Vaginal Estrogen Therapy

A decline in estrogen levels after menopause can lead to changes in the skin of the vagina, urethra, and vulva. These changes are known as “the genitourinary syndrome of menopause.”

About Urogenital Skin Changes

Estrogen plays an important role in keeping the skin and tissues of the vagina and vulva moist and healthy. With the normal decline in estrogen after menopause, the tissues and skin in the vaginal area may thin and become dry.  It is also possible for younger women to have health issues that result in lower estrogen levels in their bodies, which can lead to the same problems. For example, treatments for breast cancer can lower estrogen levels. Women who are breastfeeding or smoke are also at greater risk for this condition.

When your body stops making or produces less estrogen, the glands in the vagina make less mucus. Vaginal atrophy, thinning, dryness, and inflammation of the walls of the vagina are common. Up to 50 percent of women experience this dryness by three years after their last period. In addition, the skin and tissues of the vulva become thin and less elastic. Because of these changes, the vagina and the vulva can be easily damaged with friction. For example, this can happen with rubbing due to wearing tight clothing or from sexual activity.


Many women first notice discomfort, burning, or bleeding with sexual activities. In addition, your vagina may feel dry and irritated. You may experience a burning sensation when you urinate. Sometimes vaginal dryness is associated with itchiness or a thin yellow discharge. Changes in the pH of the vagina can increase your risk of urinary tract infections (UTIs). Skin changes can also occur at the vulva and the base of the bladder, so the area outside the vaginal opening may look different.


Be sure to discuss all of your vaginal irritation symptoms with your medical provider. This will help the provider make an accurate diagnosis. Share if you wash with perfumed powders or soaps. Also, discuss if you are using panty liners, spermicides, or any lubricants that could be contributing to your vaginal irritation.

The medical provider will examine your genital region. Signs of urogenital atrophic skin changes include pale, smooth, and shiny skin in the vagina and vulva. This can be easily irritated and cause bleeding. There may also be patchy areas of dry skin, sparse pubic hair, and decreased vaginal length.


Some simple changes can help reduce vaginal and vulvar irritation.  These include:  Using chemical-free detergents; wearing white, cotton underwear as well as keeping the area dry. If you wear pads due to urinary leakage, stay away from menstrual pads–use pads that are designed to hold urine or consider trying 100 percent cotton pads. Some women find using a vaginal moisturizer or lubricant helpful. Water- or silicone-based lubricants are best. Some inflammatory skin conditions may require treatment with a steroid cream.


If vaginal irritation or dryness is still a problem, vaginal estrogen therapy is the most effective treatment. It improves the quality of the skin and tissues in and around the vagina. Estrogen thickens the skin lining the vaginal canal and increases natural lubrication. It also restores the normal pH of the vagina. It has been shown to reduce the risk of UTIs.

Very little of the estrogen is absorbed into the bloodstream, and it is safe for most women. The estrogen can work successfully on the symptoms in the vaginal area without the risks of taking estrogen orally or wearing a patch.

It is advised to wait at least 12 hours after you insert estrogen cream to have sex, although the risk to your partner is not thought to be of concern.

Vaginal estrogen comes in different forms:

  • ESTROGEN CREAM comes in a tube, similar to toothpaste. Often you draw the dose into an applicator, then insert the applicator as deep as possible into the vagina. By pushing the plunger in, the cream is delivered into the vagina. You may also be told to squeeze out a small, pea-sized amount of the medicine onto one finger and gently rub it on the vulva and inside your vagina. You will likely start off using the cream nightly for a few weeks and then cut back to twice weekly. Ask your provider for details.
  • ESTROGEN insertables are “tablets” that come in a preloaded applicator. The applicator is similar to a plastic tampon and intended to be used only one time. It is inserted into the vagina, and the plunger is compressed to eject the tablet into the vagina as high as possible. Women start with a daily dose but gradually taper off to twice a week.
  • A VAGINAL ESTROGEN RING looks similar to a contraceptive diaphragm. It is inserted through your vulva into the vagina. It contains three months of low-dose estrogen, which is slowly released. The ring then needs to be removed and a new one placed in the vagina. Most women can do this on their own.

It is common when first starting to use vaginal estrogen therapy to be instructed to use it more frequently. Once symptoms such as dryness, cracking, and burning improve, the application or insertion of the cream or “tablet” may be done less frequently. Please ask your provider for specific instructions on use.

Research has found that all of these options work equally well. For women who experience painful sex and cannot or do not want to use estrogen, an oral medication, ospemifene, has been approved to reduce this symptom.

Ask your provider if a specific option is best for you.

Screenshot 89 - Vaginal Estrogen Therapy 1


  • Estrogen: A group of hormones that promote and maintain the female traits of the body, also referred to as the female sex hormones.
  • Vagina: The canal that connects the uterus (womb) with the vulva.
  • Urethra: Tube from the bladder to the outside of the body that urine passes through during urination.
  • Vulva: A woman’s external genitals.
  • Menopause: The time in life after a woman has stopped having periods. Menopause begins when 12 months have passed since the last period.
  • Genitourinary syndrome of menopause: Collection of symptoms resulting from a decrease in estrogen and other hormones. These include changes to the labia, vulva, clitoris, vagina, urethra, and bladder.
  • Vaginal atrophy: Thinning, drying, and irritation of the lining of the vagina caused by low levels of estrogen.
  • Urinary tract infection (UTI): The abnormal growth of bacteria in the urinary tract is combined with symptoms like urgency and urination frequency. The urine may also be cloudy, bloody, or have a foul odor. Many women experience pain with urination.
  • Vaginal estrogen: Estrogen is used in the vagina at a very low dose to treat problems of the vagina, vulva, and urinary system. This can be in cream, pill, suppository, or ring form.
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