 Typically, starting about four to five years after their last period, about half of postmenopausal women suffer what we used to call vovovaginal atrophy, now referred to by the name GSM, genital urinary syndrome of menopause, thanks to the vovovaginal atrophy terminology consensus conference who needed a more publicly acceptable term. After all, the word atrophy had negative connotations and the word vagina is not a generally accepted term for public discourse. They liken it to the shift from the pejorative impudence to erectile dysfunction. Whatever you call it involves changes to the vulva, the external genitalia, the vagina, the birth canal, and bladder, caused by menopausal changes in hormone levels. Vaginal symptoms include vaginal dryness, burning itchiness and irritation, pain during penetrative sex, and post-coital bleeding from the thinning of the vaginal lining. Urinary symptoms can include recurrent bladder infections and incontinence. Some women with mild GSM remain asymptomatic for others. Symptoms severity can preclude intercourse altogether and result in discomfort, even just sitting or wiping. In a survey of thousands of women with GSM, 59% said their symptoms considerably decreased their enjoyment of sexual activity, and 23% reported having an adverse effect on their general enjoyment of life. While other menopausal symptoms like hot flashes tend to improve over time, GSM symptoms tend to get progressively worse. Unfortunately, women rarely seek medical help, even though there are safe and simple treatments available. The first line treatment for mild to moderate vaginal dryness are lubricants and moisturizer. Lubricants are designed to reduce friction during sexual activity, whereas vaginal moisturizers are used on a regular basis, daily or every two to three days as needed, to provide day-to-day comfort by mimicking natural vaginal secretions, regardless of sexual activity. Water-based lubricants have the advantage of being non-staining and are associated with fewer genital symptoms such as discomfort or burning compared to silicone-based lubricants. What's the best vaginal moisturizer? This head-to-head study pitted vaginal estrogen versus replens, an expensive vaginal moisturizer claiming special bioadhesive ingredients versus a placebo gel of hydroxyethylcellulose, which is found in products 15 times cheaper, like KY jelly. After 12 weeks, the researchers found no difference between any of them. They all worked the same. This striking double negative finding led to an accompanying commentary in the American Medical Association Journal to conclude that until there's evidence to suggest otherwise, post-menopausal women experiencing Volvo vaginal symptoms should choose the cheapest moisturizer lubricant available over-the-counter instead of wasting your money. That was for efficacy, though. What about safety? The World Health Organization recommends, based on the SMI test, that personal lubricants and vaginal moisturizers not exceed an osmolality of 380. That's a measure of how concentrated the dissolved components are. How did they come up with that number? By lubing up slugs. SMI stands for slug mucosal irritation. They cover slugs with lubricant over a five-day period and measure how much mucosal irritation and tissue damage the slug experiences. No adverse effects below the 380 cutoff, but something like KY jelly at over 2,000, induced mild moderate irritation, and something off the charts like astroglide at 5,000 plus caused severe irritation and tissue damage. Dozens of commonly used lubricants and moisturizers available worldwide have been put to the test, and the only two vaginal moisturizers that met the WHO criteria were the Yes brand aloe vera gel-based moisturizer and the Balanced Active brand hyaluronic acid-based one. The only lubricants that made the cut were those made by brands Yes, Good Clean Love, System Joe, and one product by Durex. They're since lube gel, but not their Playfield lubricant.