Vaginal Estrogen in Menopause – Safe and Effective

By Suzanne Fenske, MD, FACOG, ABOIM, MSCP

Vaginal Estrogen in Menopause – Safe and Effective

Estrogen helps keep the skin firm, plump, and hydrated, but without enough, skin health can suffer. And not just on your face. Today we’re talking about vaginal health – the vulva, vagina, and associated tissues – and why vaginal estrogen is a safe and effective treatment for dryness, irritation, and UTIs.

The recent FDA announcement about the removal of the black box warning on vaginal estrogen will allow more women to access this safe and effective treatment. If you still have some hesitation and worry about hormone therapy, even bioidentical hormones, keep reading as we break down everything you need to know about vaginal estrogen. This article will cover:

• What is vaginal estrogen?
• Why the vagina needs estrogen
• Who virginial estrogen is for
• When should you start
• How vaginal estrogen fits into an integrative care plan

What is Vaginal Estrogen?

Vaginal estrogen refers primarily to low-dose, local estrogen products applied externally to the vulva (including clitoris, urethral opening, vaginal opening) or internally inside the vagina. There are several FDA-approved options, such as creams, suppositories, and rings, many of which are bioidentical estradiol (E2). If you need a different dose or formula, compounded products are also available. Vaginal estrogen requires a prescription from your healthcare provider.

Unlike systemic estrogen, which is a higher dose and raises blood estrogen levels, treating hot flashes and other menopausal symptoms, vaginal estrogen stays in the local tissues. Some women may use both systemic estrogen and vaginal estrogen.

Why the Vagina Needs Estrogen – Estrogen’s Role in Genitourinary Health

There are estrogen receptors throughout the body, including throughout the genitourinary system. In the vagina, estrogen helps maintain a healthy vaginal microbiome, the community of microorganisms that inhabit the area. It promotes Lactobacillus, which produces lactic acid and keeps the vagina acidic. The acidic pH is critical for creating a healthy vaginal environment and protecting against infection.

Additionally, estrogen plays an essential role in skin health and slows skin aging. It supports collagen production, which is necessary for maintaining skin thickness and firmness. Estrogen increases the production of mucopolysaccharides and hyaluronic acid, keeping skin hydrated and moisturized. Estrogen helps the skin heal from wounds or tears, and in the vagina, it promotes the production of natural lubrication.

Research demonstrates that using vaginal estrogen increases beneficial Lactobacillus and Bifidobacterium, correcting microbiome imbalances and lowering the vaginal pH to a healthy range. It improves skin thickness and helps maintain normal structures. In this way, vaginal estrogen is protective against genitourinary syndrome of menopause (GSM), including vaginal dryness, urinary tract infections (UTIs), and related symptoms, improving health and quality of life.

Genitourinary Syndrome of Menopause – GSM

As estrogen declines in perimenopause and remains low post-menopause, it can significantly affect genitourinary health. Approximately half of postmenopausal women report symptoms of GSM, including:

• Vulvar and vaginal dryness or itching
• Pain or burning with sex
• Pain or burning with urination
• Vaginal infections
• UTIs
• Decreased arousal and orgasm
• Stress incontinence (peeing with sneezing or running, for example)
• Vaginal prolapse

With so many affected, only half seek medical care, and even fewer are satisfied with the care they receive. Because of hormone therapy misinformation and black box warnings on FDA-approved HRT prescriptions, many women remain hesitant to use vaginal estrogen, and many providers may be reluctant to offer it.

Yet, vaginal estrogen may be the most effective treatment for GSM. A review of 44 studies concludes:

“All commercially available vaginal estrogens effectively relieve common vulvovaginal atrophy-related complaints and have additional utility in patients with urinary urgency, frequency or nocturia [excessive urination at night], SUI [stress urinary incontinence] and UUI [urge urinary incontinence], and recurrent UTIs.”

Who Should Use Vaginal Estrogen?

Vaginal estrogen is the primary treatment for genitourinary syndrome of menopause, but you don’t need to wait until menopause or post-menopause to begin. You can use vaginal estrogen during perimenopause. Although the ovaries are still producing estrogen, many women start experiencing low estrogen symptoms during this time.

Vaginal estrogen may also be prescribed during other low estrogen life phases to preserve tissue integrity and comfort. During the postpartum period, estrogen levels are low and further suppressed by high prolactin levels associated with breastfeeding. With similar symptoms to GSM, women may experience genitourinary syndrome of lactation and benefit from vaginal estrogen treatment.

Remember that vaginal estrogen is local, so it’s safe for women who might otherwise not be good candidates for hormone therapy, such as those undergoing cancer treatments. In an extensive study of breast cancer patients, vaginal estrogen didn’t increase cancer mortality and helped to improve genitourinary symptoms caused by estrogen-suppressing cancer treatments.

Vaginal estrogen treats recurrent UTIs. UTIs are dangerous as the infection can spread, causing sepsis and death, especially in older women. UTIs are conventionally treated with antibiotics, which have consequences for the vaginal microbiome by wiping out beneficial bacteria along with pathogens, which increases susceptibility for future infections and requires more antibiotics.

In short, vaginal estrogen is safe for just about any adult woman who needs it. But what about the warning label?

Vaginal Estrogen Safety and Black Box Warning

The Women’s Health Initiative (WHI) study was published in 2002 and caused a lot of fear around hormone replacement therapy. (Read more about the study, and its problems here.) The study didn’t even look at vaginal estrogen but evaluated systemic non-bioidentical hormones. Yet, because of the WHI, the FDA added a black box warning label to all HRT products, including vaginal estrogen, warning of the increased risks of cancer, heart attack, stroke, and dementia.

That label has been on FDA-approved vaginal estrogen products for over 20 years, even though there is an abundance of data promoting the safety of vaginal estrogen, even in vulnerable populations.

In November of 2025, the FDA announced it will remove the black box label from HRT products, including vaginal estrogen, in light of current research. This change in labeling will undoubtedly improve access to and compliance with this important, safe women’s medication.

An Integrative Approach

From an integrative medicine approach, we want to use every tool in our toolkit to help our patients achieve their health goals and prevent disease. These tools include lifestyle medicine (nutrition, exercise, stress management), holistic therapies, and allopathic medications.

Vaginal estrogen is a safe and effective treatment approach for GSM and other vulvar and vaginal issues related to low estrogen levels throughout a woman’s life. Vaginal estrogen should be considered first-line therapy. Here are some of the best ways to incorporate this treatment into your integrative care plan:

• Choose bioidentical estrogen. While most vaginal estrogen products are bioidentical (primarily estradiol), some products are not bioidentical. TārāMD always recommends the bioidentical options.

• Use vaginal moisturizers as needed. You can use moisturizers and lubricants along with vaginal estrogen, but don’t use them as a replacement for local estrogen support.

• Use lube each time you have sex. This practice reduces friction and prevents small tears in the vaginal tissue. It will help with comfort and long-term sexual health.

• Get personalized support. Work with TārāMD for an integrative, 360-degree approach to your symptoms, complaints, and goals. While vaginal estrogen may help solve one piece of the puzzle, it will work best when integrated with a comprehensive care plan to address body, mind, and soul.

The bottom line is that most women will benefit from vaginal estrogen at one point or another, particularly during perimenopause and in the post-menopause years. With the removal of the unwarranted black box warning, more women will have access to and peace of mind with this effective treatment. To learn more about HRT and if you’re a good candidate for vaginal estrogen and other bioidentical hormones, schedule with TārāMD today!

References

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