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AUA2025 PLENARY RECAP First Comprehensive Guideline for Genitourinary Syndrome of Menopause Released by AUA With SUFU and AUGS

By: Melissa R. Kaufman, MD, PhD, FACS, Panel Chair, AUA/SUFU/AUGS Genitourinary Syndrome of Menopause Guideline Vanderbilt ­University Medical Center, Nashville, Tennessee; Giulia Ippolito, MD, MS, University of Michigan Medical School, Ann Arbor; Charles R. Powell, MD, Indiana University School of Medicine, Indianapolis; Una J. Lee, MD, Panel Co-Chair, AUA/SUFU/AUGS Genitourinary Syndrome of Menopause Guideline Virginia Mason Franciscan Health, Seattle, Washington | Posted on: 02 Jun 2025

Increased knowledge and awareness have led to significant improvements in women’s health over the past few decades; however, the lack of awareness for the suffering borne by women due to menopause remains a glaring deficiency. This is particularly more profound when one realizes that women spend 40% of their lives in menopause, and that up to 84% report symptoms consistent with the genitourinary syndrome of menopause (GSM).1

Clinicians and patients have commonly recognized vasomotor symptoms (hot flashes) as a symptom of menopause, but the collection of signs and symptoms defined within GSM have not traditionally been identified as GSM. In urology, underlying GSM has been mischaracterized or diagnosed as comorbid idiopathic overactive bladder or recurrent UTI.2 Fortunately, solutions for GSM are simple, effective, safe, inexpensive, and easy for clinicians to implement. These solutions, as well as methods to recognize and categorize GSM, are described by the AUA in collaboration with SUFU (the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction) and AUGS (the American Urogynecologic Society). The effort was additionally sponsored by the Patient-Centered Outcomes Research Institute (PCORI) and the ­Agency for Healthcare ­Research and ­Quality (AHRQ).

The 2025 guideline provides a common definition for GSM such that clinicians and researchers can more readily recognize the symptoms, such as vaginal dryness, dyspareunia, dysuria, and vaginal irritation or discomfort. The guideline also highlights the importance of a pelvic exam to identify signs of GSM (vaginal skin thinning, urethral prolapse, loss of labia minora, loss of vaginal rugae).

Table. Low-Dose Hormonal Options for Genitourinary Syndrome of Menopause

Category Composition Trade name Commonly used starting dose Commonly used maintenance dose Typical serum estradiol level (pg/mL)
Vaginal creams 17β-estradiol 0.01% (0.1 mg active ingredient/g) Estrace vaginal cream 0.5-1 g/d for 2 wk 0.5-1 g 1-3 times/wk Variable, 3-5
Conjugated estrogens (0.625 mg active ingredient/g) Premarin vaginal cream 0.5-1 g/d for 2 wk 0.5-1 g 1-3 times/wk Variable
Vaginal inserts 17β estradiol inserts Imvexxy 4 or 10 µg/d for 2 wk 1 insert twice/wk 3.6 (4µg) or 4.6 (10µg)
Estradiol hemihydrate tablets Vagifem 10 µg/d for 2 wk 1 tablet twice/wk 5.5
Yuvafem
Prasterone (DHEA) inserts Intrarosa 6.5 mg/d 1 insert/d 5
Vaginal ring Silicone polymer with a core containing 2 mg estradiol Estring 7.5 mcg/d for 3 mo 1 ring/3 mo 8
Oral tablet Ospemifene Osphena 60 mg/d 1 tablet by mouth/d N/A

Abbreviations: DHEA, dehydroepiandrosterone; N/A, not applicable.

In patients with GSM, clinicians should offer the option of local, low-dose vaginal estrogen (VE) to improve vulvovaginal discomfort/irritation, dryness, and/or dyspareunia. Seven high-quality randomized clinical trials involving over 2000 women provide evidence that low-dose VE alleviates these symptoms when compared with placebo.3-9 Moreover, there is substantial evidence that VE also improves overactive bladder symptoms and reduces recurrent UTI.10-12 The Table illustrates various formulations of VE and other low-dose hormonal agents that are available along with dosing and serum estradiol concentrations. Serum estradiol levels are similar to placebo, indicating VE has few systemic effects, which has significant implications for safety related to breast and endometrial cancers, as well as thromboembolic events.13-15

There is also evidence to support the use of nonhormonal vaginal moisturizers or lubricants for vaginal dryness and dyspareunia.16,17 Nonestrogen hormonal agents such as dehydroepiandrosterone also have been shown to be effective at relieving GSM symptoms such as vaginal dryness and dyspareunia, as well as oral ospemifene.18,19 The guideline notes that evidence does not support the use of energy-based interventions and that these therapies are considered experimental outside of the context of a clinical trial.

Finally, the guideline recommends follow-up to assess response after initiating treatment as well as counseling patients that long-term treatment and follow-up will ­likely be necessary. In conclusion, this is the first evidence-based guideline addressing GSM and assembles the highest quality research in contemporary literature to answer the key questions clinicians and patients have about this common and debilitating condition.

Drs Melissa Kaufman, Gulia Ippolito, Charles R. Powell, and Una Lee highlighted this new AUA/SUFU/AUGS GSM guideline20 during the plenary session at the 2025 AUA Annual Meeting in Las Vegas, employing a case-based format of patients with symptoms of GSM you are likely to encounter in your office, with a focus on evaluation and treatment of women post ­menopause.

  1. Arias E, Xu J. United States Life Tables, 2015. National Vital Statistics Reports; 2018.
  2. The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society. Menopause. 2020;27(9):976-992. doi:10.1097/GME.0000000000001609
  3. Fernandes T, Costa-Paiva LH, Pinto-Neto AM. Efficacy of vaginally applied estrogen, testosterone, or polyacrylic acid on sexual function in postmenopausal women: a randomized controlled trial. J Sexual Med. 2014;11(5):1262-1270. doi:10.1111/jsm.12473
  4. Constantine GD, Simon JA, Pickar JH, et al. The REJOICE trial: a phase 3 randomized, controlled trial evaluating the safety and efficacy of a novel vaginal estradiol soft-gel ­capsule for symptomatic vulvar and vaginal atrophy. Menopause. 2017;24(4):409-416. doi:10.1097/GME.0000000000000786
  5. Mitchell CM, Reed SD, Diem S, et al. Efficacy of vaginal estradiol or vaginal moisturizer vs placebo for treating postmenopausal vulvovaginal symptoms: a randomized clinical trial. JAMA Intern Med. 2018;178(5):681-690. doi:10.1001/jamainternmed.2018.0116
  6. Nachtigall LE. Clinical trial of the estradiol vaginal ring in the U.S. Maturitas. 1995;22­ (Suppl):S43-S47. doi:10.1016/0378-5122(95)00963-9
  7. Eriksen B. A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing vaginal ring (estring) on recurrent urinary tract infections in postmenopausal women. Am J Obstet Gynecol. 1999;180(5):1072-1079. doi:10.1016/s0002-9378(99)70597-1
  8. Freedman M, Kaunitz AM, Reape KZ, Hait H, Shu H. Twice-weekly synthetic conjugated estrogens vaginal cream for the treatment of vaginal atrophy. Menopause. 2009;16(4):735-741. doi:10.1097/gme.0b013e318199e734
  9. Bachmann G, Bouchard C, Hoppe D, et al. Efficacy and safety of low-dose regimens of conjugated estrogens cream administered vaginally. Menopause. 2009;16(4):719-727. doi:10.1097/gme.0b013e3181a48c4e
  10. Fernández NM, Salamanca JIM, Quevedo JIPG, et al. Efficacy and safety of an ultra-low-dose 0.005% estriol vaginal gel in the prevention of urinary tract infections in postmenopausal women with genitourinary syndrome of menopause. Maturitas. 2024;190:108128. doi:10.1016/j.maturitas.2024.108128
  11. Tan-Kim J, Shah NM, Do D, Menefee SA. Efficacy of vaginal estrogen for recurrent urinary tract infection prevention in hypoestrogenic women. Am J Obstet Gynecol. 2023;229(2):143.e1-e1. doi:10.1016/j.ajog.2023.05.002
  12. Šimunic´ V, Banovic´ I, Ciglar S, Jeren L, Pavicˇic´ Baldani D, Šprem M. Local estrogen treatment in patients with urogenital symptoms. Int J Gynaecol Obstet. 2003;82(2):187-197. doi:10.1016/s0020-7292(03)00200-5
  13. Agrawal P, Singh SM, Able C, et al. Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer. Obstet Gynecol. 2023;142(3):660-668. doi:10.1097/AOG.0000000000005294
  14. McVicker L, Labeit AM, Coupland CAC, et al. Vaginal estrogen therapy use and survival in females with breast cancer. JAMA Oncol. 2024;10(1):103. doi:10.1001/jamaoncol.2023.4508
  15. Meaidi A, Pourhadi N, Løkkegaard EC, Torp-Pedersen C, Mørch LS. Association of vaginal oestradiol and the rate of breast cancer in Denmark: registry based, case-control study, nested in a nationwide cohort. BMJ Med. 2024;3(1):e000753. doi:10.1136/bmjmed-2023-000753
  16. Lee Y-K, Chung HH, Kim JW, Park N-H, Song Y-S, Kang S-B. Vaginal pH-balanced gel for the control of atrophic vaginitis among breast cancer survivors: a randomized controlled trial. Obstet Gynecol. 2011;117(4):922-927. doi:10.1097/AOG.0b013e3182118790
  17. Nappi RE, Kotek M, Breštánský A, Giordan N, Beriotto I, Tramentozzi E. Treatment of vulvo-vaginal atrophy with hyaluronate-based gel: a randomized controlled study. Minerva Obstet Gynecol. 2022;74(6):480. doi:10.23736/S2724-606X.21.04841-7
  18. Labrie F, Archer DF, Koltun W, et al. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2018;25(11):1339-1353. doi:10.1097/GME.0000000000001238
  19. Archer DF, Goldstein SR, Simon JA, et al. Efficacy and safety of ospemifene in postmenopausal women with moderate-to-severe vaginal dryness: a phase 3, randomized, double-blind, placebo-controlled, multicenter trial. Menopause. 2019;26(6):611-621. doi:10.1097/GME.0000000000001292
  20. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. Published online April 28, 2025. doi:10.1097/JU.0000000000004589

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