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When it comes to hormone replacement therapy (HRT), you have options.
In this article, we’ll cover the differences between vaginal and systemic hormone therapy. We’ll also discuss how to determine which may be right for you.
Vaginal estrogen is a type of hormone therapy that treats vaginal and urinary changes that can occur during perimenopause and menopause. Lower estrogen levels during this time can lead to changes in the labia, vagina, urethra, and bladder.
Vaginal estrogen has been shown to treat several vaginal and urinary symptoms, including:
Vaginal estrogen is available in low-dose creams, tablets, rings, and softgel inserts. These products contain estradiol, a form of estrogen that’s chemically identical to the estradiol produced by the body.
Low-dose vaginal estrogen results in very little estrogen entering the bloodstream compared with systemic hormone therapy. For some women with a history of certain types of breast cancer, low-dose vaginal estrogen may sometimes be considered after discussing the benefits and risks with their healthcare team.
4 Benefits of Vaginal Estrogen
Dr. Milhouse explains how vaginal estrogen may help with dryness, painful sex, and keeping things balanced to lower infection risk.
00:00:00:02 - 00:00:34:23
Dr. Milhouse
So benefits of vaginal estrogen are numerous. Vaginal estrogen is essential for our vulva vaginal health in multiple ways. It allows the tissue to remain healthy and supple, and allows for that dilation and expansion that makes penetration comfortable. Without vaginal estrogen, we lose what we call rugae in the vagina, and that can lead to stiffness narrowing that makes penetrative activity very, very uncomfortable.
00:00:34:24 - 00:01:05:21
Dr. Milhouse
The other thing that vaginal estrogen is important for is natural lubrication. One of the most common symptoms of genitourinary syndrome of menopause, or GSM, is dryness, and it makes sex very uncomfortable. Take a patient, for instance, who has stopped having sex because it's painful. It's dry, irritating. Put them on vaginal estrogen, vaginal hormones, and now they're enjoying sex again. That's a game changer.
00:01:05:23 - 00:01:25:23
Dr. Milhouse
Vaginal estrogen gives us a healthy pH. The pH in the vagina is acidic, and vaginal estrogen maintains that. And maintaining that pH is important for the good bacteria that kind of defend us
Vaginal estrogen has been found to increase the number of blood vessels around the urethra and bladder neck. It may also help the bladder muscle relax, which can improve urinary urgency and frequency. Vaginal estrogen may also improve symptoms of incontinence and overactive bladder.
Vaginal estrogen also increases vaginal lubrication, which can reduce dryness and pain with sexual intercourse.
Systemic hormone therapy treats vasomotor symptoms, such as hot flashes and night sweats. These symptoms involve changes in how the body controls temperature.
Vasomotor symptoms can be extremely uncomfortable and are associated with:
A 2022 meta-analysis found that systemic hormone therapy can improve symptom frequency by about 75 percent compared with placebo (fake treatment). It can also significantly reduce symptom severity.
At this time, no other treatment has been shown to be more effective than hormone therapy for treating vasomotor symptoms of menopause. Systemic hormone therapy typically takes about six to eight weeks to provide enough symptom relief. When systemic therapy is stopped, about 50 percent of people experience a return of their symptoms.
Systemic hormone therapy may also improve sleep quality during menopause. Vasomotor symptoms can disrupt sleep, such as when night sweats wake you up.
Sleep problems can significantly affect quality of life, so treating them is important. Disturbed sleep is associated with mood swings, memory problems, metabolic syndrome, and heart disease.
Determining which type of hormone therapy is right for you depends on your symptoms, health history, and individual risk factors.
Systemic hormone therapy is effective at treating hot flashes and night sweats. A research review found no significant difference between transdermal and oral estrogen-progestogen therapy for treating these symptoms. Systemic estrogen is available as oral pills, transdermal patches, sprays, and gels, as well as vaginal rings designed to deliver estrogen throughout the body.
The Biggest Menopause Myth
Dr. Milhouse explains the difference between vaginal estrogen and HRT, and how each may help different menopause symptoms.
00:00:00:02 - 00:00:28:04
Dr. Milhouse
The biggest menopause myth that I encounter is that vaginal estrogen is the same as HRT, or systemic estrogen. Menopause is not just hot flashes and night sweats. The most overlooked menopause symptom is or are GSM symptoms, genitourinary syndrome of menopause symptoms, the vulva, vaginal bladder symptoms that occur. The estrogen that is applied for vaginal estrogen stays in the local tissues.
00:00:28:05 - 00:01:05:17
Dr. Milhouse
Systemic estrogen is meant to increase estrogen in the bloodstream for a multitude of complaints in perimenopause and menopause, which can include the vasomotor complaints, like hot flashes, and night sweats that we're so familiar with, the brain fog, the fatigue, the mood changes, the sleep disturbances, dryness, skin dryness, dry eyes. But for the vaginal dryness, painful sex, the bladder and UTI symptoms, that is where vaginal estrogen plays a role.
00:01:05:18 - 00:01:09:04
Dr. Milhouse
Learn more and connect at ThisIsMenopause.com.
The risks of systemic hormone therapy may vary depending on factors such as the type, dose, and route of treatment. However, the North American Menopause Society notes that clinical trials haven’t determined whether the risks of heart attack, stroke, breast cancer, and blood clots differ with different estrogen routes and doses. Hormone therapies that aren’t taken by mouth, such as skin patches, may offer advantages because they bypass the liver, but it’s not known whether they have lower risks than oral hormone therapy.
If your main symptoms involve vaginal or urinary problems, your doctor may recommend local therapy with vaginal estrogen. If these problems continue despite systemic hormone therapy, your doctor may recommend adding low-dose vaginal estrogen.
Talk with your doctor about your health and family history to determine your individual benefits and risks of hormone therapy. Don’t start hormone therapy if you suspect you may be pregnant.
Certain health conditions and risks can affect whether systemic hormone therapy is right for you, including:
If you have a uterus and take systemic estrogen, you generally also need a progestogen. Progestogens help protect against overgrowth of the uterine lining, which can raise the risk of uterine cancer.
Combination therapy typically comes as a pill or skin patch. A progestin may also be provided through an intrauterine device.
It may be helpful to write down three to five questions to bring to your doctor before your appointment. Consider keeping a log of your symptoms and ask questions like:
Once you begin hormone therapy, your doctor may schedule follow-up appointments to monitor your symptoms and any side effects. Reach out before your next appointment if you have concerns about any changes.
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