Vaginal Estrogen Therapy is Safe and Effective
Genitourinary Symptoms of Menopause - GSM. This medical phrase refers to all the “down there” problems that women experience when they lack adequate estrogen:
Vulvar and vaginal symptoms, like dryness, burning, and irritation
Sex-related symptoms, like poor lubrication, pain and discomfort with intercourse, and impaired sexual function
Urinary symptoms, such as recurrent urinary tract infections, urgency, and frequent urination at night
Problems “down there” (GSM) might begin with or after menopause and likely will worsen over time without treatment. These same symptoms may also occur during other times of low estrogen, such as while breastfeeding or while receiving some forms of treatment for estrogen receptor positive cancers.
The good news is that GSM can be treated with estrogen products applied locally to the vulva and/or inserted into the vagina. Vaginal estrogen, as it is commonly called, is safe. Women are never too old to begin using it and are never too old to stay on it. And, did I mention that it is safe?
Women can safely [1],[2] use vaginal estrogen even with:
A history of stroke
A history of blood clots
Heart disease
Migraine with aura
A history of breast cancer [3]
Current breast cancer [4], [5], [6] (Despite the studies cited, this remains controversial. Speak with the treating clinician.)
Although women can use lubricants or vaginal moisturizers, especially those products with hyaluronic acid, the gold standard is local estrogen therapy.
Local estrogen therapy comes in many forms. Briefly, there are tablets, suppositories, creams and a ring.
Tablets are inserted with a non-reusable applicator. The size of a baby aspirin, they stick to the wall of the vagina and dissolve.
Suppositories are inserted with a finger and are melted by the body’s heat.
Cream is inserted into the vagina with a reusable applicator (or with a finger) and can be applied also to the urethra, vaginal opening, clitoris and labia minora.
Estring® is a self-administered, disposable vaginal ring that is placed inside the vagina where it releases hormone for three months.
A cream best treats the urethra, labia minora and clitoris, although some women prefer the other, perhaps less messy, forms. There are two types of vaginal creams – generic estradiol cream and Premarin® (containing conjugated equine estrogens.) Except for Premarin®, all forms of vaginal estrogen products use plant-derived, bioidentical estradiol.
Within one to four months of use, local estrogen treatment restores normal vaginal pH and microflora, thickens the vaginal and vulvar tissues, decreases vaginal dryness, and reduces the incidence of urinary tract infections and overactive bladder symptoms[7]. (It does not relieve stress incontinence.[8])
An exam with a qualified menopause practitioner is advised to best evaluate and treat individual conditions. Not all genitourinary concerns are due to low estrogen. However, an exam is not necessary to begin using vaginal estrogen. In fact, vaginal estrogen is available without a prescription in the UK and other countries. Notably, one full year of standard, local estradiol treatment is the equivalent dosage to just one, yes one, oral birth control tablet.[9]
Keep in mind, that local hormone therapy treats only local concerns. It will not treat other symptoms brought on by menopause such as hot flashes, night sweats, trouble sleeping or difficulty concentrating. It will not prevent osteoporosis nor lower the risk of medical conditions like diabetes and heart disease. Systemic hormone therapy addresses those systemic issues. Most women on systemic hormones will not need to supplement with vaginal estrogen. But if needed, one can safely use both.
One last word – about cost. Vaginal estrogen products can be expensive. Download the GoodRx app on your phone. Learn to use the coupons and compare prices. Or, check out RxOutreach, an online, nonprofit pharmacy.
[This article is meant for informational purposes only. It does not substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a qualified health provider with any questions you have regarding your health. Never disregard professional medical advice or delay in seeking it because of something you have read on this site.]
[1] Faubion, Stephanie S, et al. “The 2022 Hormone Therapy Position Statement of the North American Menopause Society.” Menopause (New York, N.Y.), vol. 29, no. 7, 2022, pp. 767–794.
[2] Bhupathiraju SN, Grodstein F, Stampfer MJ, Willett WC, Crandall CJ, Shifren JL, Manson JE . “Vaginal estrogen use and chronic disease risk in the Nurses' Health Study.” Menopause. 2018;26(6):603.
[3] Cold, Søren, et al. “Systemic or Vaginal Hormone Therapy After Early Breast Cancer: A Danish Observational Cohort Study.” Journal of the National Cancer Institute, vol. 114, no. 10, 2022, pp. 1347–1354.
[4] Faubion SS, Larkin LC, Stuenkel CA, Bachmann GA, Chism LA, Kagan R, Kaunitz AM, Krychman ML, Parish SJ, Partridge AH, Pinkerton JV, Rowen TS, Shapiro M, Simon JA, Goldfarb SB, Kingsberg, SA. “Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women's Sexual Health.” Menopause. 2018;25(6):596
[5] Streff, Alyssa, et al. “Changes in Serum Estradiol Levels with Estring in Postmenopausal Women with Breast Cancer Treated with Aromatase Inhibitors.” Supportive Care in Cancer, vol. 29, no. 1, 2021, pp. 187–191.
[6] Pavlović, R T, et al. “The Safety of Local Hormonal Treatment for Vulvovaginal Atrophy in Women with Estrogen Receptor-Positive Breast Cancer Who Are on Adjuvant Aromatase Inhibitor Therapy: Meta-Analysis.” Clinical Breast Cancer, vol. 19, no. 6, 2019, p. 731-740.
[7] Overactive bladder syndrome consists of feelings of urinary urgency (sudden, overwhelming need to pee), nocturia (waking to pee more than once or twice per night) and urinary frequency (urinating every one to two hours, or more than 8 times a day).
[8] Stress incontinence is the involuntary leakage of urine with exertion, sneezing, coughing or laughing.
[9] Dr. Streicher’s Inside Information: The Menopause Podcast. Episodes 5 and 11.