If you take one thing from this post, let it be this: dryness, painful sex, urgency and leaks are not something you just have to live with.

These are some of the most common things women tell me about in midlife, and often only once we've finished talking about everything else. They come up at the end of the appointment, almost as an afterthought. Many women have already been told it's just part of getting older.

It's common. But common doesn't mean normal, and it definitely doesn't mean untreatable.

1. It has a name: GSM

Genitourinary syndrome of menopause (GSM) is the term for the changes that happen to the vulva, vagina, bladder and urethra as estrogen declines. It used to be called vaginal atrophy, but the newer name is more accurate because it's not only about the vagina. It can include:

  • Vaginal dryness, burning or irritation
  • Pain or discomfort with sex
  • Urinary urgency, or feeling like you need to go more often
  • Recurring urinary tract infections (UTIs)

Depending on the study, somewhere between about a quarter and more than three quarters of postmenopausal women have symptoms of GSM. It's one of the most common parts of menopause.

Here's the part I really want women to know. Hot flashes often settle with time. GSM usually doesn't. Without treatment, it tends to get worse, not better.

2. Vaginal estrogen is the gold standard

Low-dose vaginal estrogen is the most effective treatment we have for GSM. It comes as a cream, a small tablet or insert, or a ring, and it works directly on the tissue where it's needed.

It helps restore the thickness, moisture and elasticity of the vaginal and urethral tissue. For a lot of women, that means less dryness, more comfortable sex and fewer bladder symptoms.

It can also help with recurring UTIs. The 2025 AUA/SUFU/AUGS guideline on GSM recommends low-dose vaginal estrogen to reduce future UTIs in women with GSM who keep getting them. If you've been through round after round of antibiotics, this is worth asking about.

3. "But isn't estrogen risky?"

This is the question I hear most often, and I understand why. There's been so much fear around estrogen.

But low-dose vaginal estrogen is different from systemic hormone therapy. It works locally, and very little of it reaches your bloodstream. The same guideline says there's no evidence linking low-dose vaginal estrogen to breast cancer, and that it doesn't increase the risk of endometrial (uterine) cancer.

It's considered safe for most women. It can also be used alongside systemic hormone therapy, because some women on a patch or gel still need local support for the tissue.

If you've had breast cancer, vaginal estrogen may still be an option, but that's a decision to make with your oncology team. There are also non-estrogen options, like vaginal DHEA and good vaginal moisturizers, that can help.

4. When estrogen isn't the whole answer

Here's what I see in practice. A woman starts vaginal estrogen, and her dryness and discomfort get so much better. But she still leaks when she laughs, sneezes, coughs or jumps.

That's because estrogen restores the tissue. It doesn't rebuild muscle.

Leaking with pressure or impact is called stress urinary incontinence, and it's often a pelvic floor strength issue. Your pelvic floor is a group of muscles that supports your bladder, uterus and bowel. When those muscles are weak, everyday pressure can push past them.

5. Leaks don't only start after menopause

This is one of the biggest myths I hear. Leaks often start much earlier, in your 30s and 40s:

  • After pregnancy and birth, which put a lot of strain on the pelvic floor
  • With running or high-impact exercise, which is far more common in active women than most people realize
  • Long before perimenopause begins

So many women quietly wear a pad to the gym or skip the trampoline with their kids and never mention it to anyone. If that's you, you're not alone, and you don't have to accept it.

6. Where Emsella fits

Emsella is a chair that uses high-intensity focused electromagnetic energy (HIFEM) to stimulate your pelvic floor muscles. In one session, it creates thousands of deep pelvic floor contractions, far more than you could do on your own.

What patients tend to like about it:

  • You stay fully clothed and just sit on the chair
  • Each session is about 28 minutes
  • A typical series is 6 sessions, usually twice a week over about 3 weeks
  • There's no downtime, so you can go right back to your day

I'll be honest with you about the research. The studies on Emsella so far have been encouraging, with improvements in leaking and fewer pads used, but many of them are small and short term. It's a promising tool, not a magic fix, and I'm not going to overstate it.

Emsella also isn't for everyone. It's not used during pregnancy, or if you have a pacemaker or certain metal implants, so we'll go through your health history first.

And it doesn't replace the basics. Pelvic floor physiotherapy is a great first-line option for leaks, and many women do best when they combine approaches. For women who have tried exercises and are still struggling, or who simply can't find the time, Emsella can be a helpful addition.

7. Why I often recommend both

For a lot of women in midlife, the problem isn't one thing. It's the tissue and the muscle.

  • Vaginal estrogen for the tissue: dryness, burning, painful sex, urgency and recurring UTIs
  • Emsella for the pelvic floor: leaking with laughing, sneezing, coughing, running or jumping

When we address both, women often get further than they would with either one alone.

8. How to bring this up with your doctor

I know this can feel awkward to talk about. If you're hoping your family doctor can help, you could say something like:

"I've been having vaginal dryness and some bladder symptoms. Could we talk about whether low-dose vaginal estrogen is right for me?"

If you've had recurring UTIs, mention that too. It's an important part of the picture.

The bottom line

Dryness, painful sex, urgency and leaks are common, but they aren't something you have to quietly put up with. Vaginal estrogen is safe for most women and works well for the tissue. If leaks are part of what you're dealing with, the pelvic floor needs support too.

Your next step

If leaks are your main concern, book a complimentary Emsella consult. We'll talk through your symptoms, make sure Emsella is a good fit for you, and you'll get a demo on the device so you know exactly what it feels like before you commit. You can learn more about Emsella here.

Book a complimentary Emsella consult

If you want to look at the bigger picture, like dryness, painful sex, recurring UTIs, your hormones and how it all fits together, book an initial consultation with your ND. If you're already a patient, book a follow-up and we'll add it to your plan.

Book an initial or follow-up consultation

Not sure which one you need? If you live in Alberta or BC, you can book a free Hormone Clarity Call. It's 10 to 15 minutes to go over your symptoms and figure out your next best step.

I see patients in person in Calgary at BioRevive Regenerative Medicine and the Mount Royal University Injury & Prevention Clinic, as well as in Fernie, BC. I also offer virtual hormone care for women anywhere in Alberta and BC.

Dr. Tricia Breckon, ND Founder, BioRevive

This article is for general education and isn't a substitute for individual medical advice. If you're experiencing symptoms, please speak with a qualified healthcare provider.