The menopause symptom almost nobody is offered treatment for

Somewhere between a third and a half of postmenopausal women have symptoms of genitourinary syndrome of menopause. A small minority are treated for it.

The gap is not caused by a lack of treatment. It is caused by nobody asking and nobody telling.

What it is

Oestrogen maintains the tissue of the vulva, vagina, urethra and bladder base. When it falls, that tissue becomes thinner, less elastic and less well-vascularised, glycogen content falls, the vaginal microbiome shifts away from lactobacilli, and pH rises.

The consequences:

• Vaginal dryness
• Burning, itching or soreness
• Pain with sex, particularly on penetration, and post-coital bleeding
• Urinary urgency and frequency
• Recurrent urinary tract infections
• Reduced sensation and difficulty with arousal

The name changed from "vulvovaginal atrophy" partly because the urinary symptoms were being missed, and partly because "atrophy" is a miserable word to have applied to your body.

The critical difference from hot flushes

Vasomotor symptoms typically resolve over time. Genitourinary symptoms do not. They are progressive, and untreated they get worse.

This matters because a lot of women wait it out on the assumption that it will pass like the flushes did. It does not, and the tissue changes become harder to reverse the longer they run.

Why it is under-treated

Nobody asks. Studies of postmenopausal consultations consistently find that clinicians rarely raise sexual or genitourinary symptoms, and patients rarely volunteer them.

People assume it is inevitable. It is common; it is not something you have to accept.

Fear of oestrogen after the WHI, which is a misapplication of that trial's findings to a treatment with minimal systemic absorption. Hormone therapy: what actually changed after the WHI.

The patient information leaflet. Vaginal oestrogen products often carry the same class warnings as systemic HRT — about breast cancer, stroke, clots — because of how medicines labelling works. Women read them and stop. Those warnings do not reflect the evidence for low-dose vaginal preparations, and professional bodies have repeatedly asked for the labelling to change.

What treatment looks like

Vaginal oestrogen is the mainstay. Available as creams, pessaries, tablets and a ring. Typically applied daily for a couple of weeks, then twice weekly indefinitely.

The important points: systemic absorption is very low, blood oestradiol levels generally remain in the postmenopausal range, and it does not require a progestogen for endometrial protection at standard doses. Current guidance supports its use in the great majority of women, and in many women with a history of breast cancer after discussion with their oncologist — particularly those not on aromatase inhibitors.

It has to be continued. Symptoms return within a few months of stopping, because the underlying oestrogen deficiency has not changed.

Vaginal moisturisers, used regularly rather than only for sex, and lubricants for sex itself. Both help and neither reverses tissue change. Choose products with a pH and osmolality appropriate for vaginal tissue; many mainstream lubricants are hyperosmolar and can be irritating.

Vaginal DHEA (prasterone) and oral ospemifene are alternatives where oestrogen is not suitable.

Pelvic floor physiotherapy, because pain leads to protective muscle guarding which becomes an independent source of pain. This is frequently the missing piece when local oestrogen alone does not fully resolve painful sex. The pelvic floor is a muscle group.

Regular sexual activity or vaginal dilator use maintains tissue elasticity and blood flow, which is a real physiological effect rather than a euphemism.

The recurrent UTI part

This deserves separate emphasis because it is where the most avoidable harm happens.

Recurrent UTIs after menopause are frequently a consequence of genitourinary syndrome, and vaginal oestrogen has good trial evidence for reducing recurrence. Women instead often receive repeated antibiotic courses, sometimes for years, with the attendant resistance and side effects.

If you are postmenopausal and having recurrent UTIs, ask specifically about vaginal oestrogen. It is one of the clearest examples in women's health of an effective treatment not being offered.

The conversation to have

Because clinicians so rarely raise it, you generally have to. Something direct works best:

"I'm having vaginal dryness and pain with sex, and recurrent UTIs. I'd like to try vaginal oestrogen."

Naming the treatment moves things along considerably. If you are told it is not suitable because of a breast cancer history, that is worth a second conversation with an oncologist rather than accepting as final, because guidance in that area has moved.

Why women wait longer for a diagnosis and how to prepare for a ten-minute appointment are both relevant here.

Track whether it works

Treatment takes weeks to months for full effect, and improvement is gradual enough that it is hard to perceive. People frequently stop at six weeks concluding it did nothing, when the trajectory was fine.

A simple record — symptoms, pain with sex, UTI episodes, dated — answers that. It also gives you the evidence to escalate if it genuinely is not working.

Naked is built to hold that alongside everything else changing in this period, because these symptoms rarely arrive alone — see the perimenopause symptoms nobody lists.