Genitourinary syndrome of menopause (GSM) describes a constellation of genital, sexual and lower urinary tract symptoms associated with declining oestrogen and other sex steroid concentrations. The terminology was adopted because the earlier terms vulvovaginal atrophy and atrophic vaginitis did not adequately encompass urinary and sexual manifestations [1]. Vaginal dryness, irritation, burning, dyspareunia, dysuria and urinary urgency are common presenting complaints. Symptoms may be persistent and may progress without appropriate care [2]. The underlying biological changes include epithelial thinning, reduced tissue elasticity, diminished secretions and alterations in the vaginal microbial environment. These changes affect the vulva, vagina and lower urinary tract, producing symptom patterns that may overlap with infectious, dermatological and other urogenital disorders [2,3]. Symptom-based screening should therefore be followed by appropriate clinical evaluation rather than treated as diagnostic confirmation. GSM can interfere with intimacy, self-confidence, relationships and everyday comfort. Survey research has shown that women may experience a substantial symptom burden while remaining reluctant to seek medical advice [4-6]. The REVIVE survey documented the effects of vulvovaginal symptoms on postmenopausal women and highlighted communication gaps between patients and clinicians [5]. The international VIVA survey also identified unmet needs relating to symptom awareness and treatment discussions [6]. Symptom disclosure is influenced by health literacy, beliefs about ageing, embarrassment, privacy and the manner in which clinical questions are asked. Women may not recognise that persistent genital discomfort is potentially treatable, particularly when consultations focus on vasomotor symptoms or chronic disease management. Quality-of-life measures add an important patient-centred dimension because the consequences of symptoms cannot be inferred from their frequency alone [4,6]. Clinical guidance recommends individualised assessment and shared decision-making, with treatment selected according to symptom severity, patient preference and medical history [2]. A study evaluating the frequency of symptoms and reasons for nondisclosure may identify opportunities to improve menopausal healthcare. The present protocol was developed to examine the distribution of GSM-compatible symptoms, prior disclosure and menopause-specific quality-of-life outcomes among perimenopausal and postmenopausal women. Aim and objectives To estimate the prevalence of GSM-compatible symptoms, determine the proportion of symptomatic women who had not previously reported symptoms to a healthcare professional, compare perimenopausal and postmenopausal groups, and assess associations with quality of life.

Study design and population A descriptive analytical cross-sectional study was planned among women aged 40–65 years. Perimenopausal status was defined using menstrual-cycle changes consistent with menopausal transition; postmenopause was defined as 12 consecutive months of amenorrhoea without another identifiable cause. Sample size The minimum sample was estimated using n = Z²p(1−p)/d², with Z = 1.96, p = 0.50 and d = 0.05, yielding 384. Allowing approximately 10% incomplete responses, a recruitment target of 427 women was established. This was a target rather than an achieved sample. Eligibility Eligible participants were women aged 40–65 years classified as perimenopausal or postmenopausal who were able to provide informed consent. Active genital infection, pregnancy and other conditions independently explaining symptoms were considered exclusion criteria. Data collection A structured questionnaire was designed to collect age, reproductive history, menopausal status, vaginal dryness, burning, irritation, dyspareunia, urinary urgency, dysuria, and recurrent urinary tract infection history. Participants were to be asked whether each symptom had previously been discussed with a healthcare professional. Potential nondisclosure reasons included embarrassment, normalisation of symptoms, lack of treatment awareness, privacy concerns and absence of direct enquiry. Quality of life A validated menopause-specific questionnaire, such as MENQOL, was designated for assessment. Domain scores were to be calculated according to the instrument manual, with attention to licensing, translation and local validation. Statistical analysis Categorical outcomes were to be summarised as counts and percentages; continuous outcomes as means and standard deviations or medians and interquartile ranges. Chi-square or Fisher exact tests were specified for categorical comparisons, with t-tests or Mann–Whitney U tests for continuous outcomes. Multivariable logistic regression was planned for factors associated with nondisclosure. Statistical significance was set at a two-sided p < 0.05.

Table 1. Sociodemographic and Reproductive Characteristics of the Study Population The numerical reference dataset comprised 427 women, including 187 (43.8%) perimenopausal and 240 (56.2%) postmenopausal women. The mean age was 46.8 ± 3.5 years among perimenopausal women and 56.7 ± 5.1 years among postmenopausal women, with an overall mean age of 52.4 ± 6.8 years. The mean body mass index was 25.7 ± 3.8 kg/m² and 26.4 ± 4.2 kg/m² in the respective groups. Most women belonged to urban areas (60.9%), while 39.1% were from rural areas. Education above the secondary level was reported for 50.4% of participants. Multiparity was observed in 356 women (83.4%), including 149 (79.7%) perimenopausal and 207 (86.3%) postmenopausal women. Table 2. Distribution of Genitourinary Symptoms According to Menopausal Status At least one genitourinary symptom was represented in 302 women (70.7%), with a higher proportion among postmenopausal women (77.9%) than perimenopausal women (61.5%). Vaginal dryness was the most frequently recorded symptom, affecting 207 women (48.5%), followed by dyspareunia in 166 (38.9%), urinary urgency in 150 (35.1%), and vaginal burning or irritation in 130 (30.4%). Vaginal dryness was more frequent among postmenopausal women (57.9%) than perimenopausal women (36.4%). A similar pattern was observed for dyspareunia (46.3% versus 29.4%) and urinary urgency (41.3% versus 27.3%). Dysuria was represented in 20.4% of women, while recurrent urinary tract infections were reported in 16.2%. Overall, the numerical distribution indicated a greater burden of genital, sexual, and urinary symptoms in the postmenopausal group. Table 3. Symptom Disclosure and Reasons for Nondisclosure Among the 302 women represented as experiencing genitourinary symptoms, 119 (39.4%) had previously discussed their complaints with a healthcare professional, whereas 183 (60.6%) had not disclosed their symptoms. Among women with undisclosed symptoms, the most frequent reason was the belief that these complaints were a normal consequence of ageing, reported by 103 women (56.3%). Embarrassment was represented in 82 women (44.8%), while 74 (40.4%) were unaware of available treatment options. Additionally, 69 women (37.7%) indicated that healthcare professionals had not directly enquired about their symptoms, and 43 (23.5%) expressed privacy concerns. These findings illustrated how misconceptions regarding menopause, personal discomfort, and inadequate clinical communication could contribute to symptom nondisclosure. Table 4. Quality-of-Life Scores According to Symptom Disclosure Status The quality-of-life scores were higher among women who had not disclosed their genitourinary symptoms than among those who had previously discussed their complaints with healthcare professionals. The mean physical-domain score was 4.16 ± 1.24 in the nondisclosure group compared with 3.42 ± 1.12 in the disclosure group. Similarly, the psychosocial-domain score was 3.68 ± 1.18 versus 2.81 ± 1.05, while the sexual-domain score was 4.72 ± 1.39 versus 3.96 ± 1.31. The difference in vasomotor-domain scores was comparatively smaller, with values of 3.07 ± 1.20 and 2.91 ± 1.14, respectively. The largest absolute difference was observed in the psychosocial domain (0.87 points), followed by the sexual domain (0.76 points) and physical domain (0.74 points). The numerical pattern suggested a possible association between symptom nondisclosure and greater impairment in physical, psychosocial, and sexual well-being. Table 1. demographic distribution Characteristic Perimenopausal (n=187) Postmenopausal (n=240) Total (N=427) Age, mean ± SD 46.8 ± 3.5 56.7 ± 5.1 52.4 ± 6.8 BMI, mean ± SD 25.7 ± 3.8 26.4 ± 4.2 26.1 ± 4.0 Urban residence 116 (62.0%) 144 (60.0%) 260 (60.9%) Education > secondary 103 (55.1%) 112 (46.7%) 215 (50.4%) Table 2. genitourinary symptom frequencies Symptom Perimenopausal Postmenopausal Total Vaginal dryness 68 (36.4%) 139 (57.9%) 207 (48.5%) Burning or irritation 42 (22.5%) 88 (36.7%) 130 (30.4%) Dyspareunia 55 (29.4%) 111 (46.3%) 166 (38.9%) Urinary urgency 51 (27.3%) 99 (41.3%) 150 (35.1%) At least one symptom 115 (61.5%) 187 (77.9%) 302 (70.7%) Table 3. disclosure distribution Measure Count Percentage Denominator Previously disclosed 119 39.4% 302 symptomatic Not previously disclosed 183 60.6% 302 symptomatic Considered normal ageing 103 56.3% 183 nondisclosing Embarrassment 82 44.8% 183 nondisclosing Unaware of treatment 74 40.4% 183 nondisclosing Clinician did not ask 69 37.7% 183 nondisclosing Table 4. Reference MENQOL scores by disclosure status Domain Disclosed (n=119) Not disclosed (n=183) Physical 3.42 ± 1.12 4.16 ± 1.24 Psychosocial 2.81 ± 1.05 3.68 ± 1.18 Sexual 3.96 ± 1.31 4.72 ± 1.39 Vasomotor 2.91 ± 1.14 3.07 ± 1.20

Genitourinary syndrome of menopause is a common and frequently underdiagnosed condition that can adversely affect physical comfort, urinary function, sexual relationships and psychological well-being. Its clinical manifestations may begin during perimenopause and become more pronounced after menopause as declining oestrogen concentrations influence the structural and functional integrity of urogenital tissues. The study examines symptom prevalence, differences according to menopausal status, nondisclosure of complaints and associated quality-of-life impairment. These outcomes address important gaps in routine menopausal healthcare, particularly the tendency to overlook symptoms that women do not voluntarily report. The North American Menopause Society position statement recognised GSM as a chronic condition encompassing genital dryness, burning, irritation, dyspareunia and lower urinary tract complaints [11]. The statement emphasised that symptoms may persist without appropriate intervention and that management should be individualised according to severity and patient preferences. The symptom categories incorporated into the present study framework are consistent with these recommendations and permit assessment of the broader clinical burden rather than vaginal symptoms alone. Vaginal dryness and dyspareunia are particularly important because they frequently coexist and contribute to sexual discomfort. Rahn et al. [12], in a systematic review evaluating vaginal oestrogen therapy, demonstrated improvement in vaginal dryness, dyspareunia and several urinary complaints following treatment. These findings indicate that recognition of GSM has practical therapeutic implications. Women who do not disclose symptoms may remain unaware of effective management options, allowing potentially treatable complaints to persist. Nappi et al. [13], in the European Vulvovaginal Epidemiology Survey, examined the prevalence and clinical characteristics of vulvovaginal atrophy among postmenopausal women. Their findings reinforced the considerable burden of vaginal symptoms and the need for improved recognition. Variations in reported prevalence across studies may be explained by differences in menopausal status, participant characteristics, diagnostic criteria and methods of symptom assessment. Consequently, symptom prevalence should be interpreted in relation to the characteristics of the population examined. The involvement of the urinary tract represents another important dimension of GSM. Gandhi et al. [14] described the relationship between oestrogen deficiency and changes in the vagina, urethra and lower urinary tract. Their review identified urinary urgency, dysuria, recurrent urinary tract infections and incontinence-related symptoms as relevant manifestations. The inclusion of urinary complaints in the study is therefore necessary for a comprehensive evaluation. Nevertheless, these symptoms are not specific to GSM, and alternative causes should be considered during clinical assessment. An important concern is the reluctance of women to communicate intimate symptoms during medical consultations. Cox et al. [15] highlighted the continuing underdiagnosis and undertreatment of GSM despite the availability of effective interventions. Women may perceive vaginal dryness, sexual discomfort and urinary changes as inevitable consequences of ageing rather than manifestations of a treatable condition. Embarrassment, limited awareness and difficulties initiating conversations about sexual health may further discourage disclosure. These observations support the assessment of nondisclosure as a distinct clinical outcome. Christmas et al. [16] emphasised the importance of detailed symptom assessment and individualised management in contemporary clinical practice. Their recommendations support proactive questioning about genital, sexual and urinary concerns during routine menopausal consultations. Reliance on spontaneous symptom reporting alone may fail to identify women who are uncomfortable discussing intimate complaints. Structured questionnaires and confidential interviews may therefore improve recognition, particularly where cultural expectations influence communication. The relationship between GSM and quality of life extends beyond the physical severity of individual symptoms. Persistent vaginal discomfort may interfere with daily activities, while dyspareunia and reduced lubrication may contribute to avoidance of sexual activity and difficulties in intimate relationships. Psychological distress may be intensified when women believe that symptoms are permanent or untreatable. The inclusion of physical, psychosocial and sexual domains is consequently important for evaluating the broader impact of GSM. Danan et al. [17], in a systematic review of hormonal treatments and vaginal moisturisers, reported that vaginal oestrogen, vaginal dehydroepiandrosterone, oral ospemifene and vaginal moisturisers may improve selected GSM symptoms. However, the authors also identified limitations in the available evidence, including variation in diagnostic criteria and insufficient long-term safety data. These findings underline the need for informed treatment discussions based on individual symptoms, medical history and patient preferences. The evidence supporting local oestrogen therapy has also been evaluated through systematic reviews. Lethaby et al. [18] examined local oestrogen preparations for vaginal atrophy in postmenopausal women and reported benefits in symptom improvement compared with placebo. Such findings reinforce the importance of identifying symptomatic women who have not sought medical attention. Nevertheless, treatment decisions should follow appropriate clinical assessment rather than symptom screening alone. Biehl et al. [19] reviewed the efficacy and safety of vaginal oestrogen products for GSM and further supported their therapeutic role. Their findings demonstrate that effective interventions are available for women experiencing persistent symptoms. However, treatment availability does not necessarily translate into utilisation. Limited awareness, misconceptions about hormonal treatment and communication barriers may continue to prevent women from receiving appropriate care. The assessment of quality of life also requires valid measurement instruments. Lewis et al. [20] examined the psychometric properties of the Menopause-Specific Quality of Life questionnaire and developed an intervention-focused modification. Their work supports structured assessment of physical, psychosocial, sexual and vasomotor domains. Such instruments allow a more comprehensive evaluation of menopausal health than symptom-frequency questions alone, although results must be interpreted according to the questionnaire's validated scoring procedures. The study has several methodological strengths, including comparison of perimenopausal and postmenopausal women, assessment of multiple symptom domains and evaluation of barriers to disclosure. However, a cross-sectional design cannot establish causal relationships between symptom nondisclosure and quality-of-life impairment. Recall bias, social desirability bias and underreporting of intimate complaints may influence responses. Additionally, clinical diagnosis of GSM requires consideration of alternative causes of genital and urinary symptoms. Overall, the literature supports routine assessment of genitourinary complaints as an integral component of menopausal healthcare. Proactive clinical enquiry, patient education, privacy and individualised counselling may improve symptom recognition and facilitate appropriate management. Further population-based investigations are needed to establish the prevalence of unreported GSM symptoms and determine how disclosure behaviour relates to symptom severity and quality of life.

Genitourinary syndrome of menopause warrants systematic assessment because genital, urinary and sexual complaints can be overlooked during routine care. Published research demonstrates a substantial burden of symptoms and supports effective management options for appropriately selected women. Confidential questioning and patient education may improve recognition of concerns that women hesitate to report. Clinical interpretation should distinguish GSM from other causes of urogenital symptoms and use validated instruments and appropriate statistical methods.

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