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For many women in perimenopause and beyond, vaginal estrogen can help treat vaginal dryness, painful sex, recurrent urinary tract infections (UTIs), and other related symptoms.
“The benefits of vaginal estrogen are numerous,” said Dr. Fenwa Milhouse, a board-certified urologist, urogynecologist, and women’s health specialist.
Vaginal estrogen is available in several forms, including creams, inserts, and rings. Keep reading to learn why it’s prescribed for menopause symptoms, what options are available, and how to choose the right one for you.
As estrogen levels decline during perimenopause and menopause, the tissues of the vagina, vulva, and urethra become thinner, drier, and less elastic. These changes, known as genitourinary syndrome of menopause (GSM), can affect both vaginal and urinary health.
Because many of these symptoms are related to declining estrogen levels, vaginal estrogen can help restore moisture, improve tissue health, and relieve symptoms. Vaginal estrogen is considered one of the most effective treatments for GSM.
“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.
Dr. Milhouse explains when vaginal estrogen may help with UTIs, dryness, pain, itching, and bladder symptoms.
00:00:00:04 - 00:00:28:07
Dr. Milhouse
If the answer to any of these questions are yes, then you need vaginal estrogen. Have you had more than one UTI in six months? You need vaginal estrogen. Are you experiencing vaginal dryness? Are you having pain with penetration? Do you have pain at the vulva? The opening? Pain or itching? Are you struggling with overactive bladder symptoms? Frequency, urgency, or urge to pee?
00:00:28:08 - 00:00:58:17
Dr. Milhouse
Are you somebody who's been labeled with interstitial cystitis, which is a chronic bladder pain syndrome? If the answer to any of these questions are yes, then you need vaginal estrogen. Fifty to 90 percent of humans who eventually will go through menopause will have one or more of these complaints. Yet medicine has neglected it. The worse it gets, the harder it is to reverse.
00:00:58:18 - 00:01:12:07
Dr. Milhouse
Never wait for it to get bad. You have a very safe treatment that gets to the heart of the problem. Maybe you need to start using vaginal estrogen and ask your doctor about it. Learn more and connect at ThisIsMenopause.com.
Vaginal estrogen comes in several forms, including creams, tablets or inserts, and rings. Tablets, inserts, creams, and rings are placed inside the vagina.
Creams may also be applied to the vaginal opening, which will benefit the vulva (the external genital area). You should avoid placing the cream on the outer vulva (labia majora), as it can cause irritation.
Understanding your options and how they’re used can help you have a more informed conversation with your healthcare provider.
Vaginal estrogen creams include estradiol cream (estradiol is a form of estrogen) and conjugated estrogen cream (Premarin). Both are applied inside the vagina using an applicator. They can also be applied directly to the vaginal opening to help relieve external symptoms such as burning, irritation, or pain.
Dr. Milhouse said most people use vaginal creams every day for the first few weeks before transitioning to a maintenance schedule of two or three applications per week. Estrogen cream is typically applied at bedtime.
Vaginal estrogen tablets and softgel inserts are placed inside the vagina with a disposable applicator. Once inside, they dissolve and release estradiol into the surrounding tissues. Like creams, vaginal tablets and inserts are usually used daily at first before transitioning to a maintenance schedule of two or three applications per week.
Tablets and inserts are often less messy than creams because they deliver a premeasured dose of estrogen. These are typically inserted at bedtime.
A vaginal estrogen ring called Estring can be inserted into the vagina, where it releases low-dose vaginal estrogen for three months. Unlike creams or tablets, estrogen rings don’t require multiple applications each week.
“Every three months, you take the ring out and put a new ring in,” Dr. Milhouse explained. She said many women are able to insert and remove vaginal rings themselves but, if needed, a healthcare provider can insert it during an office visit.
While not technically forms of vaginal estrogen, two other prescription treatments may help treat some symptoms of GSM.
Prasterone (sold as the brand Intrarosa) is a nightly vaginal insert placed inside the vagina with an applicator. It contains dehydroepiandrosterone (DHEA), a steroid that’s converted into estrogen and testosterone within vaginal tissues.
“It is not technically a vaginal estrogen,” Dr. Milhouse explained. “But it is used for genitourinary syndrome and painful sex.”
Vaginal DHEA can be used as a long-term treatment option for some women.
Another option is ospemifene (Osphena), a once-daily pill that can help treat certain symptoms of GSM, including painful sex. Ospemifene is not estrogen. Instead, it belongs to a class of medications called selective estrogen receptor modulators (SERMs), which can selectively activate estrogen receptors in specific tissues.
Ospemifene can help improve symptoms in vaginal and vulvar tissues without increasing estrogen levels throughout the body.
With multiple options available, how do you decide which type of vaginal estrogen is right for you?
Start by talking with your healthcare provider about your symptoms, preferences, and treatment goals. For example, if you have vulvar symptoms or recurrent UTIs, vaginal estrogen cream may be a good option.
Medication cost and what your insurance will cover can also be important factors. “I rarely use the oral pill and the ring,” Dr. Milhouse said. “They tend to be more expensive.”
Dr. Milhouse tends to prescribe vaginal estrogen rings and ospemifene for people with limited mobility or those who aren’t comfortable applying a treatment to the vagina.
“If they can’t put the applicator in their vagina or apply a cream, then it makes sense to do the ring,” she said.
Often, the most important factor is whether it’s a treatment you’ll use. Even the most effective option won’t help if it sits on your shelf or in a drawer because it’s uncomfortable or inconvenient.
“The best vaginal estrogen is the one you actually use,” Dr. Milhouse said.
Here are a few questions to ask yourself as you decide:
It’s also OK to try one type of vaginal estrogen and see how it goes. If it doesn’t feel like the right fit, ask your healthcare provider about other options.
“At the end of the day, I will default to what the patient is gravitating towards,” Dr. Milhouse said.
Whichever type of vaginal estrogen you use, patience and consistency are key. Because vaginal estrogen works by gradually restoring tissue health, it can take time before symptoms improve. Many people begin to notice improvement after using it consistently as prescribed for about two to three months.
“This is a long game,” Dr. Milhouse said.
While each person’s experience is unique, Dr. Milhouse said she has seen meaningful improvements in her practice. Women who were avoiding intimacy because of pain are now enjoying sex again, and many experience fewer recurrent UTIs and less bladder irritation.
“The degree of improvement with vaginal estrogen can be profound, but improvement doesn’t happen immediately,” Dr. Milhouse said. “It’s really important to understand that this takes time.”
Vaginal estrogen is different from systemic forms of hormone replacement therapy (HRT) because it works primarily where it’s applied. Typically, only a small amount is absorbed into the bloodstream, so it doesn’t significantly increase estrogen levels throughout the body.
Dr. Milhouse said several studies have found that, in certain groups of women with a history of breast cancer, vaginal estrogen did not increase the risk of cancer recurrence or breast cancer-related death.
If you have questions about the safety of vaginal estrogen, a menopause-informed provider can help you decide whether it’s appropriate for you based on your symptoms, health history, and individual risk factors.
Dr. Milhouse encourages women not to wait until vaginal and vulvar symptoms become severe before asking for help. Unlike hot flashes, which can improve over time, GSM symptoms may continue or worsen without treatment.
Addressing symptoms early can improve comfort and help reduce their impact on your quality of life now and in the future.
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