Nine percent of older women diagnosed with a menopause syndrome filled the treatment

Genitourinary syndrome of menopause is the umbrella term for what falling oestrogen does to vaginal and urinary tissue after menopause: dryness, pain with sex, urinary urgency, recurrent infections. It is common, it is chronic, and it has an effective treatment in low-dose vaginal oestrogen.

A study published in JAMA Network Open on 16 December asked a plain question about that treatment — how often does anyone actually get it — and returned a number that is hard to read as anything but a system failure [s1].

What was done

The researchers used a 20% random sample of Medicare fee-for-service beneficiaries enrolled in Parts A, B, and D from 2006 to 2018 [s1]. They identified women aged 66 and older carrying a diagnosis indicative of GSM, excluding those with breast or endometrial cancer diagnosed within six months of the GSM diagnosis [s1].

That produced a cohort of 1,838,732 women, median age 74 (IQR 69–81), with median follow-up of 8 years (IQR 4–10) [s1]. The primary outcome was simply whether a vaginal oestrogen prescription — cream, ring, or tablet — was ever filled between the first GSM diagnosis and the end of enrolment or the study period [s1].

What was found

165,530 women filled a prescription. That is 9.0% [s1].

Among those who did, the median time from diagnosis to fill was 15 months (IQR 2–46) [s1].

Two patterns emerged in who filled and who did not [s1]:

• Older and sicker women were less likely to fill. Women over 86 had adjusted odds of 0.59 (95% CI, 0.58–0.60) compared with women aged 66–70. Those with a Charlson Comorbidity Index of 5 or more had adjusted odds of 0.67 (95% CI, 0.66–0.69) versus a score of 0.
• What the syndrome looked like mattered enormously. Compared with women whose GSM presented as local sexual symptoms, women with recurrent urinary tract infections were the least likely to have a fill (aOR 0.54; 95% CI, 0.46–0.64). Women with vulvovaginal symptoms were more likely (aOR 2.70; 95% CI, 2.45–2.97), and women with GSM multimorbidity — several symptom domains at once — were most likely by a wide margin (aOR 15.91; 95% CI, 14.41–17.57).

The urinary-tract-infection finding

That the recurrent-UTI group was the least likely to receive vaginal oestrogen is the result most likely to change something, because recurrent UTI in postmenopausal women is not a minor complaint. It generates repeat antibiotic courses, emergency visits, and hospital admissions, and antibiotic exposure in this age group carries its own well-documented costs.

The study is observational and cannot explain the pattern. Several explanations are available and none is tested here: recurrent UTI is typically managed by primary care or urology rather than gynaecology, and the reflex there is antimicrobial; the connection between genitourinary atrophy and infection recurrence may not be front of mind for the clinicians seeing these patients; or the diagnosis codes used to identify recurrent UTI may capture a different population than the codes for vulvovaginal symptoms.

What the study cannot tell you

A claims database observes filled prescriptions. It does not observe conversations. A woman who was offered vaginal oestrogen and declined looks identical in this data to one who was never offered it, and both look identical to one who filled a prescription outside her Part D coverage or bought a product not captured in the claim.

The authors also point at the coding schema itself: they argue the diagnostic codes do not capture the full breadth of GSM symptoms, and call for revising them along with validating GSM clinical phenotypes [s1]. That is a real constraint on the cohort definition — the 1.8 million women here are the ones a clinician coded, not the ones who have the condition.

The data run to 2018, in a fee-for-service Medicare population aged 66 and up. It does not describe Medicare Advantage enrollees, commercially insured or uninsured women, or anyone younger. And it predates the recent public argument over how menopausal hormone therapy is labelled, so it cannot speak to whether prescribing has shifted since.

The 9.0% figure is also a cumulative measure over a median of eight years of follow-up — not an annual rate. It means that across nearly a decade after a GSM-related diagnosis, fewer than one woman in ten ever picked up the treatment.

Why this is a different problem from systemic hormone therapy

Much of the public argument about hormones in menopause concerns systemic therapy and its cardiovascular, breast, and cognitive risk profile. Low-dose vaginal oestrogen is a different exposure — local, minimally absorbed — and the study describes it as a safe and effective treatment for GSM [s1]. Whatever explains a 91% non-fill rate, it is unlikely to be a clear-eyed weighing of the evidence for this particular product.

What to watch

Whether analyses using post-2018 data show any movement. Whether urology and primary care guidance for recurrent UTI in postmenopausal women becomes more explicit about vaginal oestrogen. And whether the diagnostic coding for GSM is revised, without which every future study of this question inherits the same blind spot.

This article describes prescribing patterns. It is not medical advice, and decisions about menopause treatment belong with a clinician.

Sources

1. Vaginal Estrogen Utilization Among Medicare Beneficiaries With Genitourinary Syndrome of Menopause — JAMA Network Open, 16 December 2025