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By Dr. Alaina Garbens, MD, PhD, FRCSC, fellowship-trained urologist and founder of Élevé
There is a conversation I have with women regularly. We are discussing vaginal dryness, pain with sex, burning or urinary tract infections that keep coming back. I mention vaginal estrogen, and the response is immediate: “I can’t take hormones.”
Sometimes her medical history calls for a more detailed conversation. But often she means, “I have heard hormone therapy can be dangerous, so I assume vaginal estrogen is the same thing.” It isn’t. And that distinction can change the conversation.
Systemic menopausal hormone therapy circulates throughout the body. It may be prescribed for hot flashes, night sweats and other appropriate indications. Low-dose vaginal estrogen primarily treats local tissues affected by estrogen loss. It is not intended to treat hot flashes.
When approved low-dose products are used at the recommended dose and frequency, absorption into the bloodstream is minimal. Estradiol levels usually remain within the postmenopausal range during ongoing treatment. Absorption varies by product and may be temporarily higher when treatment begins. Local does not mean zero absorption, but the exposure is different from systemic therapy and almost always negligible.
I am referring to Health Canada–approved products. Compounded preparations can vary in hormone content and absorption, and do not undergo the same premarket review for safety, effectiveness and quality. I do not routinely recommend compounded vaginal estrogen when a suitable approved product is available. We cannot assume the evidence for an approved product applies equally to a compounded preparation.
Menopause does not stop at hot flashes. Estrogen-sensitive tissues include the vulva, the external genitals, the vagina, urethra and bladder. As estrogen declines, vaginal tissue can become thinner and less elastic. Vaginal acidity and the balance of bacteria can also change.
Some women experience dryness, irritation or pain with sex. Others notice urgency, frequency, burning or recurrent UTIs. This collection of changes is called genitourinary syndrome of menopause, or GSM.
The older terms “vaginal atrophy” or “senile vagina” were not only offensive, but made this sound like a vaginal only problem. As a urologist, that distinction matters to me.
Low-dose vaginal estrogen is a well-established treatment for GSM. The 2025 AUA/SUFU/AUGS guideline recommends offering it for vaginal dryness, discomfort and pain with sex, while acknowledging limitations in the evidence. These limitations are mainly due to the lack of high quality studies in the literature. More research is desperately needed!
You may also hear about vaginal moisturizers and lubricants. And while they can help with short term symptom relief, they do not treat the underlying cause and I usually do not recommend them. Vaginal estrogen is powerful in preventing recurrent UTIs (rUTIs) in postmenopausal women. This is lifesaving care and every post menopausal woman with recurrent UTIs should be offered this.
Do You Need Progesterone Too?
Vaginal estrogen DOES NOT need progesterone. Systemic estrogen can stimulate the uterine lining, which is why women with a uterus need to be prescribed a progestogen alongside systemic estrogen. Standard vaginal estrogen does not require progesterone when used in prescribed doses as it does not stimulate the uterine lining to grow and thicken.
Remember, any vaginal bleeding after menopause should be evaluated.
For women who have a history of breast cancer, taking vaginal estrogen is safe. Remember, that vaginal estrogen when used correctly does not increase the blood levels of estrogen above that of a post menopausal woman. A 2026 review looked at all studies published to date and found no demonstrated overall increase in breast cancer recurrence or mortality with vaginal estrogen.
Local vaginal estrogen comes as creams, tablets or inserts, and low-dose vaginal rings. Other options include vaginal DHEA (another amazing option) and oral ospemifene. They have different mechanisms and precautions. Choice depends on cost, symptoms, medical history, preferences and ease of use. Improvement take about 2-3 months. Treatment is often ongoing because symptoms can return when you stop taking the medication.
Burning, urgency or pain with sex may involve GSM, but estrogen loss may not explain everything. Pelvic-floor dysfunction, vulvar skin conditions, infection and other causes need consideration. I prefer a clinical assessment before a treatment menu.
The goal is to understand what has changed, what is contributing to your symptoms and which options make sense for you. That includes the option of no treatment.
For years, many women have understood this as a binary choice: hormones or no hormones. Clinically, it is more specific than that. Sometimes the difference between declining a treatment and considering it is finally understanding what the medication actually is.
This article provides general information only and should not be used as medical advice. This article does not replace an individual clinical assessment or directions from your doctor or care provider.
