By Rebecca Bowers

During menopause, estrogen deficiency can result in thinning of the vaginal epithelium. Women may experience vaginal dryness, itching, dyspareunia, and urinary symptoms. Although more than 33% of women 57-69 years of age report symptoms of vaginal dryness, more than half don’t report such conditions to their healthcare providers, and far fewer take advantage of proven therapies such as vaginal estrogen tablets, creams, and rings.1

Since the 2002 publication of initial findings from the Women’s Health Initiative (WHI), menopausal hormone therapy use has declined steeply among U.S. women as a result of anxiety and confusion regarding its safety. Although research has indicated that vaginal estrogen is a safe and effective treatment for genitourinary symptoms of menopause, such therapy is not prescribed as often as it could be.2

Results of a new study underline the safety of vaginal estrogen as a treatment for genitourinary syndrome of menopause.3 For the study, investigators followed postmenopausal women from the Nurses’ Health Study (1982-2012) who did not currently use systemic hormone therapy at the beginning of the study or during follow-up. They found that vaginal estrogen was not associated with an increased risk of cardiovascular disease, cancer, or hip fractures. Researchers observed no statistically significant increase in any health outcome risk with the use of vaginal estrogen.3

Genitourinary syndrome of menopause is a prevalent condition that impairs sexuality and quality of life, and that tends to progress without treatment, says Andrew Kaunitz, MD, interim chair of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine-Jacksonville and medical director of UF Health Women’s Specialists – Emerson. The new study’s data offers “reassuring information” regarding the long-term safety of vaginal estrogen, he states.

Neither the American College of Obstetricians and Gynecologists nor the North American Menopause Society suggest any time limits regarding duration of vaginal estrogen use, notes Kaunitz.4 Both organizations suggest that in women with an intact uterus using vaginal estrogen, concomitant use of progestin is not appropriate, states Kaunitz.

Over-the-counter vaginal lubricants and moisturizers often are used as initial treatments for women with symptoms of genitourinary syndrome of menopause, says JoAnn Pinkerton, MD, NCMP, executive director of the North American Menopause Society. “Persistent symptoms often need therapies such as local vaginal estrogen, intravaginal dehydroepiandrosterone, or oral ospemifene,” said Pinkerton in a press statement. “This study adds to a growing body of data showing the long-term efficacy and safety of low-dose vaginal estrogen, which works primarily locally with minimal systemic absorption.”

Two low-dose estradiol creams, a vaginal ring, and a tablet are available in the United States for treatment of genitourinary syndrome of menopause. Creams may be applied not only intravaginally, but digitally to the vestibular tissues—introitus as well.

Data indicate that low-dose tablets, the vaginal ring, and creams have comparable efficacy in treating vulvovaginal symptoms.5 Research suggests that vaginal estradiol may reduce the risk of recurrent urinary tract infections and overactive bladder symptoms in menopausal women.6 The low-dose vaginal ring is approved to treat urinary urgency and dysuria.7 In a systematic review, researchers evaluated current available evidence about the effectiveness and safety of vaginal estrogen products to treat genitourinary syndrome of menopause. The researchers concluded that commercially available vaginal estrogen therapies were effective and safe first-line therapies for moderate-to-severe genitourinary syndrome of menopause.8

Be sure to ask perimenopausal and postmenopausal women about any vulvovaginal or urinary symptoms at their comprehensive visits, the North American Menopause Society recommends. The society’s free MenoPro mobile app helps patients and clinicians with shared decision making for managing menopausal symptoms. (More information on the app is available at


  1. Waetjen LE, Crawford SL, Chang PY, et al. Factors associated with developing vaginal dryness symptoms in women transitioning through menopause: A longitudinal study. Menopause 2018;25:1094-1104.
  2. Crandall CJ, Hovey KM, Andrews CA, et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. Menopause 2017;25:11-20.
  3. Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Vaginal estrogen use and chronic disease risk in the Nurses’ Health Study. Menopause 2018; doi: 10.1097/GME.0000000000001284. [Epub ahead of print].
  4. Kaunitz AM, Manson JE. Management of menopausal symptoms. Obstet Gynecol 2015;126:859-876.
  5. Rahn DD, Carberry C, Sanses TV, et al. Vaginal estrogen for genitourinary syndrome of menopause: A systematic review. Obstet Gynecol 2014;124:1147-1156.
  6. [No authors listed]. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013;20:888-902.
  7. Shifren JL, Gass ML; NAMS Recommendations for Clinical Care of Midlife Women Working Group. The North American Menopause Society recommendations for clinical care of midlife women. Menopause 2014;21:1038-1062.
  8. Biehl C, Plotsker O, Mirkin S. A systematic review of the efficacy and safety of vaginal estrogen products for the treatment of genitourinary syndrome of menopause. Menopause 2018; doi: 10.1097/GME.0000000000001221. [Epub ahead of print].