Genitourinary syndrome of menopause (GSM) describes a group of genital, sexual and urinary symptoms associated with the hormonal changes of menopause. Vaginal dryness may be the most familiar symptom, but GSM can also involve burning, irritation, painful intercourse, urinary urgency, recurrent urinary tract infections and urinary incontinence. Unlike some vasomotor menopausal symptoms, genitourinary symptoms frequently persist without appropriate management (The North American Menopause Society [NAMS], 2020).

Physiotherapy does not replace treatment directed at oestrogen-sensitive vulvovaginal tissues. Its important role is to identify and treat associated pelvic-floor muscle dysfunction, urinary symptoms, pain, movement and behavioural contributors, while recognising when medical assessment is required. Current guidance therefore supports an integrated rather than an exclusively muscular approach to GSM.

What Is Genitourinary Syndrome of Menopause?

GSM develops as declining oestrogen and other sex-steroid concentrations affect tissues of the vulva, vagina, urethra and bladder. The term is broader than the older description vulvovaginal atrophy because symptoms commonly involve urinary and sexual functions as well as vaginal tissues (NAMS, 2020).

Typical presentations include the following:

vaginal or vulval dryness, burning and irritation;
reduced lubrication during sexual activity;
discomfort or pain with penetration;
urinary urgency, frequency or dysuria;
urinary incontinence;
recurrent urinary tract infections; and
changes in sexual comfort and function.

Not every urinary or pelvic symptom occurring after menopause should automatically be labelled GSM. Infection, dermatological conditions, pelvic-organ prolapse, vulvodynia, bladder disorders and gynaecological pathology may produce overlapping symptoms. Assessment must therefore remain symptom-specific rather than assuming that menopause explains every complaint.

Why Menopause Changes the Genitourinary System

Estrogen receptors are present throughout the vaginal, vulval and lower urinary tissues. With the menopausal reduction in estrogen, the vaginal epithelium becomes thinner and less well lubricated, while tissue elasticity, vascularity and moisture may decline. Changes can also occur around the urethra and bladder (NAMS, 2020; Berek, 2020). Current AUA/SUFU/AUGS guidance describes GSM as a spectrum of symptoms and physical changes related to declining estrogen and androgen concentrations in the genitourinary tract.

These hormonal changes can interact with the pelvic floor in different ways. Painful or dry vaginal tissues may encourage protective muscle guarding, producing an overactive and tender pelvic floor. Conversely, ageing, childbirth history, inactivity and other factors may contribute to reduced pelvic-floor strength or coordination, particularly when urinary incontinence is present.

This explains an important clinical principle:

GSM does not automatically mean a weak pelvic floor.

One patient may require progressive pelvic-floor strengthening; another may first require relaxation, desensitisation and restoration of comfortable muscle length. Automatically prescribing repeated “Kegels” without assessing muscle function can therefore be inappropriate.

Preliminary menopause-specific research has also explored whether pelvic-floor muscle training (PFMT) may influence local blood flow and tissue characteristics. A feasibility study by Mercier et al. (2019), followed by mechanistic analysis, reported improvements in pelvic-floor function and some vulvovaginal measures after training. These findings are promising but remain insufficient to consider PFMT a replacement for established GSM-directed medical therapy (Mercier et al., 2020).

Physiotherapy Assessment: Look Beyond Strength

A pelvic-health assessment begins with a sensitive history. The physiotherapist should clarify the menopause stage, symptom onset, bladder and bowel function, leakage, urgency, sexual or penetration-related pain, activity limitations and previous pelvic or gynaecological history.

With informed consent and appropriate training, pelvic-floor examination may assess muscle contraction, relaxation, endurance, coordination, tenderness and elevated resting tone (Bø et al., 2015). Functional tasks such as coughing, lifting or sit-to-stand may also be relevant when leakage or pressure symptoms are reported.

Physiotherapists should also ask how symptoms affect exercise, intimacy, sleep and quality of life. GSM is not merely an anatomical problem; avoidance of movement, sexual activity or social situations can become part of the functional presentation.

Physiotherapy Management: Match Treatment to the Impairment

Pelvic-floor muscle training

For women with urinary incontinence and demonstrable reduced pelvic-floor strength or coordination, supervised PFMT is an important conservative intervention. Training may include correct contraction technique, endurance and repeated contractions, coordination with breathing and pre-contraction before increases in intra-abdominal pressure.

Evidence supports PFMT for urinary incontinence in postmenopausal women, although studies specifically isolating women with diagnosed GSM remain fewer. Recent evidence continues to support clinically meaningful improvements in postmenopausal urinary-incontinence symptoms with PFMT.

Down-training and pain rehabilitation

Where examination demonstrates guarding, tenderness or difficulty relaxing the pelvic floor, strengthening alone is inappropriate. Treatment can instead involve diaphragmatic breathing, pelvic-floor relaxation, awareness training, graded mobility and, when indicated and consented to, manual pelvic-floor techniques.

A randomised clinical trial involving climacteric women with dyspareunia found that a pelvic-floor rehabilitation programme incorporating relaxation, myofascial treatment and pelvic-floor training improved pain and sexual-function outcomes compared with a control intervention (Schvartzman et al., 2019). The study was small, so these findings should support rather than overstate the evidence for menopause-specific pelvic physiotherapy.

Bladder rehabilitation

Urgency, frequency or mixed urinary symptoms may benefit from bladder education, scheduled voiding when appropriate, gradual optimisation of voiding intervals and urge-suppression strategies. Excessive “just in case” urination, restricted fluid intake and habitual straining should also be identified.

Graded return to comfortable penetration

When pain has produced fear or protective pelvic-floor contraction, rehabilitation may incorporate graded exposure. Depending on clinical indication and patient preference, this may involve progressive relaxation, external or internal desensitisation and vaginal dilators. The goal is not simply to tolerate pain but to restore comfortable, controlled pelvic-floor relaxation.

Physiotherapy and Medical GSM Treatment Work Together

One of the most important boundaries for physiotherapists is recognising that exercise cannot fully correct the estrogen-related tissue changes underlying GSM.

Non-prescription management may include vaginal moisturisers used regularly and lubricants to decrease friction during sexual activity. Medical treatments can include low-dose vaginal estrogen, vaginal dehydroepiandrosterone and oral ospemifene, depending on symptoms, contraindications and patient preference. The 2025 AUA/SUFU/AUGS guideline emphasises evidence-based hormonal and non-hormonal treatment rather than relying on a single treatment for every patient.

Physiotherapy becomes especially valuable when tissue symptoms coexist with:

stress or urgency urinary incontinence;
pelvic-floor weakness;
overactive or painful pelvic-floor muscles;
dyspareunia with muscular guarding;
impaired bladder habits;
constipation and straining; or
reduced confidence with exercise and daily activity.

For patients with a history of hormone-sensitive cancer, treatment decisions regarding hormonal therapies require individualised medical discussion. Physiotherapists can continue to manage relevant musculoskeletal, pelvic-floor and functional impairments while communicating with the wider healthcare team.

When Should the Physiotherapist Refer?

GSM is common, but potentially important pathology should never be attributed to menopause without appropriate assessment.

Medical or gynaecological evaluation is particularly important with postmenopausal vaginal bleeding, visible vulval or vaginal lesions, unexplained persistent discharge, haematuria, significant new pelvic pain, recurrent suspected infections, urinary retention or symptoms that remain unexplained or fail to improve.

Suspected urinary tract infection accompanied by fever, systemic illness or flank pain also requires appropriate medical assessment.

A practical physiotherapy pathway is:

Genitourinary symptoms around menopause → identify genital, urinary and sexual symptoms → screen for warning signs and differential diagnoses → assess pelvic-floor function → determine weakness versus overactivity/pain → begin impairment-specific rehabilitation → coordinate GSM-directed medical treatment when indicated → reassess symptoms and function.

The key is shared care. The physiotherapist treats the functional pelvic-floor and behavioural consequences of GSM while the medical team addresses hormonal, infectious, dermatological or other pathology where necessary.

Viva-Ready Summary

Genitourinary syndrome of menopause (GSM) is a collection of genital, sexual and lower urinary symptoms associated with declining estrogen and androgen concentrations around and after menopause.

Common symptoms include vaginal dryness, irritation, dyspareunia, urgency, frequency and urinary incontinence.
Menopause alters vulvovaginal and lower urinary tissues, but pelvic-floor dysfunction varies between patients.
The pelvic floor may be weak, poorly coordinated, overactive or painful.
PFMT is particularly useful when urinary incontinence or reduced pelvic-floor function is present.
Pain and pelvic-floor hypertonicity require relaxation, down-training and graded rehabilitation rather than automatic strengthening.
Bladder training and behavioural strategies can help urgency and frequency.
Physiotherapy does not replace moisturisers, lubricants or medically indicated hormonal/non-hormonal GSM treatment.
Postmenopausal bleeding, suspicious lesions, haematuria, significant pain or unexplained persistent symptoms require referral.

One-line recall point:
In GSM, physiotherapy treats the pelvic-floor, bladder, pain and functional consequences of menopause—while estrogen-sensitive tissue disease often requires concurrent medical management.

References

American Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, & American Urogynecologic Society. (2025). Genitourinary syndrome of menopause: AUA/SUFU/AUGS guideline. American Urological Association.

Berek, J. S. (Ed.). (2020). Berek & Novak’s gynecology (16th ed.). Wolters Kluwer.

Bø, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (Eds.). (2015). Evidence-based physical therapy for the pelvic floor: Bridging science and clinical practice (2nd ed.). Elsevier.

Mercier, J., Morin, M., Tang, A., Reichetzer, B., Lemieux, M.-C., Khalifé, S., Zaki, D., Gougeon, F., & Dumoulin, C. (2020). Pelvic floor muscle training: Mechanisms of action for the improvement of genitourinary syndrome of menopause. Climacteric, 23(5), 468–473.

Mercier, J., Morin, M., Zaki, D., Reichetzer, B., Lemieux, M.-C., Khalifé, S., & Dumoulin, C. (2019). Pelvic floor muscle training as a treatment for genitourinary syndrome of menopause: A single-arm feasibility study. Maturitas, 125, 57–62.

Schvartzman, R., Schvartzman, L., Ferreira, C. F., & Vettorazzi, J. (2019). Physical therapy intervention for women with dyspareunia: A randomized clinical trial. Journal of Sex & Marital Therapy, 45(5), 378–394.

The North American Menopause Society. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 27(9), 976–992.