If you’re dealing with menopause symptoms like vaginal dryness, painful sex, and frequent UTIs, you may be considering vaginal estrogen therapy. Vaginal estrogen is a safe, effective treatment (delivered as a vaginal cream, ring, insert, or tablet) that can restore healthy function to your vulva, vagina, and urinary tract. Research shows this treatment can quickly improve some common and troublesome symptoms of menopause. Here’s what you should know about vaginal estrogen medication.
Estrogen is one of the most important hormones you make. Almost every part of your body responds to it, including your heart, muscles, bone, brain, and skin. During menopause, your body’s production of natural estrogen decreases. This decline in estrogen levels triggers a cascade of changes throughout your body. Your vulva, vagina, bladder, and pelvic muscles (which are especially rich in estrogen receptors) are no exception.
This leads to one of the most common and distressing menopause symptoms—a cluster of issues called the genitourinary syndrome of menopause (GSM). GSM involves a short list of problems familiar to many people during menopause:
Vaginal hormone therapy eases these symptoms by delivering estrogen directly into the tissues that need it, helping restore their normal function. Research has proven that this therapy is effective. A 2015 systematic review found that vaginal estrogen helps reduce vulvovaginal atrophy (i.e. the thinning and weakening of the vagina that can cause painful sex and irritation), improve overactive bladder (which causes frequent urination), and protect against urinary incontinence.
Vaginal estrogen medication is available as a tablet, cream, or ring. Both the tablet and the cream are inserted into the vagina with a special applicator. This is typically performed daily for the first few weeks, and several times weekly thereafter. A ring, on the other hand, is inserted once and replaced every 90 days. The ring slowly releases a low dose of estrogen over this time period.
The tissues of your vagina are highly absorbent. When they begin receiving estrogen, almost immediate changes are triggered in your vaginal and urinary tissues. Estrogen causes the lining of your vagina (i.e. the epithelium) to thicken, making the tissue stronger, less fragile, and more elastic. It can also strengthen your pelvic floor muscles, helping improve urinary symptoms. In addition, estrogen seems to increase glycogen—a sugar that feeds healthy bacteria in your vagina, particularly Lactobacillus. This leads to positive changes in your vaginal microbiome, helping protect against urinary tract infections.
Vaginal estrogen is a safe and FDA-approved medication. The world’s foremost authority on menopause—the North American Menopause Society—has formally endorsed vaginal estrogen as a treatment for GSM. According to the group, vaginal estrogen is safe and effective for symptoms like vaginal irritation, pain during sex, and urinary issues.
For people with a history of cancer, there are special considerations around vaginal estrogen. Some forms of cancer are hormone-sensitive, meaning they grow in response to estrogen. (This is why many breast cancer survivors are prescribed estrogen blockers like tamoxifen.) In these cases, vaginal estrogen may still be a safe option under the care of a medical professional. The American College of Obstetricians and Gynecologists (ACOG) has stated that low-dose vaginal estrogen is an acceptable treatment option for cancer survivors, as long as the patient and doctor carefully weigh the risks and make a shared decision.
Vaginal estrogen, like other forms of hormone therapy, is best for people who are perimenopausal or have recently become menopausal. If many years have passed since you reached menopause, your doctor may find that the risks of vaginal estrogen therapy outweigh the benefits.
If you’re interested in hormone therapy, vaginal estrogen is not the only option. Estrogen can also be taken orally (as a pill) or topically (as a cream or gel absorbed through your skin). Both of these approaches offer distinct benefits and are sometimes combined for optimal effect.
Oral estrogen therapy—i.e. swallowing a dose of estrogen in pill form—has been used longer than any other hormone therapy. For that reason, it’s the best-studied. We know that oral estrogen is effective at reducing the most common and troublesome symptoms of menopause: hot flashes and night sweats. It may also help with depression, insomnia, and mood changes. These are important benefits that you cannot always obtain with vaginal estrogen, which is why the two treatments are sometimes prescribed in combination.
On the other hand, estrogen taken orally has to first pass through your liver before it reaches your bloodstream and makes its way to your vaginal tissues. This means that a higher dose of estrogen is necessary, which may increase the risk of certain side effects. And because it’s being delivered indirectly, oral estrogen may have less of an impact on GSM symptoms. That’s why certain benefits (such as protection against UTIs) can only be obtained with vaginal estrogen.
Topical hormone therapy is an estrogen cream, gel, or spray which is absorbed through your skin. Like vaginal estrogen, this route bypasses your liver. This means your circulating estrogen level tends to be more stable, which may help prevent side effects. The downside of this method is that it can be somewhat inconvenient. You’ll have to be careful to not inadvertently wash or rub off the medication—and to not let other people (e.g. children) make contact with it.
Menopause symptoms like painful sex, vaginal irritation, and urinary difficulties are not a normal part of aging that we need to accept. They’re real health issues that can take a real toll on your quality of life. Vaginal estrogen has been proven safe and effective in treating these symptoms—and it’s an increasingly important part of our modern menopause toolkit.