Vaginal Estrogen: Everything You Need to Know

Dealing with symptoms of menopause is frustrating, especially if it's causing vaginal dryness, painful sex, or frequent urinary tract infections (UTIs) — just some of the symptoms that happen with genitourinary syndrome of menopause (GSM). 

Luckily, there's a possible solution that could help: vaginal estrogen therapy. Whether it's a vaginal estrogen cream, vaginal ring, or vaginal tablet, it can restore healthy function to your vulva, vagina, and urinary tract. 

Vaginal estrogen is considered the gold standard for GSM, and it's usually the first-line treatment. Research shows that it can quickly improve some of the most common and troublesome symptoms of menopause. 

So, whether you're struggling with vaginal dryness or painful sex, vaginal estrogen may be the answer you've been looking for. If you want to know more about how it works, its benefits, and its side effects, keep reading.

What happens to estrogen during menopause? 

Estrogen is a hormone that helps regulate the menstrual cycle and impacts the function of many different parts of the body, including the urinary tract, bones, breasts, skin, heart, blood vessels, pelvic muscles, and the brain. When it comes to vaginal health, estrogen plays a very important role.

During perimenopause, which is the time leading up to menopause, the body starts producing less estrogen. This can bring about a variety of changes throughout the body. Even the vulva, vagina, bladder, and pelvic muscles (which have a high concentration of estrogen receptors) are affected by this decrease in estrogen levels.

Estrogen keeps the vaginal mucosa (the lining of the vagina) thick, lubricated, and elastic. However, as estrogen levels drop during perimenopause, the vagina, vulva, and urinary tract can become thinner and drier (called vaginal atrophy). The medical term for this condition is called genitourinary syndrome in menopause (GSM), which includes:

• Vaginal symptoms: dryness, burning, and irritation.
• Sexual symptoms: lack of lubrication, discomfort or pain during sexual intercourse, and impaired function.‍‍
• Urinary symptoms: urgency (feeling the need to pee suddenly), pain while peeing, and recurrent urinary tract infections.

Estrogen also plays an important role in the vaginal microbiome. It causes changes in the vagina that allow protective bacteria like lactobacilli to thrive. Specifically, it helps the body produce glycogen, a food source for protective bacteria called lactobacilli. These bacteria keep the vaginal pH acidic, which prevents the overgrowth of potential pathogens. 

However, a thinner vaginal lining can make it more susceptible to harmful bacteria, and lower levels of estrogen also mean that food for Lactobacilli decreases, so their numbers start to decline. This change in the vaginal microbiome results in a change in vaginal pH, which leads to an increase in rates of bacterial vaginosis (BV) and UTIs after menopause.

What is vaginal estrogen?

There are two types of estrogen treatment available: systemic and local estrogen. Both need to be prescribed by your healthcare provider. 

Hormone replacement therapy (HRT) is commonly used to manage menopausal symptoms, and it involves prescription medications that contain estrogen and progesterone, the two primary female reproductive hormones. HRT can be prescribed in the form of a pill, gel, or patch based on your lifestyle and how bad your symptoms are.

HRT is a systemic treatment, which means it releases estrogen throughout the body. This makes it unsuitable for some people with specific health problems, such as those with a history of:

• Stroke
• Ovarian cancer
• Endometrial cancer
• Beast cancer
• Heart disease
• Blood clots. 

Local estrogen treatment, on the other hand, is applied intravaginally and releases a low dose of hormones directly to the vaginal tissue, with much less getting into your systemic bloodstream. That said, vaginal estrogen isn’t recommended for people with a history of estrogen-sensitive cancer. 

Vaginal estrogen is administered directly into the vagina and is available in three different forms: 

• Vaginal insert (Vagifem)
• Vaginal ring (Estring)
• Vaginal estrogen cream (Estrace or Premarin).

Interestingly, vaginal estrogen is more effective than systemic estrogen when it comes to treating vaginal symptoms.

Research shows that using vaginal estrogen is proven to be highly successful in reducing GSM symptoms and increasing Lactobacillus levels in the vagina.

Deciding which option is best for you depends on which symptoms you have, the severity of your vaginal symptoms, and your preference for how the medication is applied (some people prefer the vaginal ring to the cream or tablet, and vice versa). Speak to your healthcare provider to determine which of these options is the right one for you.

Benefits of vaginal estrogen

Everyone experiences menopause — and menopause treatment — differently, so the benefits of vaginal estrogen will depend largely on your symptoms. 

That said, vaginal estrogen is a safe and effective treatment for GSM. Studies have shown that this therapy can help reduce the thinning and weakening of vaginal tissue, which can cause symptoms like vaginal dryness and irritation. 

The main benefit of vaginal estrogen treatments is that they release a very low dose of estrogen directly into the vaginal blood supply, without being absorbed into the rest of the body. This means that they carry fewer side effects and are a safe option, even for people who aren't suitable for HRT. 

However, it's important to keep in mind that while vaginal estrogen can help with dryness and irritation, it won't treat other symptoms of menopause such as hot flushes, mood swings, or insomnia. 

Side effects of vaginal estrogen

Vaginal estrogen, like any medication, may cause minor and temporary side effects, including: 

• Headaches
• Abdominal or vaginal pain
• Unexpected vaginal bleeding.

These side effects are usually not serious and tend to improve in the first few months of treatment. If they continue after the first few months of treatment, or they get worse, speak to your healthcare provider. You may need to change your dose or switch to a different type of HRT.

Vaginal estrogen and breast cancer

A lot of women are against estrogen treatment for menopause because of the risks for breast cancer, and GSM is a huge problem in the breast cancer survivor community. However, localized therapy poses very few risks. Menopausal women who have a history of breast cancer or are at high risk for breast cancer can assess with their doctor to see if low-dose vaginal estrogen is right for them.

However, more and more evidence is coming out that shows that topical estrogen comes with very low risks of breast cancer. A recent study published in JAMA looked at 50,000 breast cancer patients and survivors, 5% of which had vaginal estrogen. There was no evidence of increased cancer-specific mortality in this high-risk population. This should be very reassuring for patients and providers that vaginal estrogen is effective and safe. 

Additionally, there is no evidence that vaginal estrogen increases the risk of cancer cardiovascular problems, stroke, dementia, or any other issues. 

FAQ

What does vaginal estrogen do?

Vaginal estrogen can help relieve the genitourinary symptoms of menopause, such as vaginal dryness, itching, and irritation. It works by replenishing estrogen levels locally in the vagina, which can make almost immediate changes to the vaginal and urinary tissues. Estrogen thickens the lining of the vagina, making it stronger and more elastic, and even helps to strengthen the pelvic floor muscles, which can improve urinary symptoms like incontinence. Plus, estrogen helps to increase glycogen levels which feed healthy bacteria in the vagina, particularly Lactobacillus, which protects against vaginal infections.

Does estrogen make you more wet?

In a way, yes. Vaginal estrogen can help with vaginal dryness caused by menopause. It works by restoring natural lubrication and maintaining the health of vaginal tissues. It won't directly increase sexual arousal, but it can make sex more comfortable by addressing dryness and discomfort, which may indirectly enhance sexual pleasure. While increased moisture and comfort can positively affect sexual experience, vaginal estrogen works more on the physical state of the vaginal tissues than on sexual desire or arousal, which are influenced by a broader range of factors, including psychological and hormonal elements.

Where should you apply estrogen cream?

Different types of estrogen creams exist to treat different conditions, but vaginal estrogen specifically is applied inside the vagina. The cream and tablet form are both inserted into the vagina using a special applicator. During the first few weeks, the application is usually done daily and several times a week thereafter. A ring version of vaginal estrogen is also available, which is inserted once and replaced every 90 days. The ring releases a low dose of estrogen over this period.

How long does it take for vaginal estrogen to work? 

It can take up to three months to work fully, but it mainly depends on the dosage, type of administration (insert vs. ring vs. cream), and how severe your vaginal symptoms are.

Is topical estrogen bad for you?

There are different types of local estrogen treatment, but vaginal estrogens are generally considered safe. Like all drugs, it can have some minor and temporary side effects when you first start taking it, but research shows it has a very low risk of long-term complications in healthy individuals. 

What if the estrogen makes my symptoms worse?

Speak to your healthcare provider if you find that local estrogen therapy isn’t helping your symptoms or making them worse. They might want to change your dosage, or delivery system, or look into whether other forms of estrogen therapy are more suitable for you. Unfortunately, menopause treatment is one of those aspects of women's health that requires a bit of trial and error. If treatment isn’t working for you, don’t hesitate to advocate for yourself and ask your doctor for another option.