GSM: Menopause's Most Undertreated Condition

In 1998 the FDA fast-tracked approval for a small blue pill that fixes a blood flow problem in the penis. It took twenty-seven more years for regulators to strip a warning label off a cream that does something similar for the vagina, bladder, and vulva, a label that told millions of women the medicine could cause cancer, strokes, and dementia (14:01). That gap, between how fast medicine moves when the patient is a man and how slowly it moves when the patient is a woman, sits at the center of this conversation. The host, Dr. Mary Claire Haver, a board certified obstetrician-gynecologist, certified menopause practitioner, and adjunct professor at the University of Texas Medical Branch, calls the condition genitourinary syndrome of menopause, or GSM. She describes it as the single most undertreated condition of midlife, and also the easiest to fix (00:53).

GSM is not one symptom. It is a set of changes in the vulva, vagina, clitoris, urethra, and bladder that follow the drop in estrogen and testosterone at menopause (03:31). Haver cites research putting the prevalence at 50 to 80 percent of postmenopausal women, though she suspects the true number is closer to everyone who lives long enough (11:00). The symptom list is long and easy to misread as something else entirely: dryness, burning, pain at the entrance of the vagina, a harder or absent orgasm, urinary urgency, waking at night to urinate, and recurrent urinary tract infections that in frail older women can progress to delirium, falls, hip fracture, and sepsis (07:30, 22:32). Haver missed the diagnosis in herself. She spent months blaming stress and aging for a delayed orgasm until a colleague, physician Dr. Rachel Rubin, asked over text how much vaginal estrogen she was using. The answer was none (05:03).

"The prevention of UTIs in a menopausal patient for prevention should never be antibiotics, ever. It should be vaginal estrogen." — Dr. Mary Claire Haver [09:12]

A Label That Outlived Its Evidence

The name itself has a history worth sitting with. Before Haver's time, doctors called this condition "the senile vagina." Later it became "atrophic vaginitis," a term that still sounds like a diagnosis of decay. In 2014 a group of specialists renamed it genitourinary syndrome of menopause, adding the word "urinary" to a condition that had always involved the bladder, not just the vagina (02:33). The new name matters because it points to a new idea: this is a syndrome of low hormones affecting a whole connected system, not a cosmetic complaint about dryness.

The bigger obstacle has been regulatory. In 2002, headlines from the Women's Health Initiative study linked hormone therapy to breast cancer, a link Haver says was overstated and widely misunderstood. Before those headlines, roughly 30 to 40 percent of menopausal women used some form of systemic hormone therapy. Afterward, use collapsed, and by 2023 only about 4 percent of eligible women were getting a prescription (11:35, 12:05). In response, the FDA placed a sweeping black box warning, the strongest label the agency issues, on every estrogen product: pills, patches, and also the trace-dose vaginal creams meant to treat local tissue, with no distinction between the two (12:05). Viagra, by contrast, had already been approved in 1998 under fast-track status. Vaginal estrogen carried its scare label for more than 27 years before an FDA expert panel called for its removal in July 2025. The agency finally dropped the warning from low-dose vaginal products on November 10, 2025 (14:54). "The data didn't change," Haver says. "The data had been there for decades" (15:20). What changed was tens of thousands of letters, social media pressure, and a panel willing to look at the evidence again.

"Two dirty words: vagina and estrogen." — Dr. Mary Claire Haver [39:10]

The label has changed, but prescribing habits have not caught up, partly because systemic hormone therapy and local vaginal estrogen get confused. Haver stresses that systemic therapy, the pill or patch used to treat hot flashes, is a microdose compared with what the ovaries once produced, and it was never designed to fully protect genital and urinary tissue (05:26). Most women on systemic therapy, Haver included, still need a topical vaginal estrogen layered on top. She did not realize this about her own body until the diagnosis landed on her, which is partly why she tells the story: if a menopause specialist can miss it, anyone can.

Treating the Whole Neighborhood

The mechanism is straightforward once it is named. Haver compares hormones to water for a plant: at puberty, estrogen and testosterone flood the genital tissue and it blossoms, the vaginal lining thickens and folds, and a healthy microbiome takes hold. At menopause, the water stops, and the process partly runs backward (16:22). The vaginal lining thins and flattens, natural lubrication drops, and the labia minora can gradually shrink over five to twenty years, a slow process that a viral video by Dr. Rachel Rubin made famous, though Haver is careful to note the tissue does not detach or fall off (18:27). The clitoris, which is driven heavily by testosterone, also shrinks and loses blood flow and nerve responsiveness as testosterone declines, a process that Haver says begins in a woman's 30s, long before menopause itself (18:55). The clinical result is often delayed or absent orgasm, a symptom few women connect to hormones.

One structure gets missed most often: the vulvar vestibule, the ring of tissue surrounding the urethra that urologists call the "ring of fire." It is not vaginal tissue; embryologically it is closer to the inside of the cheek, and it is packed with both estrogen and androgen receptors (20:14). A standard speculum exam bypasses it entirely, so clinicians usually find it with a cotton swab test that maps exactly where pain with penetration originates (21:18). The bladder and urethra share a wall lined with the same hormone receptors, which is why low estrogen also produces urgency, frequency, and a microbiome shift that makes recurrent UTIs more likely in menopause (21:41).

Given all that, Haver argues the old standard of care, handing out lubricants and requiring women to fail them before considering hormones, treats the symptom while the tissue keeps deteriorating. The current frontline treatment, following updated American Urological Association guidance, is vaginal estrogen itself, which she calls safer than aspirin or Tylenol (23:37). It comes as a cream, tablet, insert, or ring; her clinic favors the generic cream because it is cheap, costing $13 to $20 a tube at Cost Plus, and because it can be applied precisely to the areas that actually hurt (26:01). Her instructions are specific: apply cream from the first knuckle down, insert a finger about halfway into the vagina and swirl, then spread the rest from the clitoris down across the labia and the vestibule, twice a week.

"Treat the entire neighborhood, not just one block." — Dr. Mary Claire Haver [28:43]

She tells patients to expect about six weeks before the tissue visibly heals, since the vagina needs time to regrow its lining and regain the ability to produce mucus (27:21). For pain or delayed orgasm that persists after estrogen alone, she sometimes adds vaginal DHEA, sold as Prasterone, a precursor hormone that converts locally into both estrogen and testosterone and can engage androgen receptors in the clitoris and vestibule that estrogen alone does not reach (28:43). She draws a sharp line between all of this and over-the-counter products: lubricants reduce friction during sex but do nothing for urinary tract infections, and daily moisturizers, usually built on hyaluronic acid, which can pull about 100 times its own weight in water, ease daily dryness without touching the underlying hormone deficiency (35:07). Neither is a substitute for estrogen; both are useful alongside it.

The financial case for fixing this is large and almost entirely untapped. Among Medicare patients who actually received a GSM diagnosis, only about 7 percent were prescribed vaginal estrogen (37:09), and Haver believes real-world use is lower still, since many women received the prescription and were too frightened by the old warning label to fill it. Research she cites, co-authored by Dr. Rachel Rubin, estimates that broad use of vaginal estrogen could save Medicare 6 to 22 billion dollars a year, mostly by preventing the UTIs, hospitalizations, and hip fractures that follow untreated infections in frail older women (38:10). Vaginal estrogen itself cuts recurrent UTIs roughly in half (38:36). Haver's closing advice is almost defiantly simple: ask for it by name, print the updated guidelines, and do not accept a conversation that starts and ends with a tube of lubricant. Common, she keeps repeating, does not mean normal.