Menopause affects every woman on the planet, yet appropriate care for menopause remains lacking for most patients. Certain symptoms of menopause, for example, routinely go ignored and untreated. Genitourinary syndrome of menopause (GSM) is an unfortunate example of this disconnect between symptom and relief: Up to 87 percent of post-menopausal women experience GSM, yet only 6–7 percent receive appropriate treatment. The rest are left to deal with pain and suffering on their own.
As functional medicine practitioners, we can—and must—do better for the menopausal and post-menopausal women in our care.
What Is Genitourinary Syndrome of Menopause?
GSM is a broad spectrum of symptoms that overlaps between the genital, sexual, and urinary systems. It is strongly driven by a decline in estrogen, but it can also be accelerated by a change in androgen levels.
GSM is characterized by tissue changes and microbiome shifts. Without estrogen, the body loses collagen and elastin, making vaginal tissues thin, dry, and fragile. The pH level in the vaginal canal also rises, which kills off the body’s “good” bacteria and allows harmful bacteria to grow in their place.
Symptoms often appear gradually and can be separated into two main categories:
- Genital and Sexual Symptoms: These include vaginal dryness, burning, irritation, painful intercourse, and post-coital bleeding.
- Urinary Symptoms: Patients with GSM frequently experience urinary urgency, frequency, and pain with urination. Advanced cases often involve recurrent UTIs.
The Impact of Undiagnosed GSM
The vast majority of post-menopausal women struggle with undiagnosed genitourinary syndrome of menopause.
Drs. Leslie Fuller and Jillian Moehle understand this well. They have treated countless women suffering from unmanaged GSM. These patients are either ignorant of GSM as a condition, perhaps having been told such changes are just a natural part of aging, or they are just too embarrassed to bring it up.
Dr. Moehle shares that many of these women describe the sensation as a "sandpaper feeling" or feeling raw and uncomfortable. She also notes that they have often quietly changed their lives to try to cope, with methods such as only wearing certain clothing or underwear that they can tolerate.
But the impact of these mis- or non-diagnosed cases goes beyond personal discomfort: GSM, left to its own devices, has significant consequences. It is a chronic, progressive condition that does not improve with time. Rather, it continues to cause tissue damage and worsening pathology. This explains why many women can present GSM symptoms many years post-menopause. Dr. Moehle has seen such patients in their seventies and even eighties. Elderly patients, especially, can suffer serious complications such as urogenital sepsis, which can have a major impact on mortality.
Most practitioners assess menopausal women system by system, sending them to cardiology for arrhythmias, psychiatry for mood changes, and urogynecology for atrophy. They never connect these presentations to a single hormonal transition.
The cost?
- Missed prevention of cardiovascular disease
- Musculoskeletal fragility
- Cognitive decline
- Bone loss
- And more
Without an integrative assessment, you risk treating symptoms in isolation while the underlying transition progresses unchecked.
In “Perimenopause and Menopause: A Five-System Clinical Approach,” Drs. Leslie Fuller and Jilliam Moehle teach you how to reframe menopause as integrated physiology. You’ll learn how to get to the root of menopause quickly, during the critical window when outcomes are most modifiable.
Click here to learn more and start helping your menopausal patients today.
The Clinical Clues of GSM
The symptoms of genitourinary syndrome of menopause are not always easy to pinpoint, and they often come upon patients gradually. But, according to Drs. Fuller and Moehle, there are clinical cues that can point us toward a diagnosis.
The first clue is estrogen withdrawal, the root cause of GSM. There are a number of ways to detect estrogen withdrawal, including:
- Vasomotor clues such as hot flashes and night sweats.
- Neurocognitive indicators like brain fog, short-term memory lapses, or anxiety.
- A sudden rise in LDL-C, triglycerides, and ApoB in women who previously had normal lipid profiles.
- Unexplained weight gain around the midsection and a loss of lean muscle mass despite no change in lifestyle.
- Morning stiffness, slow healing from minor injuries, and conditions like frozen shoulder or plantar fasciitis occurring without significant trauma.
Shifts in vaginal pH are another red flag and can be seen with a simple swab test. A reading of over 4.5 is considered elevated and strongly supports a diagnosis of GSM. (This measurement is also helpful for distinguishing GSM from other types of vaginal infections.)
Other physical signs of GSM include vaginal tissue pallor (paleness) or redness, decreased vaginal tissue elasticity, and urethral aversion, where the sensitive urethra becomes more exposed and prone to pain.
Finally, your patients’ own experiences can serve as valuable clues during a clinical visit. Patients may report localized burning, itching, or general soreness in the genital area, painful intercourse, or a frequent urge to urinate, among other things.
Why do your smartest, most health-conscious patients suddenly develop brain fog, lose muscle despite exercise, gain visceral fat without weight gain, and experience injuries that won’t heal?
“Perimenopause and Menopause: A Five-System Clinical Approach” by Drs. Leslie Fuller and Jilliam Moehle answers this question by distilling how the loss of estrogen, progesterone, and testosterone leads to predictable, multisystem physiological changes.
You’ll learn the core concept of menopause as a neuroendocrine transition rather than a disease state. Core concepts include:
- Recognizing symptom clusters as diagnostic evidence
- Assessing all five affected systems in sequence
- Identifying the critical intervention window
- Implementing layered protocols that address multiple pathways simultaneously
Treating GSM in Your Patients
Because the symptoms of GSM are gradual and embarrassing, women often don't report them. But as functional medicine practitioners, it is our job to normalize the conversation. This means asking specifically about physical discomfort and daily challenges our patients might be experiencing.
Additionally, it’s our job to validate and humanize these experiences, says Dr. Moehle, rather than dismissing them as just a normal part of aging.
Thankfully, there are several tools at our disposal to treat GSM. The first line of defense includes non-hormonal treatments. Lubricants and moisturizers are recommended for mild cases. Vitamin E, hyaluronic acid, and aloe vera help hydrate the epithelium, lessening symptoms temporarily.
The “gold standard” treatments for tougher cases of GSM are hormonal. Low-dose vaginal estrogen (available in creams, tablets, or rings) is the most effective treatment for restoring tissue integrity. And, don’t worry, it’s safe: Low-dose vaginal estrogen has zero evidence of increasing the risk of breast cancer, endometrial cancer, or blood clots.
Of course, the best treatment of all is catching GSM early on, before symptoms ramp up. The American Urological Association now strongly emphasizes routine screening for GSM and encourages doctors to be proactive in documenting patients’ medical histories.
Perimenopause and Menopause: A Five-System Clinical Approach by Leslie Fuller, ND, and Jillian Moehle, ND
The gap between patients suffering from genitourinary syndrome of menopause and those experiencing relief is wide. But that doesn’t have to be the case in your practice. By developing your awareness of the symptoms and ability to diagnose and treat GSM, you can bring relief to the menopausal patients in your care.
This is the subject of the latest Kharrazian Institute Master Class, “Perimenopause and Menopause: A Five-System Clinical Approach,” taught by Drs. Leslie Fuller and Jillian Moehle. This course distills the clinical evidence on perimenopause and menopause into a systematic, five-system framework for assessment and treatment.
In addition to a much deeper dive on diagnosing and treating GSM, you’ll learn:
- How to distinguish menopausal changes from disease states
- Why bioidentical hormone formulations differ from compounds used in the past
- Which multisystem protocols produce measurable outcomes
- And much more…
You can learn more about the course and register here.
Leslie Fuller, ND, is a residency-trained naturopathic physician and full-time professor at the University of Western States, where she teaches clinical neurology, nutrition, and laboratory assessment.
Jillian Moehle, ND, is a naturopathic and functional medicine physician based in Portland, Oregon. She provides integrative primary care with a focus on perimenopause, menopause, and cardiometabolic health.
Frequently Asked Questions
How can I screen for GSM if my patients are too embarrassed to bring it up?
Because many women feel uncomfortable talking about vaginal and urinary changes, you must be proactive. Directly ask them about physical comfort, such as, "Are you experiencing any vaginal dryness, burning, or discomfort during intercourse?" Normalizing the conversation during regular visits removes the stigma and helps patients open up.
What is the best way to confirm a GSM diagnosis in an office setting?
Patient symptoms and visual signs (like tissue paleness or redness) are helpful indicators. A vaginal pH swab is another quick and objective tool. A reading above 4.5 strongly indicates estrogen depletion and supports a GSM diagnosis.
Is low-dose vaginal estrogen safe for patients?
Yes. Current medical evidence shows that low-dose local vaginal estrogens (such as creams, tablets, or rings) are highly safe. It does not increase the risk of breast cancer, endometrial cancer, or blood clots, making it a safe "gold standard" treatment for GSM.
How can I learn to connect GSM with the other systemic symptoms my menopausal patients are facing?
To learn how to stop treating these symptoms as separate issues and master a whole-body treatment strategy, you can register for the Kharrazian Institute Master Class, “Perimenopause and Menopause: A Five-System Clinical Approach.” Taught by Drs. Leslie Fuller and Jillian Moehle, this course will give you a practical, systematic framework to confidently diagnose and treat the root causes of menopause. Click here to register and transform your practice today.
