Vaginal Estrogen Treats Dryness—and These 6 Other Menopause Symptoms

There are many reasons being a woman in midlife is secretly excellent. You’re wise enough not to do dumb stuff and have way fewer figs to give (go ahead, sub in the correct word). Emotionally, you may well be as well-equipped to handle the chaos of life as you’ve ever been. But there’s no way around it: In menopause (and sometimes later in perimenopause), your vagina isn’t exactly living her best life. She used to enjoy a lavish supply of estrogen, luxuriating in the abundance of lubrication and elasticity. Now, not so much. Which is where vaginal estrogen comes in. 

After menopause, your vagina might start to feel itchy and dry. Intercourse might be painful, and even if you made it through pregnancy with no leaking, your bladder might see menopause as the final straw. Oh, and you may start to have more urinary tract infections (UTIs), due to the uncomfortable combo of dry tissue, less mucus, and a weak urethra (1). 

All of this is due to the major drop in estrogen once your ovaries have gotten out of the egg production business. “Vaginal tissues are very sensitive to estrogen loss,” says Cynthia Stuenkel, M.D., Clinical Professor of Medicine at the University of California, San Diego, School of Medicine.

About the Experts

Cynthia Stuenkel, M.D., is a Clinical Professor of Medicine at the University of California, San Diego, School of Medicine, and an attending physician for UC San Diego Endocrinology and Metabolism Service.

Heather Alaniz, PT, DPT, OCS, is a physical therapist in the Des Moines University Physical Therapy Clinic who specializes in pelvic floor therapy.

What’s Happening to My Vagina?

With much less estrogen, all that tissue around the opening of the vagina, clitoris, the vagina itself, and the urethra thins, becoming dryer and less flexible, which leads to friction and irritation. You may also get recurrent urinary tract infections (UTI) because there isn’t enough estrogen to balance out the bacteria in the vagina and bladder (2).

You may also lose elasticity and strength in muscles and tissue you probably have never thought about, including those that support your pelvic floor and stabilize important internal organs like the bladder, urethra, uterus, and rectum. This means an increased risk for pelvic organ prolapse, which is when a weak pelvic floor leads to these crucial parts of your system to slip out of place (3).

Since all this is happening because estrogen has exited stage left, it makes sense that treating these issues with estrogen can make a big difference. But this isn’t the same thing as HRT (hormone replacement therapy, also called HT) which is usually a combo of estrogen and progesterone taken orally or via a patch at a higher dose to treat menopause symptoms such as hot flashes and insomnia. Vaginal estrogen is applied locally, at a much lower dose. And with a low dose it is less likely to raise your blood level of estrogen. The cream, gel, tablet, or suppository is delivered via the skin, and because it isn’t meant to course throughout your system, a much lower dose is required (4).

What Does Vaginal Estrogen Do?

Also known as topical estrogen, vaginal estrogen helps to maintain elasticity and moisturize in and around your vagina. It can’t turn back time, but it can restore estrogen to the tissues and help reverse unpleasant changes while minimizing systemic exposure, according to a study published in the Journal of Sexual Medicine. Most commonly, vaginal estrogen is used to treat symptoms of genitourinary syndrome of menopause (GSM), a newer term for what clinicians used to call vaginal atrophy (thank you for that!), which can make sex in menopause challenging. Topical estrogen can help ease GSM symptoms, including

• vaginal dryness 
• vaginal irritation/itching/burning
• vaginal inflammation 
• lack of lubrication
• discomfort or pain with sex
• impaired sexual function 
• vaginismus, involuntary tightening of the muscles at the vaginal opening 
• vulvodynia, a burning or stinging sensation or soreness in the vulva 
• pelvic pain or pressure
• painful urination
• urinary urgency or burning 
• recurrent urinary tract infections (2, 5, 6)

Unfortunately, many women with GSM are undertreated. That’s mostly because providers are not knowledgeable about how topical estrogen can help. Some women also feel too embarrassed to report symptoms (2, 5).

More Menopause

8 Signs You Might Need Menopause Hormone Therapy

Perimenopause Fatigue Is Real. Here’s What to Do About It

What Are the Benefits of Vaginal Estrogen?

The benefits of estrogen cream are many. Here’s what it does for you:

1. Relieves dryness

The low dose of estrogen is absorbed through your skin and vaginal tissues, which helps to ncrease the healthy discharge that keeps things moist (2, 4, 5).

2. Lessens pain with intercourse

Penetration may be painful for a few reasons and estrogen can help treat some of them. These include vaginitis or inflammation of the vagina; vaginismus, an involuntary tightening of the muscles at the opening of the vagina, or vulvodynia, a burning or stinging soreness that lasts for more than three months, according to NAMS (5, 6, 7).

3. Stops symptoms from getting worse

Unlike some menopausal symptoms, such as hot flashes, which will eventually fade away, symptomatic GSM isn’t going anywhere. “Usually,” says Stuenkel, “vaginal dryness just gets worse.”  Estrogen cream can improve your quality of life.

4. Helps prevent recurrent UTIs and other urinary problems

By helping to restore the bacteria balance, vaginal estrogen helps lower the risk of urinary and vaginal infections and can help prevent an overactive bladder (2, 4, 5, 7). The 2022 update to the American Urological Association (AUA) evidence-based guidelines recommends using it to reduce the risk of future UTIs in women who have them frequently.

5. Makes pelvic floor therapy work better

While many GSM symptoms can be helped with pelvic floor physical therapy, pain and dryness can get in the way of doing the strengthening and stretching exercises.

“Topical estrogen thickens the vaginal lining and vulvar tissues, making them less sensitive, less painful, and more mobile, ” says Heather Alaniz, PT, DPT, OCS, a physical therapist in the Des Moines University Physical Therapy Clinic who does pelvic floor therapy. “It can improve the elasticity of pelvic floor muscles, which can make it easier to both contract and relax them and improve their ability to be stretched,” she explains.

Pelvic floor PT is an especially good idea if you were injured giving birth, she says. “If there’s an issue that’s not addressed postpartum, you can get along with it. But after those permanent hormonal changes, those issues come back,” she says. “Many times, we treat birth injuries that may have happened years ago

6. Works quickly

It won’t completely kick in immediately, but some women notice improvement within weeks. “Women report improvement in symptoms in 2 to 4 weeks, ” note authors Gloria Bachmann, M.D. and JoAnn Pinkerton, M.D. in their 2024 Up to Date article, Genitourinary syndrome of menopause: Treatment. Everyone is different, of course, so it may be a bit quicker or slower for you, depending on your history and symptoms. 

7. It is easy peasy

Because vaginal estrogen is so safe and routine, you don’t need time-consuming follow-ups. “Low-dose vaginal estrogen does not require any monitoring,” says urologist and sexual medicine specialist Ashley Winter, M.D., in a video commentary for Urology Times. “You don’t have to check somebody’s blood levels of estrogen both to start using it or to continue using it.”

How to Apply Estrogen Cream

If you’re hoping to reap the benefits of estrogen cream, application is pretty straightforward. You’ll find instructions on the package, but generally speaking, vaginal creams (and gels and suppositories) come with a plastic applicator. You fill the applicator to your prescribed dose, and then, lying on your back with your knees bent or standing with one foot on a chair, you slide the applicator into your vagina, then press the plunger slowly. When you remove the applicator, the cream stays up there (8).

How Long Does it Take for Vaginal Estrogen to Work?

It can take a few weeks to notice improvement or as long as four months to experience the full effect.

Is Vaginal Estrogen Safe?

Yes. Because it is applied directly to the skin, only a small amount of estrogen is needed to treat vaginal symptoms. And because you’re using a very low dose, it can be used without progesterone (which is needed to protect the uterus with higher estrogen doses used in systemic hormone therapy) (2, 4, 7).  “Vaginal estrogen is really simple and straightforward…It is pretty easy, and it is safe,” says Stuenkel. “I’m not saying it’s for everyone,” she adds, but it’s one way to find relief.

Alternatives

If you’re not ready to try vaginal estrogen, lubes and vaginal moisturizers help ease symptoms in some women (2, 3) (Ask your gynecologist for product recommendations.) According to a review published in Sexual Reproductive Health Matters, over-the-counter lubrication can help improve sexual pleasure and reduce pain related to vaginal dryness, and moisturizers actually moisturize the tissue. Pelvic floor therapy and other treatments may also help.