Updated Guidelines for “Down There”—Listen Up!
A 2025 Guide to Vaginal Health, Hormones & Why You're Not Just Making It Up
I love when updated medical guidelines finally catch up to what women have been complaining about for years—especially when it comes to what’s happening “down there.” So if you're experiencing dryness, pain, irritation, or leaking when you sneeze (seriously, the betrayal), you’re going to want to listen up.
The American Urological Association just released its 2025 guidelines on Genitourinary Syndrome of Menopause (GSM)—and they’re worth celebrating.
Wait, What Is GSM?
GSM stands for Genitourinary Syndrome of Menopause, which refers to a group of symptoms caused by declining estrogen and androgen levels in the vaginal and urinary tract during perimenopause and beyond. These symptoms can include:
Vaginal dryness, burning, or irritation
Pain during intimacy (aka dyspareunia)
Urinary urgency or frequency
Leaking when you sneeze, laugh, or move wrong
Frequent UTIs
Low libido or inability to orgasm
Bleeding or discomfort
And it’s not just a “menopause thing.”
Women who are on the pill, dealing with amenorrhea, recovering from chemo, or have otherwise low estrogen/androgen levels can experience these same symptoms—even in their 30s.
What Do the New Guidelines Say?
✅ You Should Be Screened
Your healthcare provider should be asking you about any of the following:
Dryness, pain, irritation, or itchiness
Changes in sensation like ability to orgasm
Discharge or odor
Leaking or overactive bladder
UTIs (bladder infections)
External skin changes or shrinkage (yep, even the labia can change with hormone loss)
If you say yes to any of these, they should perform an exam—inside and outside. You may need a pap, infection screening, or even pH testing. (Fun fact: vaginal pH should be below 5. Higher = too alkaline = potential issues.)
Treatment Options You Should Be Offered
1. Local Vaginal Estrogen (Low Dose)
Used topically (on the outside) or inserted (on the inside) depending on where your symptoms are.
Outside irritation = apply topically
Inside dryness = insert vaginally
Sometimes you need both
2. Vaginal DHEA or Ospemifene
DHEA supports tissue and moisture through androgen support (my favorite option here)
Ospemifene is a non-hormonal oral option with estrogen-like effects (but may have more side effects)
3. Systemic Hormones Aren’t Always Enough
Even if you’re on estrogen pills or patches, it might not be reaching your vulvovaginal tissue. The new guidelines say: add local support if needed.
4. Overactive Bladder or Frequent UTIs?
Use local estrogen near the urethra (not just up inside the vagina)
If you’re struggling with both GSM and recurrent UTIs, vaginal estrogen may reduce your UTI risk
What About Testosterone?
There is some research showing that vaginal testosterone may help with arousal, orgasm, and lubrication—but the evidence is limited and some women had side effects. More research is needed according to the guidelines but anecdotally, I found a lot of women really loved it.
Are There Non-Hormonal Options?
Yes—and some are great add-ons to your plan:
✔️ Helpful:
Vaginal moisturizers (used regularly)
Lubricants (used during intimacy)
Pelvic floor physical therapy for leaking, weakness or bladder pressure
Pure vitamin E oil (they said no on this but anecdotally I’ve heard from women it’s helpful with dryness or irritation. There are some small studies affirming this but this guidelines didn’t think it was strong enough)
❌ Not-So-Helpful (According to the Guidelines):
Supplements like soy, fenugreek, vitamin E/D/A—even though small studies exist, the evidence isn’t strong enough (yet) for formal recommendations.
🚫 Please Avoid:
Scented soaps, douches, or cleansers in or around your vagina
“Fragrance” or essential oils on sensitive tissue
Over-cleaning (your vagina is self-cleaning—no need to evict the microbiome)
What About Breast Cancer Risk?
The updated guidelines are refreshingly clear:
Low-dose vaginal estrogen, DHEA, and ospemifene do not increase breast cancer risk
They do not increase the risk of recurrence if you had breast cancer in the past
If you have a BRCA mutations or a high risk for breast cancer, always discuss this with your provider as you may or may not be a candidate
Low dose vaginal estrogen and DHEA treatments also do not increase uterine hyperplasia or uterine cancer risk
📅 What About Follow-Up?
Once you begin treatment, your provider should follow up:
Are your symptoms better?
Any side effects?
Is your treatment plan still working?
Final Thought: You Deserve Relief. Period.
If you’re experiencing symptoms—even the ones you feel too awkward to mention—it’s time to speak up. You are not being dramatic, and you are not supposed to just put up with it.
I get it though. Some health practitioners don’t mention it or are too embarrassed themselves to talk about it. This means you’ll have to be proactive and say something. Hopefully with all this updated training, that will change.
Your vaginal and urinary health matter. And thanks to the 2025 GSM guidelines, more healthcare providers are finally being told to listen.