Vaginal Atrophy (GSM): Symptoms, DHEA & Natural Support

QUICK SUMMARY

Vaginal atrophy is now more commonly called genitourinary syndrome of menopause (GSM). It can include vaginal or vulvar dryness, burning, irritation, pain with sex, urinary symptoms, and changes in sexual comfort as estrogen and androgen levels decline around and after menopause.

There is no one-size-fits-all solution. Vaginal moisturizers and lubricants can help with dryness and friction, pelvic floor therapy can help when muscle function or urinary leakage is part of the picture, and prescription options include local low-dose vaginal estrogen, vaginal DHEA (prasterone), and the oral SERM ospemifene.

Vaginal DHEA has meaningful human clinical evidence. A 2026 systematic review and meta-analysis of randomized trials found that intravaginal DHEA improved vaginal dryness and painful intercourse compared with placebo. (1) However, those trials studied DHEA placed inside the vagina, including the FDA-approved 6.5 mg prasterone insert. They did not test every non-prescription DHEA cream or external vulvar moisturizer.

One product I have shared with our Natural Living Family for years is Julva, an external vulvar moisturizer formulated with DHEA. I still think it is worth knowing about, but it is important to understand exactly what the research supports and how Julva differs from prescription intravaginal prasterone.

What is vaginal atrophy? This is a subject that doesn't get talked about enough but that many women experience with aging, perimenopause, menopause, surgical menopause, certain medications, or other low-estrogen states. Today, the broader medical term is genitourinary syndrome of menopause, or GSM, because the changes can involve the vulva, vagina, bladder, urethra, sexual function, and pelvic comfort.

This post includes a lot of research and experience to help anyone struggling with these challenges. We'll look at the current treatment options and spend extra time on one that has fascinated me for years: DHEA.

The strongest clinical research is on intravaginal DHEA, also called prasterone. We'll also talk about my friend Dr. Anna Cabeca's non-prescription Julva vulvar moisturizer with DHEA, while keeping the distinction clear between research on a prescription vaginal insert and a cosmetic product applied externally to the vulva.

Disclosure: Natural Living Family has a financial relationship with Dr. Anna Cabeca's company and may earn a commission when you purchase through our Julva links. The research discussed below includes studies of prescription vaginal DHEA and other therapies that are not the same product as Julva.

What Is Vaginal Atrophy?

Vaginal atrophy is the older term many women still search for. Today, clinicians commonly use genitourinary syndrome of menopause (GSM) to describe the vulvar, vaginal, sexual, and urinary changes associated with declining estrogen and androgen concentrations during the menopause transition. A 2025 multisociety guideline notes that as many as 84% of women report symptoms consistent with GSM. (2)

Symptoms can include:

• vulvar or vaginal thinning, dryness, burning, itching, or irritation
• painful intercourse related to dryness or tissue sensitivity
• changes in vaginal pH and vaginal flora
• urinary urgency, burning, or recurrent urinary tract infections
• decreased sexual comfort, arousal, lubrication, or satisfaction
• spotting or bleeding related to fragile tissue, which should always be evaluated if it is new or unexplained

Urinary leakage and pelvic organ prolapse can occur during the same season of life, but they are not automatically caused by vaginal atrophy. Pelvic floor weakness, pregnancy and childbirth history, aging, chronic pressure on the pelvic floor, and other health factors can contribute as well.

Younger women can experience similar symptoms, especially during breastfeeding, after removal of the ovaries, or while taking certain hormone-suppressing treatments.

Before menopause, a woman’s ovaries produce many of her sex hormones including estrogen. Estrogen helps maintain the thickness, blood flow, elasticity, lubrication, and acidic environment of vaginal tissue. During perimenopause and after menopause, women experience declining hormone levels, including estrogen, progesterone, testosterone, and dehydroepiandrosterone (DHEA).

As these hormones decline, the vaginal lining can become thinner, drier, and less elastic. Lactobacilli can decrease and vaginal pH can rise, which changes the local environment. For some women these changes are mild. For others they can interfere with exercise, intimacy, sleep, bladder comfort, and quality of life.

These symptoms are life-affecting, but they are not something women simply have to accept without asking for help.

One important update from the older language in this article is that GSM symptoms often persist unless they are addressed. Unlike hot flashes, which frequently improve with time, vulvovaginal symptoms can continue or progress after menopause.

If you have unexplained vaginal bleeding, persistent discharge, sores, severe pelvic pain, recurrent infections, or symptoms that do not improve with simple care, see your gynecologist. Not every irritation or urinary symptom is caused by GSM.

Special 7-Day Sample Just for Natural Living Family Readers! With our Natural Living Family “group buy”, try a 7-day sampler of Julva, a topical moisturizer for delicate feminine tissue. The current Julva trial is free, with shipping and handling charged by the seller. Grab your FREE sample here.

Current Treatment Options for Vaginal Atrophy

There are more treatment choices for GSM today than when this article was first written, and calling them all ineffective would no longer be accurate. The better question is: Which option best matches the symptoms, medical history, preferences, and goals of the woman using it?

Current options include:

• vaginal moisturizers and lubricants
• pelvic floor physical therapy and Kegel exercises when pelvic floor dysfunction or urinary leakage is involved
• local low-dose vaginal estrogen
• prescription vaginal DHEA, or prasterone
• the oral selective estrogen receptor modulator ospemifene
• systemic menopausal hormone therapy when broader menopausal symptoms warrant it
• surgery for true pelvic organ prolapse or stress urinary incontinence when conservative options are not enough

A 2025 evidence-based guideline found that local low-dose vaginal estrogen has the most robust evidence base for GSM overall, while current evidence also supports vaginal DHEA for dryness and dyspareunia. (2) That does not mean every woman should use estrogen or that one therapy is automatically best for everyone.

Lubricants & Vaginal Moisturizing Creams

Lubricants and moisturizers are still important first-line tools, especially for women who want to begin with nonhormonal care.

Lubricants reduce friction during sexual activity. Vaginal moisturizers are used regularly to improve day-to-day moisture and comfort. They do not work in exactly the same way, and neither should be dismissed as merely cosmetic. Current clinical guidance recognizes them as useful for vaginal dryness and dyspareunia. (3)

• Water-based lubricants include: K-YJelly, FemGlide, Summer’s Eve and others are non-staining. Silicone-based lubricants include Pink, Pure Pleasure, and others.
• Oil-based lubricants include mineral oil, petroleum jelly, baby oil, and natural oils. Oil-containing products can weaken latex condoms, so check condom compatibility before using them together. Some women also find petroleum-derived products irritating and prefer plant-based options.
• Vaginal moisturizers include Replens, Moist Again, Fresh Start, and K-Y Liquibeads.

Natural solutions such as organic coconut oil-based homemade lubricants, Ayurveda ghee combined with herbs, and cleaner OTC lubricants are also available for women who prefer to avoid synthetic fragrance, petroleum-derived ingredients, and unnecessary additives. Remember that oils are not compatible with latex condoms.

Herbal therapies such as black cohosh, soy isoflavones, magnolia bark, and other ingredients are commonly marketed for menopause. The evidence for treating GSM specifically is much weaker than the evidence for established local therapies. Whole-food soy can still fit into a healthy diet when appropriate, but it should not be presented as a proven treatment for vaginal atrophy.

This chart summarizes the above treatment options:

Editorial note: This legacy comparison chart is preserved from the original article. Current guidance in the updated text should control wherever details in the older graphic differ.

Estrogen Therapies for Vaginal Atrophy

One common treatment for vaginal atrophy is replacing some of the diminished estrogen effect locally or systemically. The risks and benefits depend heavily on the product, dose, route, age, health history, and whether the goal is to treat local GSM symptoms or broader menopausal symptoms.

Low-Dose Vaginal Estrogen Therapy

Predominant medical therapy for vaginal dryness and pain has long included low-dose vaginal estrogen.

This therapy can be prescribed as vaginal tablets, creams, inserts, or rings. Because these products are delivered locally, systemic estrogen exposure is generally much lower than with systemic hormone therapy. They can improve vaginal tissue maturation, pH, dryness, irritation, and pain during intercourse.

Examples include prescription medications such as Vagifem, Premarin vaginal cream, Estring, and Estrace vaginal cream.

The old blanket statement that vaginal estrogen should never be considered after breast cancer is too broad. Current ACOG guidance says nonhormonal options should usually be tried first in women with a history of estrogen-dependent breast cancer, but low-dose vaginal estrogen may be considered after a discussion of risks and benefits. Women taking aromatase inhibitors should make that decision together with their gynecologist and oncologist. (3)

Hormone Replacement Therapy (HRT) & Vaginal Health

Systemic menopausal hormone therapy can help vasomotor symptoms such as hot flashes and night sweats and can also improve GSM for some women. However, local symptoms sometimes persist even when systemic therapy is being used, which is why local treatment may still be considered.

Systemic hormone therapy is not the right choice for every woman. Risk depends on the formulation, dose, route, timing, age, and personal medical history. Oral estrogen can carry different clotting risk than transdermal estrogen, and a woman with a uterus generally needs adequate endometrial protection when systemic estrogen is used.

My friend Dr. Anna has long preferred bioidentical hormones, when hormones are appropriate, using the lowest effective dose needed for the individual woman. That is her clinical position and one reason DHEA became such an important part of her work.

One clarification matters here: “bioidentical” does not automatically mean compounded or automatically mean safer. FDA-approved bioidentical estradiol, progesterone, and prasterone products exist. ACOG currently recommends FDA-approved menopausal hormone therapies over custom-compounded products when an approved option is available because compounded formulations have less standardized evidence, potency, and quality control. (4)

Kegel & Pelvic Floor Strengthening Exercises

Kegel exercises strengthen the pelvic floor muscles that support the bladder, rectum, and uterus. They can help some women with urinary leakage and may improve sexual function. (5)

• Kegel exercises involve contracting, holding, and fully relaxing the muscles of your pelvic floor.
• A pelvic floor physical therapist can help identify whether your muscles are weak, overactive, poorly coordinated, or a combination of these.
• Biofeedback or specially designed pelvic floor weights may help some women learn correct muscle activation.
• It is also important to avoid repeatedly straining or bearing down in ways that increase pressure on a weak pelvic floor.

Kegels are not automatically the answer for every pelvic floor problem. If your pelvic floor is already too tight, repeatedly squeezing it can make pain worse. This is one reason an individualized pelvic-floor evaluation can be so helpful.

Here is a summary of the estrogen treatment options, as well as the pelvic floor health (Kegels) options:

Editorial note: This legacy comparison chart is preserved from the original article. Use the current evidence and safety guidance in the updated text when a detail in the older graphic differs.

Surgical & Energy-Based Options

Surgery can be appropriate for true pelvic organ prolapse or urinary incontinence when symptoms are significant and conservative treatment has not been enough. Cosmetic genital procedures and energy-based “vaginal rejuvenation” treatments are a different category and should not be confused with evidence-based prolapse surgery.

Labiaplasty, Vaginoplasty & Cosmetic Procedures

Some women pursue labiaplasty or other genital cosmetic procedures for appearance, comfort, or sexual concerns. These procedures carry real surgical risks, including pain, bleeding, infection, scarring, altered sensation, and painful intercourse. A gynecologic evaluation is important when symptoms, rather than appearance alone, are driving the request.

Vaginal Laser & Energy-Based Therapy

This section needed an important correction. Vaginal laser treatments such as the MonaLisa Touch are not FDA-approved to treat menopausal symptoms, urinary incontinence, sexual dysfunction, or vaginal atrophy. ACOG's current patient guidance says the FDA has warned that laser and other energy-based vaginal treatments can cause burns, scarring, pain with sex, and persistent pain. (6)

The 2024 AHRQ systematic review also found that, compared with sham treatment, carbon dioxide laser may produce little to no difference in several GSM outcomes and that evidence for many other outcomes remains very uncertain. (7)

That does not mean future research will never identify a useful role for these devices. It means they should not currently be promoted as proven or FDA-approved treatments for GSM.

Pelvic Prolapse & Incontinence Surgery

Surgical options for prolapse and stress urinary incontinence address structural or functional pelvic-floor problems. They can be appropriate when symptoms are significant and conservative management has not provided enough relief.

These surgeries are not treatments for every symptom of GSM. A woman can have prolapse and vaginal dryness at the same time and need different approaches for each problem.

SERMs & DHEA

Less commonly discussed prescription options include selective estrogen receptor modulators (SERMs) and vaginal DHEA.

Ospemifene is an oral SERM. The FDA-approved label indicates it for moderate to severe dyspareunia and moderate to severe vaginal dryness due to menopause. It also carries important contraindications and warnings, so it requires individualized prescribing. (8)

Vaginal DHEA, or prasterone, is another prescription option. This one deserves special attention because it connects directly with Dr. Anna's long-standing interest in DHEA.

Special 7-Day Sample Just for Natural Living Family Readers! With our Natural Living Family “group buy”, try a 7-day sampler of Julva, a topical moisturizer for delicate feminine tissue. The current offer is free, with shipping and handling charged by the seller. Grab your FREE sample here.

DHEA for Vaginal Atrophy

While much of the menopause conversation focuses on estrogen and testosterone, another hormone has become an important part of the GSM discussion: dehydroepiandrosterone, or DHEA.

DHEA is an androgen precursor. It is naturally produced in the body, primarily by the adrenal glands, and can be converted within tissues into active androgens and estrogens. DHEA levels generally decline with age.

That local conversion is one of the reasons vaginal DHEA has attracted so much clinical interest. Vaginal tissue contains enzymes capable of converting prasterone into downstream sex steroids. The FDA-approved prasterone label states that prasterone is converted into active androgens and/or estrogens and that its exact mechanism in vulvar and vaginal atrophy is not fully established. (9)

DHEA can be taken orally or used locally, but those routes should not be treated as interchangeable.

Natural decline of DHEA

Oral DHEA

Oral DHEA has been studied for a variety of purposes, but the evidence for GSM and sexual function is much less convincing than the evidence for local vaginal treatment. Current evidence does not support treating oral DHEA as a substitute for vaginal DHEA when the goal is vaginal dryness or painful intercourse. (4)

Prescription Vaginal DHEA

In November 2016, the FDA approved prasterone, sold as Intrarosa, as a vaginal insert for moderate to severe dyspareunia due to menopause. The current prescription contains 6.5 mg of prasterone and is inserted vaginally once daily at bedtime. (9)

Clinical trials show that this route can improve vaginal cell maturation, lower vaginal pH, and reduce pain during intercourse. Serum estradiol and testosterone can rise slightly with prescription prasterone, so it is inaccurate to say there is absolutely no systemic exposure. However, the changes observed in clinical studies remained small and generally within postmenopausal ranges. (9)

External Vulvar DHEA Is Not the Same Treatment

This distinction is extremely important for understanding the rest of this article.

The major clinical trials evaluated DHEA placed inside the vagina. Julva is currently marketed as an external vulvar moisturizer. Dr. Anna's instructions say to apply it to the vulva, clitoris, and surrounding skin. It is not the FDA-approved Intrarosa vaginal insert, and the Intrarosa trials do not automatically prove that Julva treats GSM, dyspareunia, urinary incontinence, prolapse, or sexual dysfunction. (10)

What the research does support is the biological and clinical relevance of DHEA in vulvovaginal health. That is part of why Dr. Anna formulated Julva with DHEA, but product-specific claims should stay within what has actually been studied.

Here is a summary of surgical options, SERMS, and DHEA.

Editorial note: This legacy comparison chart is preserved from the original article. In particular, current guidance on vaginal laser therapy and the distinction between prescription intravaginal DHEA and external vulvar DHEA should take precedence over older chart language.

What Research Says About Vaginal DHEA

There is now a stronger body of research on intravaginal DHEA than when this article was originally published.

A 2026 systematic review and meta-analysis published by The Menopause Society included six reports representing five unique randomized controlled trials and 1,611 postmenopausal women. Compared with placebo, intravaginal DHEA significantly improved vaginal dryness and dyspareunia, with no major safety concerns reported in the included trials. (1)

That is meaningful evidence. It is also evidence for intravaginal DHEA, not every topical DHEA product.

1. Reduce Vaginal Dryness & Irritation

In a randomized, double-blind, placebo-controlled phase III trial, 325 women received daily intravaginal 0.50% DHEA, or 6.5 mg prasterone, while 157 received placebo for 12 weeks. Compared with placebo, DHEA improved vaginal cell maturation, lowered vaginal pH, and reduced moderate to severe pain during sexual activity. (11)

The treatment group also improved from baseline in vaginal dryness. The important point is that this was a controlled clinical trial using a specific vaginal preparation and dose.

2. Improve Vaginal Tissue Health

A 2009 randomized trial evaluated local intravaginal DHEA across the three layers of vaginal tissue: the epithelium, lamina propria, and muscularis. The trial also reported improvements in several domains of sexual function. (12)

The older version of this article called this “strengthening vaginal musculature.” That goes beyond what the trial actually established. Histologic or tissue-level effects are not the same as proving stronger pelvic-floor muscles or showing that DHEA treats prolapse or stress urinary incontinence.

3. Bone Mineral Density Is a Separate Question

The earlier article attributed bone-density benefits to locally applied vaginal DHEA. Current evidence does not support that claim. ACOG's 2023 review of randomized trials found no significant bone-mineral-density benefit from vaginal testosterone or DHEA. (4)

That does not diminish the vaginal research. It simply keeps the claim matched to what was actually measured.

4. Decrease Pain During Intercourse (Dyspareunia)

Pain with sex is where vaginal DHEA has some of its strongest evidence. The FDA approved Intrarosa specifically for moderate to severe dyspareunia due to menopausal vulvar and vaginal atrophy. In the pivotal trials, the 6.5 mg insert produced a greater reduction in dyspareunia severity than placebo after 12 weeks. (9)

5. Support Sexual Function

In the 2009 randomized trial, 1.0% intravaginal DHEA improved measures of desire, arousal, lubrication, orgasm, and dryness during intercourse compared with placebo. (12)

A later 52-week open-label study of 154 postmenopausal women using 0.50% intravaginal DHEA reported improvements from baseline across desire, arousal, lubrication, orgasm, satisfaction, and pain domains. Because that study was open-label and did not have a placebo comparison for the 52-week results, those percentages should be interpreted as within-group changes rather than proof that every improvement was caused by DHEA. (13)

What About Women With a History of Breast Cancer?

This is an area where the older article needed a major safety update.

The current Intrarosa prescribing information carries a warning for women with a current or past history of breast cancer because estrogen is a metabolite of prasterone, and the FDA-approved product was not studied for its approval in women with a history of breast cancer. (9)

ACOG takes a more individualized clinical approach. Its consensus guidance says nonhormonal therapies should generally be considered first in women with a history of estrogen-dependent breast cancer. If vaginal estrogen is not an option, vaginal DHEA or testosterone may help with dyspareunia and vaginal tissue health, but decisions should be individualized with the woman's gynecologist and oncology team. (3)

The same caution applies to a non-prescription topical product containing DHEA. The current Julva product information advises women who have or have had breast cancer, are pregnant or breastfeeding, or have an active vaginal infection to consult their doctor before use. (10)

Special 7-Day Sample Just for Natural Living Family Readers! With our Natural Living Family “group buy”, try a 7-day sampler of Julva, a topical moisturizer for delicate feminine tissue. The current seller offer is free, with $4.95 shipping and handling at the time of this update. Grab your FREE sample here.

Dr. Anna’s Clinical Experience Using DHEA

As an Emory-trained physician, Dr. Anna started using androgen therapy in her private practice in 1999. She used bioidentical DHEA and testosterone vaginally or applied it topically to the vulvar area. Patients came to her complaining of vaginal atrophy symptoms including vaginal dryness, irritation, pain during intercourse, urinary leakage, and libido issues.

She routinely observed positive results in her practice, including improvements in sexual health, vaginal dryness, irritation, pain during intercourse, libido, and sexual satisfaction. Some patients also reported decreased incontinence symptoms.

For some women, physical examination also showed visible tissue changes in the vaginal lining and rugae, the normal folds and elasticity of the vagina.

This is Dr. Anna's clinical experience, not a randomized trial of Julva. Clinical experience can help generate good questions and guide individualized care, but it should not be presented as proof that a topical cosmetic cream prevents surgery, reverses prolapse, or treats urinary incontinence.

The Birth of Julva & Natural Living Family Special

Dr. Anna wanted to provide women with a non-prescription topical option for caring for delicate vulvar tissue without requiring an internal prescription product.

Years of research along with her clinical experience led her to combine DHEA with other moisturizing and skin-conditioning ingredients. The current Julva formula includes DHEA, Alpine Rose Stem Cell extract, emu oil, vitamin E tocopherol, coconut oil, shea butter, glycerin, and other ingredients used to create the cream base. (10)

DHEA is a naturally occurring hormone precursor that declines with age. In Julva, it is included in a product intended for external vulvar application.

Vitamin E Tocopherol is an antioxidant commonly used in skin-care formulations. Coconut oil, shea butter, glycerin, and emu oil help moisturize and soften the skin.

Alpine Rose Stem Cell extract is a cosmetic botanical ingredient. The old article attributed antiviral, anti-aging, and tissue-rejuvenation effects to this ingredient that were not supported by product-specific human clinical evidence, so I would not use those claims to sell the cream.

The current directions from Dr. Anna's company are to apply Julva externally to the vulva, clitoris, and surrounding skin. Their standard instructions recommend daily use initially and less frequent maintenance use once desired cosmetic results are reached. (10)

This is where the distinction matters most: Julva is not Intrarosa. It is not the FDA-approved 6.5 mg prescription vaginal insert studied in the pivotal GSM trials. Julva is sold as a vulvar moisturizer, and I think the most responsible way to talk about it is exactly that way.

If that external-care approach fits what you are looking for, you can see the current Julva trial offer here.

Dr. Anna perfected this cream with love and prayers that it helps women around the world feel more comfortable and confident in their sexual health as they deal with the normal changes of age. We've shared it with our Natural Living Family in the past, and the testimonials have been encouraging.

If you want to try it, use it according to the current product directions. Stop if you develop irritation or another unwanted reaction. If you have unexplained vaginal bleeding, a hormone-sensitive cancer history, are pregnant or breastfeeding, have an active vaginal infection, or take hormone-related medication, talk with your qualified healthcare professional before using a DHEA-containing product.

Try my friend Dr. Anna's Julva trial pack here and see whether it is a good fit for your personal care routine.

Vaginal Atrophy & DHEA FAQs

Is vaginal atrophy the same as genitourinary syndrome of menopause?

Vaginal atrophy is part of what clinicians now call genitourinary syndrome of menopause, or GSM. GSM is broader because it includes vulvar, vaginal, urinary, and sexual symptoms associated with hormonal changes around menopause.

Does vaginal DHEA work for vaginal atrophy?

Yes, prescription-strength intravaginal DHEA has randomized controlled trial evidence for improving vaginal dryness and painful intercourse in postmenopausal women. A 2026 meta-analysis of five unique randomized trials found significant improvements in both outcomes compared with placebo. (1)

Is Julva the same as prescription prasterone?

No. Intrarosa is an FDA-approved prescription vaginal insert containing 6.5 mg of prasterone that is placed inside the vagina. Julva is a non-prescription vulvar moisturizer containing DHEA that is applied externally to the vulva, clitoris, and surrounding skin. Research on Intrarosa or other intravaginal DHEA preparations cannot automatically be used as proof that Julva produces the same clinical outcomes.

Can DHEA help urinary incontinence or pelvic prolapse?

The current evidence does not establish vaginal DHEA as a treatment for stress urinary incontinence or pelvic organ prolapse. Pelvic floor muscle training can help urinary leakage, and a pelvic floor physical therapist can help determine which exercises are appropriate. (5)

Can women with a history of breast cancer use DHEA?

This requires individualized medical guidance. The FDA-approved Intrarosa label warns about current or past breast cancer because prasterone can be converted to estrogen. ACOG notes that vaginal DHEA may be considered when vaginal estrogen is not an option, but women with a hormone-sensitive cancer history should make that decision with their gynecologist and oncology team. (3, 9)

What is the most effective treatment for GSM?

There is no single best treatment for every woman. Local low-dose vaginal estrogen has the largest evidence base overall, vaginal DHEA has good evidence for dryness and dyspareunia, ospemifene is another prescription option, and moisturizers, lubricants, and pelvic floor therapy can be useful depending on the symptom pattern. The right choice depends on your medical history, goals, and preferences. (2)