What do NHS and NICE recommend first-line for GSM?
For genitourinary syndrome of menopause (GSM)—also called vaginal dryness/atrophy—NHS and NICE advise a stepwise start: regular vaginal moisturisers and a suitable personal lubricant, then consider low-dose local vaginal oestrogen (or DHEA) when symptoms affect quality of life. Local therapy can be used with or without systemic HRT, and benefits build over 2–6 weeks. Gentle skincare and friction reduction sit alongside care; devices or injectables are optional adjuncts later, not first-line.
Detailed Medical Explanation
What do NHS and NICE recommend first-line for GSM? UK guidance takes a practical, stepwise approach to genitourinary syndrome of menopause (GSM)—also called vaginal atrophy. The first aim is to reduce friction and support tissue biology. That starts with a scheduled vaginal moisturiser and a generous, compatible personal lubricant for higher-friction moments (intimacy, speculum tests, dilators). If symptoms affect quality of life, NICE advises considering low-dose local vaginal oestrogen (cream, pessary/tablet, or ring) and notes that local therapy can be used with or without systemic HRT. A licensed vaginal DHEA (prasterone) is another local option some women consider. Benefits build over 2–6 weeks as the epithelium re-matures, pH normalises, and protective lactobacilli recover.
Foundations that nearly everyone can start. Choose a fragrance-free, minimal-ingredient moisturiser (many favour hyaluronic-acid gels) 2–4 nights weekly and match lubricant to your needs—water-based for versatility/condoms, silicone-based for the longest glide on a tender vestibule, and oil-based for richness (but avoid with latex condoms/toys). Gentle skincare matters: lukewarm water or a bland emollient as a soap substitute; breathable fabrics; rinse off chlorine; avoid fragranced washes, liners and “tingle/warming” products that can sting.
Technique often beats switching products. If discomfort is entrance-focused, internal-only routines miss the hotspot. With creams (including oestrogen), add a fingertip to the vestibule and posterior fourchette as well as inside. Before higher-friction activities, smooth a pea of lubricant directly at the entrance and internally. Many women report fewer “paper-cut” splits by targeting placement, not by endlessly changing brands.
Where HRT fits. Systemic HRT improves vasomotor symptoms (hot flushes/night sweats) but does not reliably resolve vulvo-vaginal symptoms for everyone. NICE supports adding local vaginal oestrogen even if you are already on systemic HRT. If you do not wish to use systemic hormones, local therapy remains appropriate because systemic absorption from licensed low-dose vaginal preparations is minimal at recommended dosing.
Devices and injectables are not first-line. Radiofrequency/laser and regenerative injectables (platelet-rich plasma, polynucleotides) are adjuncts for selected cases after foundations and local therapy are optimised. They do not replace lubricant/moisturiser or local hormonal options and should be weighed against guideline-supported steps, expected timelines, and your goals.
Safety and sequencing. Defer procedures and seek assessment if you have malodorous green/grey discharge (possible BV), intense itch with thick white discharge (possible thrush), fever, visible blood in urine, or new post-menopausal bleeding. If deep pelvic pain dominates, evaluate pelvic floor contributors or conditions like endometriosis/adenomyosis; pelvic health physiotherapy and graded dilators help when muscle guarding is the limiter. For a plain-English overview of our pathway, see what the treatment is and how the treatment steps are sequenced.
Setting expectations. Lubricants help immediately but wear off; moisturisers improve day-to-day comfort within days; local oestrogen/DHEA trends appear over weeks; pelvic floor work changes tolerance over weeks to months. Reviews at 6–12 weeks and again at 3–6 months let you adjust to a lowest effective maintenance plan that fits your life.
Clinical Context
Who is most likely to benefit first-line? Those with entrance-focused sting, dryness and dyspareunia who adopt a scheduled moisturiser and a generous, compatible lubricant—and who target the vestibule with creams (including local oestrogen). Many achieve comfortable intimacy and daily movement at this stage alone.
Who may need additional steps? People with persistent symptoms after an excellent foundation phase, mixed urinary features (urgency/frequency) that continue despite local therapy, or significant pelvic floor guarding. Consider pelvic health physiotherapy, refine local therapy dose/format, and only then weigh adjunct devices/injectables.
When to pause and seek review. Red flags—malodorous discharge, severe itch with thick white discharge, fever, visible haematuria, or new post-menopausal bleeding—need assessment before escalation. If you are postpartum/breastfeeding, or on anticoagulants, plans are individualised. Educational only. Results vary. Not a cure.
Evidence-Based Approaches
NHS overview (patient-facing): Practical advice on symptoms, moisturisers, lubricants and when to seek help for vaginal dryness is provided by the NHS.
NICE guidance (clinical): The NICE Menopause Guideline (NG23) recommends offering vaginal moisturisers and lubricants and considering low-dose local vaginal oestrogen when GSM affects quality of life, with or without systemic HRT.
Prescribing detail (UK): Dosing, cautions and product information for vaginal oestrogens and prasterone (DHEA) are summarised in the British National Formulary (BNF).
Comparative effectiveness: Systematic reviews in the Cochrane Library show local vaginal oestrogens improve dryness, soreness, dyspareunia and vaginal pH versus placebo across creams, tablets/pessaries and rings.
Pathophysiology & nuance: Peer-reviewed overviews on PubMed describe GSM biology (thinner epithelium, higher pH, reduced Lactobacillus), clarifying why moisturiser/lubricant plus local therapy and pelvic floor strategies outperform devices alone in early care. ® belongs to its owner.