Genitourinary syndrome of menopause (GSM)

Genitourinary syndrome of menopause (GSM) is a chronic condition caused by oestrogen deficiency affecting the vulva, vagina, urethra and bladder. Symptoms are common but frequently under-reported, and women with diabetes may experience greater severity owing to increased susceptibility to infection, microvascular changes and neuropathy.

Symptoms and clinical features

Symptoms may include:

• Vaginal dryness, burning or irritation. 
• Dyspareunia (pain during intercourse).
• Reduced lubrication.
• Vulval itching or discomfort.
• Recurrent urinary tract infections.
• Urinary urgency, frequency or dysuria.
• Post-coital bleeding.

Women with diabetes are at increased risk of recurrent candidiasis and urinary tract infections, which may compound GSM symptoms and negatively affect quality of life and sexual well-being. Because symptoms can develop gradually, many women assume they are an inevitable part of ageing and may not volunteer concerns unless asked directly.

NICE provide a useful visual summary of the symptoms associated GMS symptoms.

Assessment in practice

Nurses are well placed to identify GSM during diabetes reviews by incorporating sensitive questioning. For example:

• “Have you noticed any vaginal dryness or discomfort?”
• “Do you have any bladder symptoms, such as urgency or recurrent infections?”
• “Has menopause affected intimacy or sexual comfort?”

It is also important to differentiate between GSM symptoms and other causes, such as infection, dermatological conditions or sub-optimal glycaemic control.

Management

Management aims to restore vaginal tissue health, relieve symptoms and improve quality of life.

First-line options

• Vaginal moisturisers (regular use).
• Water-based or silicone lubricants during intercourse.
• Avoidance of irritants, such as perfumed soaps.

Vaginal oestrogen therapy

Local vaginal oestrogen is highly effective and considered safe for most women, including those with diabetes. Benefits include:

• Improved vaginal lubrication and elasticity. 
• Reduced urinary symptoms. 
• Reduced risk of recurrent urinary tract infections. 
• Improved sexual comfort.

Systemic absorption is minimal, and treatment can usually be continued long term if symptoms persist.

Guidance from NICE (2026) and the British Menopause Society (2025) supports the use of local oestrogen therapy even in women who cannot take systemic HRT, although specialist advice may be needed in women with hormone-dependent cancers.

Diabetes-specific considerations

For women with diabetes, improving glycaemic control can reduce infection risk and may improve symptoms. Nurses should also consider:

• Screening for recurrent candidiasis. 
• Reviewing SGLT2 inhibitor therapy, if genital infections are problematic. 
• Encouraging good vulval hygiene practices. 
• Discussing sexual health openly and without stigma.

SGLT2 inhibitor therapy

Sodium–glucose co-transporter 2 inhibitors are associated with an increased risk of genital mycotic infections due to glycosuria. This risk is particularly relevant in postmenopausal women, who may already be predisposed to GSM, vulvovaginal atrophy and recurrent infections.

However, the development of genital infections should not automatically lead to discontinuation of therapy. Evidence and clinical experience suggest that many women can successfully continue SGLT2 inhibitor treatment with appropriate education and prompt management of symptoms.

A pragmatic approach includes:

• Early recognition and treatment of candidal infections with topical or oral antifungal therapy. 
• Reinforcement of perineal hygiene measures and avoidance of irritants. 
• Optimisation of glycaemic control, where needed. 
• Discussion of symptom patterns to distinguish infection from GSM-related irritation or dryness.

Importantly, GSM itself may increase susceptibility to irritation and infection-like symptoms, and addressing underlying oestrogen deficiency with vaginal oestrogen therapy can significantly improve tolerance of SGLT2 inhibitors in some women.

When to refer

Referral may be appropriate when:

• Symptoms persist, despite adequate treatment. 
• There is diagnostic uncertainty. 
• Suspicion of vulval dermatological disease. 
• Recurrent infections, despite good diabetes management. 
• Complex comorbidities.

Key practice points.

• Genitourinary symptoms are common, treatable and often overlooked.  • Proactive questioning during diabetes reviews can significantly improve comfort, sexual well-being and quality of life.