Genitourinary syndrome of lactation: An underrecognized postpartum condition affecting women's vulvovaginal, urinary and sexual health.

Abstract

Postpartum care is increasingly viewed as a continuum of maternal recovery rather than a single visit at six weeks. Within this broader view, however, the genitourinary and sexual health of breastfeeding women remains insufficiently addressed. Genitourinary syndrome of lactation (GSL) has recently been proposed to describe postpartum and lactation-related vulvovaginal, urinary and sexual symptoms that may be linked to the hypoestrogenic hormonal environment of breastfeeding. During lactation, suckling-related prolactin secretion suppresses hypothalamic-pituitary-ovarian activity and may maintain low estradiol levels, particularly during amenorrhea. Although the term deliberately echoes genitourinary syndrome of menopause, GSL belongs to a different clinical setting: a woman recovering from pregnancy and birth, adapting to breastfeeding, living with sleep deprivation and body changes, and gradually rebuilding sexual intimacy. This narrative perspective review summarizes the emerging evidence on GSL and offers a practical framework for recognition, differential diagnosis, screening and breastfeeding-supportive management. GSL should not be reduced to vaginal dryness, nor should every postpartum sexual or urinary symptom be attributed to lactation-related hormonal deprivation. Assessment should consider perineal scar pain, pelvic floor dysfunction, vestibulodynia, vulvovaginal infections, vulvar dermatoses, urinary tract disorders, hormonal contraception and psychosocial contributors; bowel symptoms may indicate broader pelvic floor or obstetric injury rather than GSL itself. Management is best approached in a stepped and individualized manner, beginning with education, validation, vulvar care, lubricants, vaginal moisturizers, pelvic floor physiotherapy and sexual counselling when indicated. For persistent moderate-to-severe mucosal symptoms, low-dose vaginal estrogen is a reasonable option after shared decision-making, particularly once lactation is established. Vaginal prasterone lacks lactation-specific safety and efficacy evidence and cannot currently be recommended routinely. Recognizing GSL is not an argument against breastfeeding; it is a way to make postpartum care more complete.