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NICE Guidelines Updated to Include Genitourinary Syndrome of Menopause as Core Condition

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NICE Updates Menopause Guideline to Formally Recognise Genitourinary Symptoms

The National Institute for Health and Care Excellence (NICE) has updated its guideline on menopause to formally define genitourinary symptoms as a core part of the condition and to recommend active treatment across all severity levels. The updated guideline, NG23, was published in November 2024.

Guideline Update and Condition Definition

The NICE guideline NG23, titled "Menopause — identification and management," was updated in November 2024. The revision defines genitourinary symptoms associated with menopause as a core component of the menopause syndrome.

Genitourinary syndrome of menopause (GSM) describes a cluster of symptoms affecting the lower genitourinary tract, including the vulva, vagina, urethra, and bladder neck.

These symptoms result from declining estrogen levels during and after the menopause transition. The term GSM has replaced older descriptions such as "atrophic vaginitis" to reflect that the condition affects areas beyond the vagina.

Unlike vasomotor symptoms like hot flushes, GSM symptoms are described as chronic and progressive, typically worsening without treatment. Symptoms can begin during perimenopause, before menstrual periods have stopped completely.

Reported Symptoms and Prevalence

Reported symptoms are categorized as genital, urinary, and sexual.

  • Genital symptoms include vaginal dryness, burning, itching, soreness, unusual discharge, and tissue fragility.
  • Urinary symptoms include increased frequency, urgency, waking at night to urinate (nocturia), pain during urination (dysuria), recurrent urinary tract infections (UTIs), and stress incontinence.
  • Sexual symptoms include painful intercourse (dyspareunia), postcoital bleeding, and reduced arousal, lubrication, and orgasmic capacity.

Prevalence data cited from the North Tees and Hartlepool NHS Foundation Trust indicates vaginal dryness, a common symptom, affects approximately:

  • One in four women before menopause
  • One in two women after menopause
  • About seven in ten women in their seventies

It is reported that GSM overall affects approximately half of women after menopause.

Treatment Recommendations

The NICE guideline outlines a stepped treatment approach.

  • First-Line Self-Care: NICE NG23 supports the use of non-prescription vaginal moisturizers for regular use and lubricants for sexual activity as first-line, non-hormonal management.

  • First-Line Prescription Treatment: For persistent or moderate-to-severe symptoms, the guideline recommends vaginal estrogen as the first-line prescription treatment. This is recommended for individuals with genitourinary symptoms, including those already using systemic hormone replacement therapy (HRT). Vaginal estrogen is available in tablet, pessary, cream, gel, or ring forms.

  • Alternative Prescription Options: If vaginal estrogen is ineffective or not tolerated, NICE recommends prasterone (a DHEA vaginal pessary). The guideline also recommends ospemifene (an oral tablet) when locally applied treatments are not practical.

  • Laser Therapy: The Royal College of Obstetricians and Gynaecologists (RCOG) Scientific Impact Paper No. 72 and NICE NG23 state that vaginal laser treatment for GSM should not be offered outside of randomized controlled trials.

Clinical Guidance and Treatment Gap

The NHS recommends seeking a medical assessment when symptoms:

  • Persist for more than a few weeks despite self-care
  • Affect daily life or sexual function
  • Involve post-menopausal bleeding, unusual discharge, or recurrent UTIs

Post-menopausal bleeding requires prompt clinical review to rule out other causes.

For individuals with a history of breast cancer, non-hormonal treatments are recommended first. Vaginal estrogen may be considered only if these are ineffective and in consultation with the treating oncologist.

Data indicates a significant gap between symptom prevalence and treatment. It is reported that approximately 70% of women with GSM symptoms do not discuss them with a healthcare professional, and between 4% and 35% of affected women use any form of treatment.

Assessment and treatment can be initiated by a general practitioner (GP). Referral to a menopause specialist or gynaecologist may occur for more complex cases or if initial management is ineffective. Assessment is also available through NHS sexual health services or private specialists.