By Stephanie Anderson Witmer
Medically Reviewed by Natalie Kunsman, M.D.For many women, menopause can bring with it some unwelcome additions: more inches to the waistline, more anxiety and depression, and more urinary tract infections.
But menopause can also make other things start to disappear: sleep, mental clarity, and also the libido—the desire to have sex.
It’s estimated 60 percent (or more) of postmenopausal women will experience some form of sexual dysfunction, including low libido and arousal, vaginal dryness, and pain during intercourse. Of these, loss of sexual desire was most prevalent (1, 2).
“One of the first things menopausal women say is how distressing it is not to be able to have sex, not just for themselves, but because they’re worried about their partners’ happiness, as well,” says Paige Kuhlmann, M.D., a urologist and urogynecologist specializing in female sexual health at Tower Urology and Cedars-Sinai Medical Center in Los Angeles.
While there are lots of options for hormonal therapy, both vaginal estrogen and transdermal systemic estradiol creams have been shown to provide relief for some of the sexual symptoms of menopause. Systemic estradiol increases estrogen levels, which can boost libido, combat vaginal dryness, and regulate body temperature to ditch hot flashes and night sweats (3).
Menopause doesn’t mean you have to kiss your sex life goodbye. Here’s how transdermal estradiol cream may get things going in the bedroom again.
About the Experts
Alyssa Dweck, M.D., FACOG, an OB-GYN focusing on menopause and sexual health. She’s the Chief Medical Officer at Bonafide Health and a practicing gynecologist at Well by Messer in New York City.
Paige Kuhlmann, M.D., a urologist and urogynecologist specializing in female sexual health at Tower Urology and Cedars-Sinai Medical Center in Los Angeles.
Does Estradiol Cream Increase Libido?
Transdermal estrogen for systemic hormone replacement does increase libido, as does progesterone and testosterone at systemic hormone replacement doses.
There are a number of ways estradiol can help. First, it can increase vaginal lubrication so that sex is more comfortable. It also helps to rebuild the lining of the vagina, which can become thinner as estrogen levels decline—also accounting for painful intercourse. This vaginal (and urethral) atrophy can also lead to more frequent urinary tract infections (4, 5, 6).
A study published in JAMA Internal Medicine found women using transdermal estrogen showed moderate but noticeable improvements in overall sexual function compared to a placebo. Those taking oral estrogen did not show significant improvement compared to the placebo. Women using transdermal estrogen also reported better lubrication and less pain during sex (7).
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Let’s Get StartedWhat Is Estradiol Cream?
Vaginal estradiol cream is a topical prescription medication that can treat vaginal irritation, dryness, and pain during intercourse. Systemic estradiol cream can also improve vasomotor symptoms (hot flashes and night sweats), while aginal estrogen cream decreases the prevalence of UTIs.
Estradiol (E2) is one of three types of estrogen. The different types are made during different times in a woman’s life. Estradiol is the strongest of the three and the body’s main form of estrogen throughout the reproductive years.
It starts to decline at perimenopause and menopause. Estrone (E1) is the primary type that’s made postmenopause. Estriol (E3) is the weakest of the three. Its production picks up during pregnancy, and then dies down afterward (8).
Estrone is already present in the body at menopause, so these medications are created to replace estradiol—the strongest type of estrogen—to alleviate menopause symptoms.
Also, note that some women can’t use topical estradiol or other hormonal therapies because they’ve had breast cancer or other health conditions. Research has found non-hormonal lubricants and vaginal moisturizers can also improve vaginal dryness (6).
Types of Estradiol Cream
Several types of estradiol cream are available, and your physician will prescribe one based on your symptoms.
Dweck says vaginal estrogen cream can be in the form of 17Beta-Estradiol—the same chemical structure as what was previously made by the ovaries—or can be made from conjugated equine estrogen, which is sourced from pregnant mare urine. (That’s right: pregnant horse pee, hence the name “Premarin”.)
Systemic estradiol can be applied to the skin as a transdermal patch, spray, gel, or cream (3). Patches are applied to the lower stomach or upper buttocks once a week. Estradiol spray is applied to the inside of the arm between the wrist and elbow daily. Gels are applied daily to the inside and outside of the upper arm or upper leg.
Vaginal estradiol also comes in the form of an ovule, ring or vaginal tablet. “All work to promote blood flow to the vaginal epithelium to manage cellular changes due to atrophy,” Dweck says.
Dosing differs for each patient, depending on the severity of symptoms (3, 9).
Estradiol-only cream
Transdermal estradiol cream is applied as a patch, gel, or cream to the arm, leg, abdomen, or butt—not into the vagina or onto the vulva.
Vaginal estriol cream
Estriol is the weakest of the three types of estrogen. It’s usually undetectable in the body, except during pregnancy, as it supports fetal and uterine health and prepares the body to deliver the baby (10).
Vaginal estriol cream is inserted with an applicator into the vagina or rubbed into the vulva and vaginal opening by hand, usually two to three times a week.
Bi-est cream
Bi-est cream is a form of topical hormonal therapy that includes two forms of estrogen—estriol and estradiol—made from wild yam, soy, or another substance that’s bioidentical to natural estrogen.
Made by compounding pharmacies, the formulation is typically 50/50 of both or 80 percent estriol and 20 percent estradiol. The idea is that you’ll get the benefit of the stronger estradiol while the weaker estriol helps tamp down possible side effects (11).
How Long Does Estradiol Cream Take to Work?
You can expect to see a difference within about six weeks, with maximum benefit coming after two or three months. The first changes you’ll likely notice are less skin irritation in and around the vagina and increased lubrication.
But experts warn that, with HRT, there is no playbook on exactly what changes you’ll experience and when.
How long to wait for sex after applying estrogen cream?
Estrogen is absorbed into the bloodstream when using these products. If they’re inserted into or applied to the vagina or vulva, that means your partner could come into contact with them if they’re not fully absorbed.
Research has found a sexual partner can absorb some estrogen from skin-to-skin contact. One study found estrogen levels in men increased by 25 percent after skin-to-skin contact two hours after and again eight hours after their female partner applied it to her arm. Still, even this increased amount of estrogen was well below the normal amount for men (12).
To prevent the cream from either transferring to someone else or rubbing off before it’s fully absorbed, it’s recommended to wait several hours before having sex. Often, people will apply creams at bedtime to fully absorb during sleep. If you’re planning on having sex at bedtime, though, applying it earlier in the day is a better option. Vaginal rings don’t need to be removed before having sex (13, 14).
Another note of caution: Some creams may contain ingredients that can weaken latex condoms (13).
Why Does Sex Drive Drop Off During and After Menopause?
Changes to women’s sex life—and sex drive—are all too common in menopause. But symptoms can differ from woman to woman. Usually, it’s a combination of factors, both physical and emotional. But the decline in estrogen is what’s behind all of it.
Vaginal dryness
Estrogen helps keep the vagina’s lubrication, thickness, and elasticity. Less estrogen often means less moisture in the vagina and vulva, in everyday life and during sexual encounters. Not being adequately “wet” during sex can make intercourse painful. And if sex hurts, women will likely not be as interested in having it as frequently as before (15).
Hormonal imbalance
Dwindling levels of estrogen have wide-reaching impacts on the sex drive. It can cause exhaustion from crappy sleep, lowered self-confidence from weight gain, and increased anxiety and depression. During sex, lowered estrogen levels cause blood to flow more slowly into the genital area, which can cause women to take longer to get aroused and have more difficulty having an orgasm (16, 17).
Sexual function
“More than half of women experience some kind of negative impact on sexual function during menopause—probably closer to 70 to 80 percent,” Kuhlmann says. And, she adds, “This can be devastating to a woman’s sense of self and also to her relationship with her partner.”
This term “sexual function” encompasses many aspects of sex: libido, arousal, orgasm, and general physical comfort. Menopause can affect each one of these.
There’s also the emotional component. “There are already associations between depressed mood and menopause, and the loss of sexuality and ability to have intimacy in relationships just compounds these negative changes in mood,” Kuhlmann says.
Now for the good news: Treatments are available to ensure negative changes to your sex life don’t last forever.
“Don’t hesitate to ask your doctor about these things,” Kuhlmann says. “If they don’t specialize in menopause management, then ask for a referral to someone who does. Don’t take no for an answer. Your sex life does not have to end after menopause.”
The Bottom Line
Menopause can have a negative effect on women’s sex lives. Less estrogen can cause lowered libido, as well as vaginal dryness and atrophy, and pain during intercourse. Transdermal estradiol patches and creams have been shown to improve sexual dysfunction in menopause by replacing estrogen when the body is no longer producing enough on its own.
