Genitourinary Syndrome of Menopause and Lower Urinary Tract Symptoms: A Primary Care Approach

This literature synthesis reviewed current evidence on the pathophysiology, diagnosis, and management of genitourinary syndrome of menopause (GSM)-related lower urinary tract symptoms (LUTS) in postmenopausal persons, with implications for primary care. GSM is a chronic, progressive condition caused by estrogen deficiency affecting vaginal, urethral, and bladder tissues. An estimated 50% to 70% of postmenopausal persons experience symptoms, including urinary urgency, frequency, incontinence, and recurrent urinary tract infections. Despite its prevalence and effect on quality of life, GSM remains substantially underdiagnosed: fewer than half of symptomatic persons seek treatment, and clinicians often fail to screen proactively. Low-dose vaginal estrogen therapy remains the most effective evidence-based intervention, with minimal systemic absorption and no elevated risk of endometrial or breast cancer. In contrast, systemic hormone therapy may exacerbate or trigger urinary incontinence, reinforcing the need for local administration. Emerging microbiome research offers a plausible framework, linking estrogen deficiency to loss of Lactobacillus predominance in vaginal and urinary microbiomes, though these findings remain mechanistic. Non-hormonal approaches—pelvic floor muscle training, vaginal moisturizers, and behavioral strategies—serve as first-line or adjunctive options. A brief, validated two-question screening prompt is introduced for postmenopausal wellness visits. Future research should define long-term local estrogen safety, validate case-finding tools, explore urobiome-targeted therapies, and standardize outcomes.