NAMS Position Statement: The 2020 Genitourinary Syndrome of Menopause Position Statement of the North American Menopause Society

Menopause. 2020;27(9):976-992. 

In This Article

Evaluation and Diagnosis

The evaluation of GSM includes a history and pelvic examination. A medical history may identify contributing factors, alternative etiologies, and effective therapeutic interventions. The pelvic examination should identify signs consistent with GSM and eliminate other pathologic conditions that may cause similar symptoms.


Because women may not spontaneously report symptoms of GSM and related sexual concerns, providers should inquire about symptoms in all perimenopausal and postmenopausal women as part of a routine review of systems. The EMPOWER survey queried 1,858 menopausal US women with symptoms suggestive of GSM and found that in women who had never used any treatment, almost three-quarters had never discussed their symptoms with a healthcare provider.[6] The main reason for this reticence was the assumption that GSM was simply a natural part of aging with which women needed to live. Results of the Women's Voices in the Menopause survey revealed that in more than 1,000 US respondents, one-third of those with vaginal discomfort had not spoken with anyone regarding their condition and one-third preferred that discussion regarding vaginal discomfort be initiated by their healthcare providers.[65]

These survey results underscore the importance of clinicians being proactive in asking menopausal women whether symptoms suggestive of GSM are present. The goal of the history is to determine whether symptoms of GSM are present, whether they are bothersome, and how they affect the woman's sexual health and QOL. In the absence of symptoms, atrophic changes noted on examination do not necessarily require treatment, although women should be informed that these changes may worsen over time without proactive management.

Symptoms similar to GSM result from many other conditions. The differential diagnosis includes allergic or inflammatory conditions (eg, lichen sclerosus, erosive lichen planus, desquamative inflammatory vaginitis, contact dermatitis, and cicatricial pemphigoid), vulvovaginal candidiasis and other infections, trauma, foreign bodies, malignancy, vulvodynia, vestibulodynia, chronic pelvic pain, provoked pelvic floor hypertonia (previously known as vaginismus), and other medical conditions (eg, diabetes, lupus erythematosus) or psychological disorders. An alternate etiology is more likely in women with chronic or recurrent vulvovaginal symptoms that were present before menopause.

Documentation of GSM should include a description of symptoms, including time of onset, duration, level of associated distress, and effect on QOL. A sexual history that includes partner relationship(s), current level and types of sexual activity, and the effect of GSM symptoms on sex life and partner relationships is useful in determining management strategies. Previous interventions should be discussed, including their efficacy and adverse effects.

For a woman with a history of cancer, additional information is relevant, including cancer site, age at diagnosis, hormone receptor status, treatments (past, current), and type of menopause (spontaneous or induced). Cancer treatments, especially surgery and radiation therapy, can damage the vaginal epithelium, the vascular supply, and the anatomy of the vaginal canal. Some treated women experience a narrowed or foreshortened vagina. Genitourinary changes associated with cancer treatments can produce pain with pelvic examinations, dyspareunia, recurrent UTIs, and an increased risk of vaginal infections.[52,66]

Physical Examination

The pelvic examination helps to exclude other vulvovaginal conditions that can cause similar symptoms. As GSM progresses, examination of the external genitalia often reveals reduced mons pubis and labia majora bulk, reduced labia minora tissue and pigmentation, and prominence (telescoping) and erythema of the urethral meatus. Urethral caruncle, a benign outgrowth of inflammatory tissue arising from the posterior urethral meatus, is common in postmenopausal women and likely related to hypoestrogenism. The clitoris may recede and in some cases become completely flush with the surrounding tissue. The vestibular tissue may become pale.

If the introitus is noted to be narrow, use of a narrow pediatric vaginal speculum with lubricant is appropriate. The vaginal mucosa may appear smooth (loss of rugation), shiny, and dry. Minimal blunt trauma from the speculum may result in petechiae (reflecting mucosal thinning) or bleeding (friability). With progression of GSM, attenuation of the vaginal fornices may be apparent, and the cervix may appear flush with the vaginal apex.

With atrophic vaginitis, brown or yellow (sometimes malodorous) discharge may be present. With severe GSM, there may be such shortening of the vaginal vault and narrowing of the introitus that speculum insertion and visual inspection of the vaginal vault as well as cervix may not be possible.

Although the vaginal maturation index (VMI) and vaginal pH are routinely assessed in clinical trials, they are not essential to make a diagnosis of GSM in clinical practice. With GSM, vaginal pH is typically greater than 5.0. Wet-mount microscopy shows more than one white blood cell per epithelial cell, immature vaginal epithelial cells with relatively large nuclei (parabasal cells), and reduced or absent lactobacilli. Repopulation with diverse flora can occur, including enteric organisms commonly associated with UTIs.[67] The appearance of the wet mount in severe GSM may be difficult to distinguish from that of desquamative inflammatory vaginitis or vaginal erosive lichen planus.[68] A culture or vulvovaginal biopsy should be considered if there are atypical findings or if the vulvovaginal symptoms fail to resolve after a trial of vaginal estrogens or DHEA.

A woman's symptoms do not always correlate with physical findings. For example, a woman who is not sexually active may have few symptoms, despite signs of advanced genitourinary atrophy on examination. In contrast, a woman with an active sex life may complain of dryness and discomfort with sex, whereas the pelvic examination suggests only mild atrophy. Of note, women who are not sexually active also may be bothered by symptoms related to GSM, including discomfort with exercise or dysuria and benefit from treatment. Thus, both history and examination are essential to making a correct diagnosis.