Recommendations for the Diagnosis and Treatment of Genitourinary Syndrome of Menopause from the Italian Society of Menopause (SIM) and Italian Society of Gynecology of the Third Age (SIGiTE).

Abstract

Genitourinary syndrome of menopause (GSM) is a chronic condition associated with estrogen and androgen deficiency that affects the vulva, vagina, urethra, and bladder, significantly impairing quality of life, sexual wellbeing, and urinary function. Despite its high prevalence, GSM remains frequently underdiagnosed and undertreated. These recommendations, developed by the Italian Society of Menopause (SIM) and the Italian Society of Gynecology of the Third Age (SIGiTE), provide updated evidence-based guidance for the diagnosis and management of GSM. The recommendations were formulated through a comprehensive literature review and expert consensus process, with evidence graded according to the Oxford Centre for Evidence-Based Medicine criteria. Diagnosis should rely on both patient-reported bothersome symptoms and objective clinical signs identified during physical examination. Assessment tools such as the Vaginal Health Index and Vestibular Trophic Health Score may assist in evaluating disease severity and monitoring treatment response. Management should be individualized according to symptom severity, patient preferences, contraindications, and treatment goals. Vaginal lubricants and moisturizers represent the preferred first-line option for women with mild symptoms, whereas local low-dose estrogen therapy remains the treatment of choice for women with moderate to severe GSM. Vaginal DHEA, ospemifene, and pelvic floor physical therapy may be considered in selected clinical settings. Emerging therapies, including energy-based devices, injectable treatments, and vaginal oxygen with hyaluronic acid, may represent additional options in selected patients, although further evidence is needed. Special consideration is required for breast cancer survivors, for whom nonhormonal therapies remain first-line, while low-dose vaginal hormonal therapies may be considered after multidisciplinary evaluation.