Vaginal Estrogen
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What is vaginal estrogen used for?
It’s a low-dose local estrogen applied directly to the vulva and vagina. It helps with genitourinary syndrome of menopause (GSM).
Symptoms can include:
- Vaginal symptoms like dryness, burning, and irritation
- Urinary symptoms like pain, urgency, UTIs
- Sexual symptoms like discomfort or pain
GSM causes symptoms due to a lack of estrogen in the female genitourinary tract, including the vaginal, labia, urethra, and bladder. GSM usually worsens over time without treatment.
You don’t need to be in peri/menopause to have GSM.
You can also get GSM when you have low estrogen, such as when taking certain medications (like some birth control pills, Lupron/Zoladex, Dienogest, Ryeqo, etc) at any age.
People “with surgical menopause often present with a more severe GSM symptom profile than do women with natural menopause, likely because of the concomitant, abrupt, and persistent 50% decline in circulating androgen levels that occurs in addition to the loss of estradiol.” [North American Menopause Society 2020 Genitourinary syndrome of menopause]
What is the safety profile of vaginal estrogen?
In general, it has a very good safety profile due to the little to no systemic estrogen absorption. Unlike with systemic estrogen, you do not need to take progesterone to prevent endometrial cancer if you have a uterus.
Unfortunately though, vaginal estrogen has a misleading black box warning on it because the FDA requires this on all estrogen products. This scares people away from using vaginal estrogen, even though vaginal estrogen has not been shown to have the same risks as systemic estrogen. Multiple menopause experts have come together to petition the FDA to remove the outdated black box warning from vaginal estrogen as it doesn’t reflect the actual risk/safety profile of the product. Go to letstalkmenopause.org to sign the petition!
Can I use vaginal estrogen if I have endo?
In general, yes. Low-dose vaginal estrogen has shown minimal detectable systemic absorption.
And even with systemic estrogen (which vaginal estrogen is not), endometriosis is not an automatic contraindication for use. We deserve a conversation with our doctors about potential risks vs benefits based on our personal medical history if we have symptoms that estrogen therapy could help.
What kinds of vaginal estrogen are there?
Low-dose local estrogen comes in:
- cream
- vaginal insert
- vaginal ring
In placebo-controlled RCTs, each was proven to be effective. The best one for you will be the one you can access that you can easily use as directed.
In the USA, each of these options are FDA-approved and may be covered by insurance.
What is the difference between vaginal estrogen and the estrogen patch/gel/pill?
Vaginal estrogen is local, not systemic. Local estrogen leads to very little, if any, increases in your circulating serum estrogen.
On the contrary, systemic estrogen’s goal is to raise your circulating serum levels, treating peri/menopause symptoms like hot flashes. Systemic estrogen may also help GSM, but some people find it won’t be enough and will need both.
If you only have GSM symptoms, you would take local estrogen, not systemic.
What hormone testing needs to be done to have this prescribed?
None. This is based on your symptoms.
- You don’t have to take systemic estrogen or other types of HRT/MHT to use this.
- You don’t need to be a certain age or in peri/menopause to use this.
How long does it take to work?
People usually see improvement in a few weeks, but it can take up to 12 weeks to see results.
How long should you be on vaginal estrogen?
Speak to your doctor about your particular case, but in general, patients stay on this while in low menopause states as symptoms will recur when they stop using it.
Who can prescribe vaginal estrogen?
Your gynecologist, urogynecologist, PCP, GP, Nurse practitioner, PA, etc
Unfortunately, many gynecologists have had little to no training in menopause and may not be up to date in their practices. In the USA, you can go to the Menopause Society’s Choosing a Healthcare Practitioner webpage to find a certified menopause practitioner. There’s also telehealth menopause clinics if you can’t find a provider near you.
My personal experience
I love my vaginal estrogen. I started having vaginal burning last year and began using the vaginal estrogen ring. Within several weeks, the irritation down there was gone. Additionally, I noticed that my urinary frequency went WAY down, which was amazing. I still have bladder issues but the estrogen helped a lot.
I used the ring for a year and loved it, but my insurance company decided to stop covering it, so unfortunately I had to change products even though I didn’t want to. I liked the ring because I just put it in and forgot about it for 3 months. Now I’m using an insert, which I prefer over the cream because it’s not as messy.
Resources
For more information
Genitourinary Syndrome of Menopause – from the Menopause Society MenoNotes
Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline
Related podcast episodes
Sources
- 2019 NAMS Commentary on low-dose vaginal estrogen therapy labeling – from the old NAMS website
- Why the product labeling for low-dose vaginal estrogen should be changed. Menopause: The Journal of The North American Menopause Society. Vol. 21, No. 9, pp. 911/916. 2014 by The North American Menopause Society. DOI: 10.1097/gme.0000000000000316