Menopause & GSMAugust 9, 20266 min read
The One That Doesn't Fade
Hot flashes fade and get talked about; what replaces them for many women doesn't fade, and almost nobody mentions it beforehand.
Heather Florio
CEO, Desert Harvest
Menopause & GSM
Hot flashes get a punchline. Every comedian has one. Every made-for-TV scene has a woman fanning herself in a meeting, and underneath the joke is a real, disruptive fact of a real transition — one that is also, for most women, temporary. It arrives, it complicates a decade or so, and then it goes.
Genitourinary syndrome of menopause does not follow that pattern.1GSM, for short. I use the full name at least once every time, because the abbreviation is easy to skim past and the whole problem here is that nobody says it. It has a real clinical name — GSM, in the shorthand almost nobody says out loud either — for the changes that happen to vaginal, vulvar, and urinary tissue once estrogen drops and stays down:
- dryness and thinning where tissue used to hold up fine
- irritation, or pain during sex that was not there before
- urinary urgency, frequency, and infections that keep circling back
- a general fragility that does not resolve on its own the way a hot flash eventually does
Desert Harvest has spent three decades sitting at exactly this intersection — pelvic, sexual, urological, and menopausal health, named as one throughline because in a woman's body they were never four separate things. I have watched this particular syndrome from the vantage point of running that company, and later of writing a monthly column women write in to, for longer than I have watched almost anything else. Almost none of the women I have heard from had ever heard its name before someone said it to them directly.
The recent conversation about menopause has gotten louder, and I am glad of it. Hot flashes, sleep, mood, brain fog — all of it finally has language, panels, workplace policies being written for the first time. What that same conversation still skips is the part that does not announce itself in a meeting. Under-researched, under-funded, and under-discussed already describes most of the field I work in. GSM is the under-discussed corner of an under-discussed corner.
A name nobody says first
A hot flash happens in a conference room, in front of witnesses, and by definition it is already public. What GSM does happens nowhere anyone else can see, and that turns out to matter more than it should. In the letters that reach Dear HER-Health2My monthly column in BELLA Magazine. Women write in; I answer. It is where most of what I know about this comes from., the pattern repeats itself: sleep gets mentioned first. Mood gets mentioned first. The actual sentence — that sex hurts now, that the infections keep coming back — arrives last, if it arrives at all, sitting at the bottom of an email like an afterthought instead of the reason the email got written.
Doctors get some of the blame, and they should. A visit built around blood pressure and a prescription refill was never going to leave room for a conversation that starts with embarrassment and takes real time to have. But the larger share of the silence gets built long before anyone sits down across from a physician. It gets built in every "signs of menopause" checklist that stops at night sweats and skips the part that does not go away on its own. It gets built at the kitchen table, where hot flashes are a shared joke between women and this is not.
It also gets inherited. Most of the women I hear from were never told anything about this by their own mothers — not because their mothers were withholding, but because nobody had told them either. A silence that skips a generation does not weaken on the way down. It just arrives at the next woman fully formed, dressed up as something too private, or too minor, or too embarrassing to be the reason she called her doctor.
Say nothing long enough, and a real symptom starts to feel invented — that's the actual harm.
What the quiet costs
The cost is not only the symptom sitting there, unaddressed, year after year — though it is that too. It is what silence does to a woman's read of her own body.
It compounds. A woman who mentions it once, gets a shrug, and does not mention it again is not choosing peace. She is choosing to carry it alone rather than carry it in a room where someone might have taken it seriously the first time. The next doctor she sees starts from zero, because she has learned not to bring it up first — and the doctor after that starts from zero too.
It reaches past the exam room. A marriage can absorb a lot of quiet before anyone names what the quiet is actually about. I have heard from women whose partners assumed distance, or disinterest, or something gone wrong between two people, when what had actually gone unspoken was a syndrome with a name, sitting undiagnosed in the space where an ordinary conversation should have been.
Saying it first
None of this is a case for a particular fix, and I would not make one. I have spent three decades adjacent to this field as a writer and a CEO, not as a clinician, and nothing here replaces an actual conversation with one. What I can do is say the name of the thing out loud, in a place where a woman looking for it might actually find it — the same reason the column exists at all. The letters that come in after a column runs on this subject are rarely about the syndrome itself. They are about the relief of someone else saying it first, plainly, without flinching.
I would rather a reader leave this piece knowing the actual name for what is happening in her body than leave it with an answer I am not qualified to give her. Naming a thing does not resolve it by itself. But it is the sentence that has to happen before anything else can — the one that, unlike the hot flash it keeps getting filed under, does not fade on its own timeline.
Often asked
- What is genitourinary syndrome of menopause (GSM)?
- GSM is the clinical name for a group of changes to vaginal, vulvar, and urinary tissue that follow the drop in estrogen after menopause — including dryness, thinning, irritation, pain during sex, and recurring urinary symptoms. Unlike hot flashes, which typically ease with time, GSM tends to persist rather than resolve on its own.
- Why don't more women talk about GSM with their doctors?
- In decades of running a women's-health company and writing a monthly advice column, Heather Florio has seen the same pattern: symptoms tied to sex and urinary health get mentioned last, if at all, because they carry more embarrassment and a short appointment rarely leaves room for them. That silence compounds — a woman who raises it once and gets a shrug often stops raising it at all.
- Does Heather Florio give medical advice about GSM?
- No. She is a writer and the CEO of Desert Harvest, not a clinician, and nothing she publishes is medical advice or a substitute for care. Her writing on GSM draws on three decades adjacent to pelvic, sexual, urological, and menopausal health as a business leader and columnist; anyone with these symptoms should raise them with a qualified healthcare provider.