New Menopause Guidelines Every Woman Should Know: Protecting Bladder and Vaginal Health

By Lisa Lenhart, PT

Most women in their 40s, 50s, and 60s know the “classic” symptoms of perimenopause and menopause: hot flushes, night sweats, heart palpitations, weight gain, missed or heavy periods, and brain fog.

But there are also important changes that occur in the pelvic floor and bladder that don’t always get talked about. These changes are part of what’s now recognized as Genitourinary Syndrome of Menopause (GSM).

What is GSM?

GSM is a collection of symptoms in the pelvis, vagina, bladder, and urethra that occur due to declining estrogen levels.

Common GSM symptoms include:

• Vaginal dryness, itching, or burning

• Pain with intercourse (dyspareunia)

• Urinary urgency and increased frequency

• Recurrent urinary tract infections (UTIs)

• Overactive bladder symptoms

These changes aren’t just inconvenient. They can affect quality of life medically, physically, socially, psychologically, and sexually.

Why UTIs Become a Bigger Deal After Menopause

Lower estrogen leads to thinning of the vaginal and urinary tissues, a decrease in protective lactobacilli, and a rise in vaginal pH. Together, these factors make the urinary tract more vulnerable to infection. Add in pelvic floor weakening (which can affect bladder emptying), and it’s easy to see why UTIs often become more frequent and harder to shake after menopause.

This broader picture is GSM—and the good news is, there are now new, evidence-based guidelines to help.

The AUA’s 2025 Guideline: A New Standard of Care

In April 2025, the American Urological Association (AUA) released the first comprehensive guideline on GSM, in collaboration with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) and the American Urogynecologic Society (AUGS).

This landmark guideline outlines safe, effective treatment options to restore tissue health, improve urinary symptoms, and reduce recurrent UTIs.

Key Treatment Options

1. Vaginal Estrogen (Low-Dose)

   • Applied as a cream, pill/suppository, or ring.

   • Treats dryness, irritation, painful intercourse.

   • Improves bladder symptoms and reduces UTI risk.

   • Works locally, without significant systemic absorption.

2. DHEA (Dehydroepiandrosterone)

   • Offered as a cream or suppository.

   • Helps with vaginal dryness and painful intercourse.

3. Ospemifene

   • An oral pill prescribed for vulvovaginal dryness and painful intercourse.

4. Combination with Systemic Hormone Therapy

   • Patients on systemic estrogen (like a patch or pill) can still use vaginal estrogen or DHEA for added vulvovaginal or bladder support.

   
   

Evidence and Safety

The AUA guidelines strongly support local, low-dose vaginal estrogen for managing GSM symptoms and preventing recurrent UTIs. Clinical data show:

• Vaginal estrogen can cut UTI recurrence risk by more than 50%.

• Trials demonstrate up to a 95% UTI-free probability at 4 months versus 30% with placebo.

• Tissue health, lubrication, and beneficial vaginal microbiota improve significantly with use.

Importantly, the guideline reassures:

• Vaginal estrogen is not linked to breast or endometrial cancer.

• DHEA and ospemifene do not increase breast cancer risk.

Energy-based devices such as CO₂ or Er:YAG lasers and radiofrequency are not recommended, as there isn’t sufficient evidence to support their safety or effectiveness.

Beyond Prescriptions: Whole-Person Support

While medication is often front-line, GSM treatment doesn’t stop there. The guideline encourages shared decision-making so women can explore options that fit their needs, preferences, and health history.

Additional supportive strategies include:

• Moisturizers and lubricants for comfort

• Pelvic floor physical therapy to improve bladder control, mobility, and sexual function

• Lifestyle and wellness support, including movement, hydration, and stress management

Why This Matters

Genitourinary symptoms of menopause don’t have to be endured silently. With the release of the AUA’s new guidelines, women now have clear, evidence-based options to restore pelvic and bladder health, prevent UTIs, and reclaim comfort and confidence in daily life.

👉 Takeaway: If you’re experiencing symptoms of GSM—whether it’s bladder urgency, painful intercourse, or recurrent UTIs—know that help is available. Talk with your healthcare provider about these new treatment options, and explore how pelvic health physical therapy can complement your plan.

For more information, visit the AUA guideline on GSM.