Dr. Barbara Chubak, urologist and professor at Weill Cornell Medicine and a trusted member of our Semaine Medical Advisory Board, recently joined us live on Instagram to dig into what’s really going on “down there” during perimenopause and menopause.
Menopause is a major transition, but some of its most disruptive effects often go undiscussed. As Dr. Chubak reminded us, the symptoms so many women experience, dryness, irritation, increased UTIs, or urinary urgency, aren’t just “a normal part of getting older.” They're real, they're valid, and they deserve attention. Here’s what we learned.
What is GSM and Why Does It Matter?
Dr. Chubak introduced the term Genitourinary Syndrome of Menopause (GSM), a clinical name for the collection of symptoms caused by declining estrogen levels. That includes not just vaginal dryness or pain during sex, but also urinary frequency, urgency, and recurring infections.
“These symptoms are more common as we age,” Dr. Chubak explained, “but ‘common’ doesn’t mean ‘nothing can be done.’”
Many people associate menopause with hot flashes and mood changes, but vaginal and urinary discomfort can be just as disruptive, and are often far less talked about.
Why It’s So Hard to Talk About
One of the biggest barriers to care? Social stigma. “It’s still not considered polite to talk about genitals,” Dr. Chubak noted, even sometimes among medical professionals. Patients are often met with vague phrases like “How are things down there?” It can be a kind of linguistic dance that reflects deeper discomfort around naming and addressing these concerns. The result? Many people don’t realize what they’re experiencing is part of menopause, or that help exists.
The Estrogen Conversation: Facts vs. Fear
A big focus of our conversation was topical estrogen, a treatment with decades of clinical evidence behind it, yet still shrouded in fear due to confusion over safety.
Dr. Chubak pointed to the Women’s Health Initiative (WHI), a landmark study in the 1990's that caused widespread concern about hormone therapy. “That study focused on systemic hormone replacement, not local vaginal estrogen,” she emphasized. Unfortunately, the fallout from WHI led to a black box warning being applied to all estrogen products, regardless of how they're used.
But here’s the truth: topical estrogen is not systemic HRT. It stays local to the tissue and has not been shown to increase risks of cancer, stroke, or heart disease, according to Dr. Chubak.
OTC vs. Prescription Options
Over-the-counter vaginal moisturizers can help with dryness and irritation, but they don’t restore the underlying tissue. “They act like a moisture barrier, not a treatment,” Dr. Chubak said. If you're dealing with deeper symptoms, such as pain during sex or recurrent UTIs, a topical estrogen cream, insert, or ring may be more effective.
These treatments rebuild the mucosal lining, help maintain healthy tissue, and may reduce the frequency of urinary symptoms by improving the vaginal and urethral environment.
UTIs, Biofilms, and the Role of Estrogen
A particularly eye-opening part of our conversation was on recurrent UTIs and their connection to GSM. Thinning tissue and low estrogen can allow bacteria to colonize more easily. Some bacteria even form biofilms, protective layers that help them survive antibiotic treatments and cause recurring infections.
“Preventing those symptoms starts with restoring the tissue environment,” Dr. Chubak noted. “And that’s where estrogen plays a key role.”
How to Advocate for Yourself in the Doctor’s Office
Dr. Chubak encouraged patients not to settle for being dismissed. “Yes, these symptoms are more common with age,” she said, “but that doesn’t mean you have to live with them.” She recommends being specific with providers, naming symptoms clearly, and, if needed, asking to speak with a gynecologist, urologist, or even dermatologist who understands the skin and hormonal dynamics of this part of the body.
The Big Takeaway
If there’s one thing Dr. Chubak made clear, it’s this: menopause doesn’t have to mean discomfort. Whether it’s vaginal dryness, increased urinary frequency, or pain during sex, these symptoms are real, and manageable. You are not alone, and you do not have to suffer in silence.
As more providers and patients push for the removal of outdated warnings and stigma, conversations like this one help open the door to evidence-based care and meaningful relief.