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

Conclusions and Recommendations

• Education about and screening for GSM is recommended for perimenopausal and postmenopausal women. [Level C]

• First-line therapies for women with GSM include nonhormone lubricants with sexual activity and regular use of long-acting vaginal moisturizers. [Level A]

• For women with moderate to severe GSM and those who do not respond to lubricants and moisturizers, several safe and effective options are available:

  • Low-dose vaginal ET [Level A]

  • Vaginal DHEA [Level A]

  • Ospemifene [Level A]

  • Systemic ET (when VMS are also present) [Level A]

• For women with a history of breast or endometrial cancer, management depends on a woman's preferences, symptom severity, and understanding of potential risks after consultation with her oncologist. [Level C]

• Although product labeling for low-dose vaginal ET notes risks associated with systemic HT (including CHD, stroke, VTE, breast and endometrial cancer), these risks are highly unlikely given minimal systemic absorption and reassuring findings from clinical trials and observational studies. [Level B]

• Use of a progestogen is not recommended with low-dose vaginal ET, although women at increased risk of endometrial cancer may warrant endometrial surveillance. Endometrial safety clinical trial data are not available for use longer than 1 year, although observational studies are reassuring regarding longer-term use. [Level B]

• Routine endometrial surveillance is not recommended for asymptomatic women using low dose vaginal ET. Transvaginal ultrasound or intermittent progestogen therapy may be considered for women at increased risk of endometrial cancer. [Level C]

• Spotting or bleeding in a postmenopausal woman requires a thorough evaluation that may include TVU and/or endometrial biopsy. [Level A]

• Energy-based therapies, including vaginal laser and radiofrequency devices, require long-term, sham-controlled safety and efficacy studies before their routine use can be recommended. [Level C]

• Therapy for GSM should be continued, with appropriate clinical follow up, for as long as bothersome symptoms are present. [Level C]