Why GSM Gets Missed, and What That Silence Actually Costs

GSM affects most women but they think it's just aging. So they don't bring it up to their doctors.

Most postmenopausal women experience genitourinary syndrome of menopause (GSM). But almost none have heard of it.

Only about 1 in 4 women ever discuss these symptoms with a doctor, and one survey found 96% of women never connected their symptoms, dryness, burning, recurrent UTIs, to GSM at all.

This isn't a small gap. It has real consequences, and one of the clearest examples is what's happening with recurrent UTIs.

Antibiotics that don't fix the problem

If you've had round after round of antibiotics for UTIs that keep coming back, you're not alone, and the pattern itself is worth questioning. One study found that 41% of antibiotics prescribed for recurrent UTIs in older women were unnecessary (Critchlow et al., International Urogynecology Journal, 2025).

Here's why. Chronic UTIs after menopause are often caused by tissue and bacterial changes from declining estrogen, not a new infection each time. That's GSM. Antibiotics treat the infection in front of you, but they don't fix what's causing it to keep coming back.

Vaginal estrogen treats the actual cause. It's been shown to reduce recurrent UTI frequency by roughly 50% (Tan-Kim et al., Am J Obstet Gynecol, 2023).

This matters more than it might seem. Left untreated, a "simple" UTI can become a life-threatening emergency as women get older. One large study, drawing on over 2 million patient records, found women over 55 with recurrent UTIs who weren't using vaginal estrogen had significantly higher rates of sepsis and death compared to those who were (Wells et al., J Urology, 2025).

Why doesn't this come up sooner?

A few things are happening at once.

Symptoms overlap with other conditions. The 2025 AUA/SUFU/AUGS clinical guideline notes there's no medical consensus on which symptoms confirm GSM, since the same urinary symptoms overlap with overactive bladder, recurrent UTI, and other conditions like infectious vaginitis or dermatitis.

The patient-doctor silence gap. Only about a quarter of women ever bring these symptoms up with a provider, often because they believe it's simply a normal part of aging. As Harvard's Dr. Caroline Mitchell put it, describing this exact pattern: "They don't bring it up with their doctors, and we don't ask."

Tissue changes get missed on exam. Early-stage changes can be subtle, and are often attributed to normal aging rather than examined closely.

Fragmented care. Urinary symptoms often go to a urologist. Hormonal symptoms go to a gynecologist. GSM affects both systems at once, and treating them separately means missing the actual cause.

Why early diagnosis matters

GSM doesn't behave like other menopause symptoms. Hot flashes and night sweats tend to fade with time. GSM doesn't. Left untreated, it tends to get worse: skin gets thinner, itchier; sex gets more painful; UTIs happen more often. None of that resolves on its own.

The reassuring part: it's very treatable, and it's not too late to start, even years after symptoms began. Vaginal estrogen may be used at any age and for extended duration (NAMS, 2022).

If any of this sounds familiar, don't wait for your doctor to ask first. Bring it up.

This article is for educational purposes only and does not constitute medical advice. Always consult your doctor about your specific symptoms and treatment options.

References:

• Critchlow E, Kuzma A, Koelper N, Agrawal S, Dutcher L, Arya L. Unnecessary Antibiotics in Older Female Patients with Recurrent Urinary Tract Infections. International Urogynecology Journal. 2025;36(6):1319-1326.

• Tan-Kim J, Shah NM, Do D, et al. Efficacy of vaginal estrogen for recurrent urinary tract infection prevention in hypoestrogenic women. Am J Obstet Gynecol. 2023.

• Wells BA, De EJB, Feustel PJ, et al. Impact of Vaginal Estrogen on Serious Adverse Outcomes in Postmenopausal Women with Recurrent Urinary Tract Infections. Abstract IP15-36. The Journal of Urology. 2025.

• AUA/SUFU/AUGS Clinical Practice Guideline on Genitourinary Syndrome of Menopause. American Urological Association. 2025.

• Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) survey. Climacteric. 2012;15(1):36-44.

• The NAMS 2022 Hormone Therapy Position Statement Editorial Panel. Menopause. 2022;29(7):767-794.