Vaginal estrogen is one of the most effective treatments for genitourinary syndrome of menopause (GSM), a group of symptoms that can affect the vulva, vagina, and urinary tract.

“The degree of improvement with vaginal estrogen is often profound,” Dr. Fenwa Milhouse, a board-certified urologist, urogynecologist, and women’s health specialist, told ThisIsMenopause.

Here’s what to know about vaginal estrogen, including how it works, who it’s for, and which menopause symptoms it may help relieve.

What Symptoms Does Vaginal Estrogen Treat?

Many of the vaginal, vulvar, and urinary symptoms that develop during perimenopause and menopause are caused by declining estrogen levels. Vaginal estrogen can often help relieve these symptoms by delivering low-dose estrogen locally.

“People who are on vaginal estrogen are less likely to have painful sex, less likely to have UTIs, and less likely to have vulvar pain,” Dr. Milhouse said.

Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM) is a collection of symptoms that affect the vulva, vagina, bladder, and urethra. You may also hear it called vaginal atrophy, but GSM is the preferred term because it better reflects the range of symptoms people can experience.

GSM is extremely common, affecting an estimated 50 percent to 90 percent of people during and after menopause, Dr. Milhouse explained.

Symptoms of GSM may include:

• Vaginal dryness
• Vaginal burning or itching
• Changes in vaginal discharge
• Pain during sex
• Bleeding or spotting after sexual activity
• Recurrent urinary tract infections (UTIs)
• Painful urination
• Frequent urination
• Urinary incontinence

GSM symptoms can get worse over time without treatment.

Vaginal Dryness, Burning, and Itching

Vaginal dryness is one of the most common symptoms of GSM. Some women also experience burning or itching as vaginal tissues become thinner. Vaginal estrogen can help by restoring moisture and improving the health of these tissues.

“If you have vaginal dryness or itching, you probably need vaginal estrogen,” Dr. Milhouse said.

“People who are on vaginal estrogen are less likely to have painful sex, less likely to have UTIs, and less likely to have vulvar pain.”

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— Dr. Fenwa Milhouse

Painful Sex

Vaginal lubricants and moisturizers can make sex more comfortable, but they don’t address the underlying estrogen loss that contributes to vaginal dryness and thinning tissues, Dr. Milhouse explained. Some people also notice light spotting or bleeding during or after sex because these tissues have become thinner and more fragile.

Vaginal estrogen helps restore the health of those tissues and can be used alongside lubricants and moisturizers.

“People who are on vaginal estrogen are less likely to have painful sex,” Dr. Milhouse said.

Bladder Problems and Recurrent UTIs

Vaginal estrogen can help keep the tissues around the urethra and bladder healthy, which may improve urinary symptoms. It can also help reduce irritation.

“Women have 50 percent less UTIs with vaginal estrogen,” Dr. Milhouse said. “It’s the best thing we have to curb UTI risk — even better than antibiotics.”

Vulvar Symptoms

Declining estrogen levels in menopause can also affect the vulva, or external genital area, leading to burning, irritation, or pain. Vaginal estrogen cream can be especially helpful for these symptoms. Applying the vaginal estrogen cream to the vaginal opening can improve vulva symptoms.

What Improvements Can You Expect?

Vaginal estrogen can provide noticeable relief, improving comfort, sexual health, and overall quality of life.

“The degree of improvement with vaginal estrogen can be profound,” Dr. Milhouse said.

While each person’s experience is unique, Dr. Milhouse has seen her patients resume comfortable sex after avoiding intimacy because of pain, experience fewer recurrent UTIs, and have less bladder irritation after starting treatment.

“When someone starts vaginal estrogen, it’s really important that they understand that this takes time. Improvement doesn’t happen immediately.”

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— Dr. Fenwa Milhouse

Dr. Milhouse cautioned that despite being highly effective, vaginal estrogen doesn’t work overnight. It requires patience and consistency.

“When someone starts vaginal estrogen, it’s really important that they understand that this takes time,” she said. “Improvement doesn’t happen immediately.”

Dr. Milhouse said you can expect to notice symptom improvement after about two to three months of consistent use. Because vaginal estrogen works by gradually restoring tissue health, using it as prescribed is key to getting the full benefit.

“This is a long game,” Dr. Milhouse said. “It won’t work if you’re inconsistent in using it, and it won’t work if you don’t give it enough time.”

Who Is a Candidate for Vaginal Estrogen?

“Who is a candidate for vaginal estrogen? Anybody who has a vagina or a vulva,” Dr. Milhouse explained. She said that she talks to all her patients over 40 about GSM and how vaginal estrogen can help with symptoms. In some cases, she prescribes preventive vaginal estrogen.

Women with a personal or family history of cancer can also be candidates for vaginal estrogen, Dr. Milhouse noted.

Because vaginal estrogen works differently from systemic hormone therapy and acts primarily where it’s applied, you may still be able to safely use vaginal estrogen even if you’re not a candidate for systemic hormones.

Dr. Milhouse explained that there have been several studies of women with a history of breast cancer that have found that vaginal estrogen did not increase the risk of cancer recurrence or breast cancer death.

Seek out a menopause-informed healthcare provider and let them know about your medical history, so they can help you understand if vaginal estrogen is right for you.

Don’t Be Afraid to Talk to Your Doctor

If you experience vaginal dryness, burning, itching, painful sex, frequent UTIs, or other genitourinary symptoms, talk with your healthcare provider about whether vaginal estrogen can help.

Dr. Milhouse encouraged women to be proactive and not wait until symptoms become severe before seeking care. Unlike hot flashes, which often improve over time, GSM symptoms can continue to worsen without treatment.

“Never wait for it to get bad,” Dr. Milhouse said. “Because the worse it gets, the harder it is to reverse.”