Vaginal Estrogen During Perimenopause: The Under-Prescribed Option That Changes Everything

Vaginal dryness. Discomfort during sex. A burning sensation that does not quite go away. Urinary tract infections that keep coming back. These are not minor inconveniences. They are symptoms of a real, treatable condition that affects a significant portion of women during perimenopause and beyond. And they respond extremely well to a safe, low-risk treatment that is vastly under-prescribed.

Local vaginal estrogen is one of the most effective and least complicated interventions available for this cluster of symptoms. Yet many women have never heard of it, or they have heard it dismissed because of concerns about hormones. Those concerns do not apply here in the same way. Vaginal estrogen is not the same as systemic hormone therapy. Understanding the distinction matters.

What is GSM and why does it happen

The medical name for this collection of symptoms is genitourinary syndrome of menopause, or GSM. The term replaced the older phrase "vulvovaginal atrophy" because it better captures the full scope of what happens.

Estrogen is essential to the health of vaginal, vulvar, and urethral tissue. It keeps the vaginal walls thick, elastic, and well-lubricated. It supports the beneficial bacteria that maintain vaginal pH. It preserves the lining of the urethra and bladder. When estrogen declines, as it does during perimenopause and accelerates after menopause, these tissues change. They thin, dry, and become more fragile. The vaginal pH shifts, making the environment more hospitable to bacteria that cause discomfort and infection.

Unlike hot flashes, which many women find ease after several years, GSM tends to worsen over time without treatment. It does not resolve on its own. The tissue changes are progressive. This is why starting treatment sooner rather than later makes a real difference.

GSM affects roughly half of postmenopausal women, and many women begin experiencing symptoms during perimenopause while they are still having periods. Low estrogen does not wait for menopause to be official.

The symptoms of GSM

GSM symptoms fall into two main categories: vaginal and urinary.

On the vaginal side: dryness and a feeling of chafing or rawness, burning and irritation even without any specific trigger, pain or discomfort during sex, light bleeding or spotting after sex, and discharge changes. For many women, the effect on sexual intimacy is significant. Pain with sex that is dismissed as "just part of getting older" deserves better than that. It has a cause and a treatment.

On the urinary side: increased urgency and frequency, urinary leakage with urgency, discomfort when urinating, and recurrent urinary tract infections. Recurrent UTIs are particularly important to recognize as a GSM symptom because they are often treated repeatedly with antibiotics without addressing the underlying cause. Estrogen-depleted urethral tissue is more vulnerable to bacterial colonization. Treating the root cause reduces the infection cycle.

Not every woman gets every symptom, and the severity varies. But if any of these sound familiar, local vaginal estrogen is a conversation worth having with your provider.

Why vaginal estrogen is different from systemic HRT

This is the distinction that clears up most of the confusion and most of the unnecessary avoidance.

Systemic hormone therapy, whether pills, patches, gels, or sprays, raises estrogen levels throughout the whole body. It treats systemic symptoms like hot flashes, sleep disruption, and mood changes. It also carries the risk profile associated with elevated estrogen levels systemically, including the considerations around breast tissue and cardiovascular effects that make some women and their providers cautious.

Vaginal estrogen is applied directly to local tissue and stays there. The doses are very small. The absorption into the bloodstream is minimal. Blood estrogen levels in women using vaginal estrogen formulations are typically at or near the levels seen in postmenopausal women who are using no hormones at all. The systemic exposure is negligible.

This is why vaginal estrogen is categorized separately from systemic HRT and why the cautions that apply to systemic therapy do not automatically apply here. The North American Menopause Society, the British Menopause Society, and the International Society for the Study of Women's Sexual Health have all published position statements supporting the safety of vaginal estrogen, including for many women who have been told to avoid systemic hormones, such as breast cancer survivors, depending on their oncologist's guidance.

Vaginal estrogen is not a second-tier consolation option. It is the appropriate, targeted treatment for a localized problem.

The forms of vaginal estrogen available

There are several formulations. They all work. The best choice depends on your preferences around application, convenience, and comfort.

Vaginal cream. The original and most studied form. Applied internally with an applicator, or sometimes directly to the external vulvar tissue. It works well for both internal symptoms and external dryness and irritation. Some women find the application messy or inconvenient, particularly for nightly use at the beginning of treatment. Brands include Estrace and generic versions of conjugated estrogen cream.

Vaginal tablets or suppositories. Small tablets inserted with a slim applicator. Many women find these easier to use than cream. Vagifem (estradiol vaginal tablets) and its generic versions are widely available.

Vaginal rings. A flexible ring inserted into the vagina by the user, similar to a diaphragm. It releases a continuous low dose of estrogen for 90 days. Estring is the low-dose version for GSM. Many women appreciate not thinking about it for three months at a time.

Vaginal DHEA suppositories (prasterone, Intrarosa). DHEA is a precursor hormone that the vaginal tissue converts locally into both estrogen and testosterone. This is an option for women who prefer not to use estrogen directly. Research shows it is effective for GSM symptoms including pain with sex.

Ospemifene (Osphena). This is an oral medication, not a vaginal application, but it belongs in this category because it works locally on vaginal tissue as a selective estrogen receptor modulator. It is a tablet taken daily and does not involve any insertion. It is approved for moderate to severe dyspareunia (pain with sex) due to GSM.

How to use vaginal estrogen and what to expect

Most vaginal estrogen regimens start with a higher-frequency induction phase, typically daily application for two to four weeks, followed by a maintenance phase of two to three times per week. The maintenance dose is what you continue long-term.

Improvement is gradual. Tissue changes take time to reverse. Many women notice reduced dryness within two to four weeks, but fuller symptom relief, including reduced pain with sex and improvement in urinary symptoms, typically takes eight to twelve weeks. If you stop using it, symptoms will return. This is a long-term treatment for a condition that does not resolve on its own.

The amount of estrogen in maintenance doses is very small. Estrace vaginal cream at the standard maintenance dose delivers about 0.5 mg of estradiol per application. The Estring ring delivers 7.5 micrograms per day. These are tiny amounts compared to any systemic formulation.

Most providers do not require you to take a progestogen alongside low-dose vaginal estrogen, the way systemic estrogen users with a uterus typically do. The doses are too low to cause endometrial stimulation. This simplifies the treatment considerably.

Some providers recommend using a small amount of low-dose vaginal estrogen cream externally on the vulvar tissue as well, particularly if external dryness and irritation are part of the symptom picture. This is worth asking about specifically if external symptoms are prominent.

Why it is under-prescribed

Despite its strong safety profile and clear effectiveness, vaginal estrogen is significantly underused. Several things contribute to this.

First, women do not always bring up these symptoms to their providers. Dryness and discomfort during sex feel private and are sometimes treated as embarrassing. Many women assume it is just part of aging and do not know there is a straightforward treatment. The symptoms go unmentioned, so treatment is never offered.

Second, some providers conflate vaginal estrogen with systemic HRT and apply the same cautions without distinguishing between the two. Women with a history of breast cancer, for instance, are sometimes told to avoid all hormones when the specific question of local vaginal estrogen deserves a separate, individualized conversation with their oncologist.

Third, there is a cultural tendency to normalize these symptoms as an inevitable consequence of menopause rather than a treatable medical condition. "That's just what happens" is not a sufficient response when effective treatment exists.

If you have been experiencing GSM symptoms and the topic has not come up with your provider, you can raise it directly. You do not need to wait to be asked.

What about lubricants and moisturizers

Over-the-counter options play a role, but they are not a substitute for vaginal estrogen when tissue changes have occurred.

Vaginal lubricants are used during sexual activity to reduce friction in the moment. Silicone-based lubricants last longer than water-based ones. Both are helpful for comfort during sex. They do not treat the underlying tissue changes or improve urinary symptoms.

Vaginal moisturizers like Replens or YES VM are applied regularly (not just during sex) and help maintain hydration in the tissue over time. They reduce day-to-day dryness and irritation. They are a reasonable first step or a complement to vaginal estrogen.

For moderate to severe GSM, most gynecologists and menopause specialists consider vaginal estrogen the more effective long-term solution. Moisturizers manage the surface. Vaginal estrogen restores the tissue.

Vaginal dryness, pain with sex, and recurrent UTIs are not things you have to accept. They are not inevitable. They are symptoms of a well-understood condition that responds to a safe, targeted treatment. The threshold for discussing vaginal estrogen with your provider should be low. If these symptoms are affecting your comfort, your intimacy, or your quality of life, the conversation is worth having.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.