Despite the significant impact it has on women, menopause, which is the biological process marking the end of a woman’s menstrual cycle, continues to be undertreated and highly misunderstood.
The same can be said for perimenopause, or the transitional period that leads up to menopause when women’s estrogen levels start declining. For some women, perimenopause can begin as early as their 30s, typically seen in women ages 40 to 44. Menopause can start in women’s 40s or 50s, with the average age being 51 in the United States.
Both menopause and perimenopause can continue for several years each. The average length of perimenopause is around four years, while menopause typically lasts about seven years. However, in some cases, menopause can last for up to 14 years, depending on different factors, including the age it began, ethnicity, and smoking. Menopause is typically not officially diagnosed until a woman has gone without a period for 12 months.
But about 30% of women never seek information about menopause before experiencing it themselves, according to the 2021 State of Menopause Study, which included 1,039 women in the U.S. ages 40 to 64. Additionally, 45% of women don’t understand the difference between menopause and perimenopause. This underscores the need for more awareness and education — especially considering how menopause and perimenopause can affect women’s quality of life.
An estimated 85% of women going through menopause will experience a range of symptoms, including night sweats, hot flashes, burning, vaginal itching, dryness (also known as vaginal atrophy), mood changes, painful sex, and urinary tract infections.
However, according to experts, there is an effective treatment for several symptoms that haven’t received as much attention as it should — vaginal estrogen. So, why aren’t more women using it?
Urologist: “Vaginal estrogen is the holy grail”
Experts are finally speaking out about menopause and perimenopause, as well as effective treatments for these symptoms — specifically, Los Angeles urologist Dr. Ashley Winter, who offered her insight via X, formerly known as Twitter, about topical estrogen and how it can help treat a plethora of menopause-related symptoms. Now, more experts have weighed in with similar sentiments.
“Vaginal estrogen is the holy grail for managing postmenopausal vulva or vaginal symptoms and recurrent UTIs,” said Dr. Fenwa Milhouse, a Chicago urologist. “It is recommended by the American Urological Association for postmenopausal women with three or more UTIs per year due to its proven benefit in reducing the incidence of UTIs.”
But that isn’t where the benefits stop. “So many postmenopausal women suffer from burning, painful, itching, or irritating vulvovaginal symptoms and/or painful sex, and vaginal estrogen helps with this too,” said Milhouse. “Every single postmenopausal woman with UTIs, painful sex or vulva or vaginal symptoms should be recommended to use vaginal estrogen.”
Dr. Anika Ackerman, a New Jersey urologist, agrees. “I believe that peri- and postmenopausal women need vaginal estrogen. From a urologic perspective, which is my specialty, lack of estrogen leads to UTIs, urinary urgency, frequency, incontinence, dryness, and painful intercourse, and [while] I believe hormone replacement therapy is safe, vaginal estrogen is even safer [as] it is not absorbed much systematically and has an incredible effect locally on the vaginal tissues.”
Vaginal estrogen helps lower the pH of the vagina to prevent infections, as well as thicken the mucus membranes in the vagina and increase lubrication to improve dryness, itching, and discomfort, said Ackerman.
Vaginal estrogen — “Extremely safe”
Even though most experts agree topical estrogen is safe, there is still a widespread misconception that vaginal estrogen leads to increased health problems, including blood clots and cancer. “There should be no concern about using vaginal estrogen,” said Ackerman. “It does not increase cancer or clotting risk [and] is necessary for most aging women.”
Newport Beach, California, pelvic surgeon and urologist Dr. Rena Malik, who specializes in sexual health, agreed and said, “Vaginal estrogen has so many benefits, and the best part is it’s extremely safe.”
“There has never been a reported uterine, breast or ovarian cancer related to vaginal estrogen use, though sadly there is a lot of misinformation and misinterpretation of the data when it comes to women’s hormone management, and when a doctor is not comfortable explaining the treatment they often don’t prescribe it,” added Malik.
When prescribed, vaginal estrogen is typically offered in three different formulations: a suppository, a ring, or a cream.
“The cream and suppository is dosed once daily for two weeks and then two to three times a week after that forever,” Malik said. “The ring is inserted intravaginally and replaced once every three months.”
Milhouse highly recommends vaginal estrogen for her patients, including those with breast cancer or a history of it. “I’ve seen countless of my own patients’ lives changed after instituting vaginal estrogen,” she said. “Unfortunately, it is underutilized by both prescribers and patients thanks to the demonization of estrogen hormone therapy. Estrogen risks have been overemphasized and its benefits minimized or ignored.”
Los Angeles urologist Dr. Kevin Chu echoes statements from his peers. “There is some stigma and concerns around hormone replacement therapies, but studies have shown the mediation is very safe, and the benefits are significant. It can stop recurrent UTIs, improve vaginal health and decrease pain with sex.”
Experts recommend that if you’re experiencing symptoms associated with perimenopause, menopause, or post-menopause, including painful sex, recurring UTIs, or vaginal dryness, experts recommend asking your doctor about vaginal estrogen, which could help.