Genitourinary syndrome of menopause (GSM) — the term now preferred over "vaginal atrophy" — affects a majority of postmenopausal women and causes vaginal dryness, soreness, itching, dyspareunia and recurrent urinary symptoms. It is common, under-diagnosed, treatable and tends to worsen over time without intervention.

Local vaginal oestrogen is the most effective treatment for GSM and is available on the NHS. Non-hormonal moisturisers and lubricants, available over the counter in UK community pharmacies, are a parallel toolkit — sometimes used instead of vaginal oestrogen, sometimes alongside it, always worth discussing because many women will never raise the symptom in a GP appointment and will simply walk up to a pharmacy counter to ask.

This is a pharmacy-counter guide to what the products are, what the pH and osmolality numbers on the packaging actually mean, and how to match a product to a patient.

Moisturiser versus lubricant — the terminology

Vaginal moisturiser — used regularly (typically every 1–3 days regardless of sexual activity) to restore and maintain vaginal tissue hydration over the longer term. Products often contain hyaluronic acid, polycarbophil or other hydrophilic polymers designed to bind water at the epithelium.

Vaginal lubricant — used at the time of intercourse to reduce friction. Shorter-acting. May be water-, silicone- or oil-based.

The two categories are not interchangeable. A woman with daily GSM discomfort is better served by a moisturiser regimen. A woman whose symptoms are confined to painful intercourse may only need a lubricant. Many patients benefit from both.

Why pH and osmolality matter

Normal premenopausal vaginal pH is roughly 3.8–4.5, maintained by lactobacilli. In GSM the pH rises, the microbiome shifts and the epithelium thins. Products applied intravaginally interact with this environment — a supposedly innocuous gel with the wrong pH or osmolality can actually worsen symptoms.

pH:

• Aim for a product with a pH close to the premenopausal range of 3.8–4.5.
• Alkaline products can disturb the lactobacilli-dominated microbiome.
• Intravaginal glycerol-rich or strongly acidic formulations can sting.

Osmolality:

• The WHO guidance on personal lubricants recommends an osmolality below 1,200 mOsm/kg, with a preferred target under 380 mOsm/kg (the physiological range).
• Many commercial lubricants — including some very familiar brands — substantially exceed this, because high-glycerin formulations produce a smooth sensory profile. These hyperosmolar products can draw water out of epithelial cells and cause cellular injury with repeated use.
• Silicone-based lubricants are inherently low-osmolality because silicone itself is not a solute.

Preservatives and additives:

• Parabens, chlorhexidine, strong fragrances and "warming" additives are frequent triggers of irritation and contact dermatitis.
• Preservative-free and fragrance-free formulations are preferred in sensitive tissue.

What to recommend, broadly

For daily maintenance (moisturiser):

• Hyaluronic acid-based vaginal gels — well tolerated, evidence for improving symptom scores in small RCTs. Apply every 2–3 days per product label.
• Polycarbophil-based gels (e.g. Replens) — one of the most-studied non-hormonal moisturisers; bioadhesive and long-acting.

For intercourse (lubricant):

• Water-based, low-osmolality, low-glycerin formulations — first-line for routine use.
• Silicone-based lubricants — excellent for tolerability and longevity, compatible with latex condoms. Not compatible with silicone sex toys.
• Oil-based products — useful for some women, but damage latex condoms and latex diaphragms. Mineral oil can alter vaginal microbiome in some studies. Natural oils (almond, coconut) are tolerated by some and irritating to others; trial cautiously.

A reasonable UK counter conversation organises the shelf mentally into: moisturiser (regular use), water-based lubricant (low-osmolality, routine use), silicone lubricant (longevity, non-latex-partner compatibility, not with silicone toys), and oil (specific requests, with condom caveat).

Where local vaginal oestrogen sits

Vaginal moisturisers and lubricants are symptom relievers. They do not reverse the atrophic epithelial changes of GSM. Local vaginal oestrogen — cream, pessary, tablet or ring — does.

• Prasterone, estriol and estradiol preparations are available on prescription.
• Systemic absorption is minimal at licensed doses, and the safety profile is favourable in most women, including many with a past history of breast cancer (a specialist discussion).
• NICE NG23 and NICE CKS endorse local vaginal oestrogen as first-line pharmacological treatment for GSM.
• Patients using systemic HRT may still need local oestrogen if GSM symptoms persist.
• Local oestrogen is long-term: GSM returns quickly after stopping.

The pharmacy position: non-hormonal moisturisers and lubricants can be recommended freely over the counter. Patients with persistent or severe GSM, or who have tried moisturisers without adequate relief, should be actively signposted to their GP for consideration of local vaginal oestrogen. Not mentioning vaginal oestrogen is a missed opportunity.

In October 2024 some local vaginal oestrogen preparations were reclassified from prescription-only to pharmacy medicine in the UK, meaning community pharmacy can now supply specific low-dose products under a licensed OTC route — a significant change in practice. Keep track of the current list of reclassified preparations via reclassified OTC medicines: prescription to pharmacy and the menopause continuity guide: menopause HRT continuity and vaginal oestrogen.

Practical counter points

Safety and what NOT to recommend

• Petroleum jelly — not suitable as a vaginal lubricant; damages condoms and can increase bacterial vaginosis risk.
• Soap or douches — disrupt vaginal pH, exacerbate GSM, do not recommend.
• Lidocaine-containing lubricants — numbing products without clear clinical need are not a substitute for addressing GSM; can mask symptoms.
• Scented or flavoured products — higher risk of irritation, avoid for women with symptomatic GSM.

Red flags that require medical review

Not all vaginal symptoms are GSM. Signpost urgently if the patient describes:

• Post-menopausal bleeding — always a red flag.
• Persistent vaginal discharge change or offensive odour.
• Pelvic pain distinct from dyspareunia.
• Urinary symptoms with haematuria.

These warrant a GP or gynaecology review — a moisturiser is not the answer.

Further reading on PharmSee

• Menopause HRT continuity and vaginal oestrogen
• Reclassified OTC medicines: prescription to pharmacy
• When a pharmacist refuses to supply: OTC red flags

Find a UK community pharmacy on PharmSee.

Sources and caveats

Content drawn from NICE NG23 and CKS on menopause, NHS patient information and WHO guidance on personal lubricants. Product ingredients and UK regulatory status evolve; check current SmPC and label before supply. This article is general UK pharmacy guidance, not personalised medical advice.