Vaginal Estrogen Therapy - A Complete Guide

Mar 15, 2023
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Medically reviewed by: 
Dr. Leah Millheiser

Genitourinary symptoms of menopause (GSM for short) are some of the most troublesome parts of menopause. GSM includes vaginal dryness, vulvovaginal itching, painful intercourse, frequent urination, and UTIs. So, not exactly a party in your pants. While GSM affects different people to different extents, it is extremely common, and it can put a tremendous damper on your self-confidence, comfort, and sex life. 

The good news about GSM is that there is an extremely effective, low-side effect, accessible treatment that does an excellent job of relieving pain with intercourse and feelings of dryness and irritation: vaginal estrogen therapy. Vaginal estrogen is the gold standard in treatment for GSM, and it is great at what it does.  

What's Happening in Your Body

When you approach and enter menopause, you experience a fast hormonal shift, with estrogen levels dropping off sharply. This hormonal change causes a wide range of symptoms, and when it comes to your vagina, it often causes GSM. As you lose estrogen, you lose thickness in your vaginal tissues (which makes them more prone to irritation and damage) as well as blood flow. As this happens, you might notice that sex is uncomfortable (or downright painful), that you don’t get aroused and lubricated like you used to, and that orgasm is more difficult to achieve and less intense when you do. You might also notice an increase in UTIs and irritation in the tissues of your vulva. 

When the symptoms of GSM begin, they may be easy to ignore or accept. As your estrogen levels continue to decline throughout menopause, however, symptoms often become more severe and thus more disruptive to the rich, joyful life you want to be living. And when that happens, it’s time to consider treatment, because there is real, impactful help available. Vaginal estrogen works so well for GSM that dryness and irritation tend to go away completely after a few months of therapy. Pain with intercourse tends to improve significantly, if not completely resolve, as well (though experiences do vary from person to person).  

Vaginal Estrogen Cream and Vaginal Estrogen Tablets

When you start treatment with vaginal estrogen, you’ll choose what form to use (tablet or cream), and begin with what’s known as a loading dose, using your prescription nightly for two weeks. After that, you’ll transition to a maintenance protocol, where you’ll use your prescription twice a week. You and your Evernow provider will work together to decide whether the tablet or the cream is best for you, based on your symptom factors and your personal preference.

Vaginal estrogen tablets have the advantage of being neat, easy to insert, and dosed for you so you know you’re getting the exact right amount. To insert the tablet, you’ll wait until the end of the day and then use the vaginal applicator that comes with your prescription to place the tablet at the top of your vagina. Then, just lie down and go to bed—you’re all set. 

The cream form of vaginal estrogen has pros and cons as compared to the tablet. The main issue some people have with the cream is messiness—you load an applicator with estrogen cream and insert it into your vagina, and you’ll need to lie down right after applying so that it doesn’t excessively drip out of your body. Some people do find that they need to wear a pantyliner the day after using vaginal estrogen cream, as minor dripping can continue, and sometimes, the cream can cause vaginal itching, irritation, or yeast infections.

If you have irritation, pain, or itching in your vulva, however, that messiness can work in your favor, because estrogen cream will give location-specific treatment to your labial tissue as it drips out. Your vulva will naturally absorb some of the cream, and you can also use your finger to apply a little cream directly to your vulvar tissues.

Vaginal estrogen tablets are prescribed at 10 micrograms, and the recommended dose for the cream is two grams as a loading dose, then one gram as a maintenance dose. For both forms, you’ll want to avoid vaginal penetration for eight hours after insertion, so if sex is on the menu on your medication night, make sure you do it first, and then insert your estrogen afterwards. 

What to Expect With Vaginal Estrogen

One of the best features of vaginal estrogen delivery is that it won’t raise your systemic hormone levels—it just increases the estrogen in your genitourinary system. That means that vaginal estrogen is safe for most people (with contraindications for certain estrogen receptor positive cancers and unexplained vaginal bleeding). If you don’t have those contraindications, you can take vaginal estrogen for as long as you want. Side effects are typically very minimal, with some people experiencing breast tenderness, headache, and bloating that appear when they first begin treatment and resolve within a month or two. Vaginal discharge, itching, and increased yeast infections can also occur, specifically with the cream, so if those symptoms are an issue for you, you may want to talk to your Evernow provider about switching to the tablet.

When you first start taking vaginal estrogen, it can be hard to know what to expect, but many people notice a distinct improvement in their GSM immediately after the loading period. The full effect of your treatment protocol will take two to three months, so, as with so many things during menopause, patience is the name of the game here.  

How to Support Your Vaginal Health and Comfort

Along with vaginal estrogen therapy, there is a lot you can do to support your vagina in feeling better on a daily basis, and to bring more pleasure into your sex life. Lubrication is key for intimacy during menopause, so if you’re new to the world of lube, get excited: there are a lot of amazing products out there. We particularly love and recommend silicone-based lubricants for their long-lasting silky feel (Pjur is the cream of the crop). 

Another product that you might not be aware of is vaginal moisturizer, which works to help restore moisture to your vaginal canal. (We love Replens and Revaree.) Like all moisturizers, you have to use it faithfully to enjoy results, so build some vag-care into your nightly routine along with your face creams and serums.

When it comes to sex (whether solo or with a partner), bringing a vibrator into the bedroom can help you rediscover your orgasm. As blood flow to the genitals decreases with the loss of estrogen in menopause, it can be more difficult to achieve orgasm—that’s where a tireless vibrator comes in. Obviously, there is a ton of personal preference that goes into choosing the perfect vibe for you, but the Womanizer or a similar clitoral stimulator is a great choice to start with.

Reclaiming Your Body

Menopause is a time of transition, and there are some aspects of your younger body, like fertility, that are going to change no matter what. Your sexual and vaginal health don’t have to be on that list, however—vaginal estrogen can extend your sexual years for as long as it is safe for your body to take, and for as long as you wish to take it. You deserve a life that feels like yours, and if the changes you’re experiencing aren’t to your liking, there is a real solution available for you.