“Your vulva changes with age,” said Dr. Fenwa Milhouse, a urologist and certified menopause practitioner, told ThisIsMenopause.

Some women will experience genitourinary syndrome of menopause (GSM), which can include dryness, thinning tissue, irritation, painful sex, and urinary symptoms.

“[GSM] can interfere with intimacy, change your bladder, and increase your risk of UTIs,” Dr. Milhouse explained.

One of the most effective treatments for GSM is vaginal estrogen. If you wondered about how it works and whether it’s safe, Dr. Milhouse answered some of the most common questions below.

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As estrogen levels drop during menopause, the vaginal tissues become thin, dry, and less stretchy. This can lead to uncomfortable GSM symptoms.

Vaginal estrogen treats GSM symptoms by restoring the health of the vaginal lining. It also improves the vaginal pH and increases natural vaginal moisture.

As a result, vaginal estrogen can help relieve symptoms such as:

• Vaginal dryness
• Vaginal irritation, burning, and itching
• Dyspareunia (painful intercourse)
• Urinary urgency and frequency
• Recurrent urinary tract infections (UTIs)

Even though vaginal estrogen works well for GSM, it doesn’t treat whole-body menopause symptoms, like hot flashes or night sweats.

Systemic estrogen used in hormone replacement therapy (HRT) is different from vaginal estrogen. Vaginal estrogen is applied directly to the vagina. It works mainly in the genital and urinary tract.

Studies show that low-dose vaginal estrogen has very little absorption into the bloodstream. Because of this, it has little effect on overall estrogen levels in the body. This is different from estrogen pills or patches that work systemically.

Vaginal estrogen comes in many forms. Each form requires you to place the product inside your vagina, where it slowly releases low-dose estrogen over time. Below are some examples:

• Vaginal cream (Estrace, Premarin) — Creams are the most common form of vaginal estrogen treatment. You use an applicator to place the cream inside the vagina or the vaginal opening a few times a week, usually at bedtime.
• Vaginal tablet — The vaginal estrogen tablet is inserted inside the vagina, much like a tampon, usually twice a week. This option is less messy than a cream.
• Vaginal ring (Estring) — A low-dose vaginal estrogen ring is a soft, flexible ring that’s placed inside the vagina. It slowly releases estrogen over three months before it needs to be replaced. This option is convenient because it doesn’t have to be applied several times a week.

Your doctor can help you decide which product is best for you based on your preferences and GSM symptoms.

The right time to start using vaginal estrogen will depend on the person, but you should never wait for symptoms to get severe before seeking help for GSM.

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

Your doctor may recommend trying nonhormonal treatments, such as vaginal moisturizers and lubricants, first. If these products don’t provide enough relief, your doctor may recommend you start vaginal estrogen.

Many women may start treatment during perimenopause, while others begin after menopause. Dr. Milhouse supports using vaginal estrogen proactively in perimenopause before symptoms become bothersome, but different healthcare providers may have different approaches.

You may have to wait two to four weeks to notice improvement in your GSM symptoms. It can take up to six to eight weeks for the medication to reach its full effect.

“When someone starts vaginal estrogen, it’s really important that they understand that this takes time,” explained Dr. Milhouse. “It changes tissues and it changes your microbiome and your pH. That takes time to build.”

It’s also important to follow your application schedule. “It won’t work if you’re inconsistent in using it, and it won’t work if you don’t give it enough time to use,” Dr. Milhouse added.

GSM is a long-term condition. Without treatment, symptoms can continue or get worse.

There aren’t the same concerns about long-term use of vaginal estrogen as there are with systemic estrogen. Menopause experts, including those at The Menopause Society, say that low-dose vaginal estrogen can be used as long as bothersome symptoms remain, which may be indefinitely for postmenopausal women.

“Until you stop having a vagina or stop breathing, that’s when you can stop using it,” Dr. Milhouse said.

If you stop using treatment, your symptoms could return, along with your risk of recurrent UTIs. It’s important to regularly see your doctor while on treatment to go over your symptoms and make sure the treatment is still meeting your needs.

If you’ve had breast cancer, or a gynecologic cancer like ovarian or cervical cancers, you may be able to use vaginal estrogen. It’s important to consult with your oncology team to help you determine the best course of action.

Unlike estrogen pills or patches, vaginal estrogen works mainly in the vaginal tissues and urinary tract. Very little estrogen is absorbed into the body. This difference makes the thinking about the safety of vaginal estrogen different from systemic estrogen options.

Breast Cancer

Guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend trying nonhormonal options like vaginal moisturizers and lubricants before vaginal estrogen for women who’ve had an estrogen-dependent breast cancer.

ACOG supports the use of vaginal estrogen for some women with a history of breast cancer, if nonhormonal approaches aren’t helping enough. A consultation with an oncologist and gynecologist is a must.

Evidence from recent large studies supports the safety of using vaginal estrogen in breast cancer survivors. For example, a 2025 review of eight studies found no increase in breast cancer recurrence in postmenopausal breast cancer survivors who used low-dose vaginal estrogen.

Gynelogic Cancers

Gynecologic cancers include ovarian, cervical, and endometrial cancers. There is less available research about the safety of vaginal estrogen for women who’ve had these cancers.

However, the evidence that is available doesn’t point to increased risks of cancer recurrence. A 2020 study of survivors of ovarian, cervical, and endometrial cancer who were prescribed vaginal estrogen found that incidents of recurrence were rare and concluded that vaginal estrogen can be considered safe.

A 2026 study of pre- and perimenopausal women diagnosed with endometrial cancer did not find an increased risk of recurrence in those who used vaginal estrogen.

Ask your care team if vaginal estrogen is an appropriate option for you.

Most women who use vaginal estrogen have few, if any, side effects. Possible side effects, especially early in treatment, include:

• Mild vaginal irritation
• Spotting or light bleeding when starting treatment
• Breast tenderness

If you develop unusual vaginal bleeding, swelling, chest pain, or any new symptoms that concern you, contact your doctor right away. Serious side effects are rare, but knowing the warning signs can help you get medical care quickly.

Many healthcare providers recommend using vaginal estrogen along with nonhormonal treatments. Vaginal estrogen restores healthy vaginal tissue, while vaginal moisturizers and lubricants maintain hydration and reduce discomfort during sex.

“Pelvic floor physical therapy is another adjunct treatment to a lot of these symptoms,” said Dr. Milhouse. “A lot of patients with genitourinary syndrome of menopause may also need pelvic floor physical therapy because they’ve developed pelvic floor dysfunction.”

Vaginal estrogen is just one of several treatment options for GSM. Some people may benefit from a combination of treatments to provide the best symptom relief. With the right treatment plan, you can find relief and get back to feeling like yourself again.