcare provider and pharmacist before starting any new medication or supplement.