Is Vaginal Estrogen Safe? What The Science Says.

4 min read

Written by: Elektra Team

Medically reviewed by: Kara Govoni, CNM, MSCP

Like most things related to menopause, hormone therapy (formerly known as hormone replacement therapy, or HRT) isn’t one size fits all. There are multiple types, which can be broken down into categories based on origin, composition, type of manufacturing, and whether they affect the whole body or are active locally.

We’re breaking down what you need to know about the safety of vaginal estrogen therapy.

First things first: what is vaginal estrogen?

Vaginal estrogen is a form of local hormone therapy which, as the name suggests, acts only on a specific part of the body. Topical, also referred to as local hormones are applied directly to the vagina and sometimes the vulva or vestibule (entrance to the vagina) with a low-dose estrogen or occasionally DHEA (a hormone produced naturally in the adrenal glands that’s converted by the body intro estrogen). It works by helping to maintain the structure and function of the vulvar and vaginal tissue as well as the vaginal microbiome.

What is vaginal estrogen used to treat?

Local vaginal estrogen application is an effective treatment for genitourinary syndrome of menopause (GSM), an umbrella term that encompasses various urinary, vulvar, and vaginal symptoms that occur during menopause as a result of decreasing estrogen levels. Local vaginal estrogen has been shown time and time again to be beneficial for:

Vaginal dryness or “vaginal atrophy” in science speak
Pain during intercourse for postmenopausal women
Bladder health by decreasing frequent urinary tract infections (UTIs) and urinary urgency

Is vaginal estrogen safe?

Unlike systemic estrogen, which is absorbed throughout the body to treat things like hot flashes/night sweats, local options don’t carry the same risks since they only work on the tissues you apply them to, and don’t go through the bloodstream elsewhere in the body. This is why vaginal estrogen estrogen is considered safe for most, if not all women.

Unfortunately, there is still an FDA black box warning that warns it can increase the risk of stroke, heart attack, and dementia or affect lab values and that it requires an opposing progestin. Clinicians and the ACOG have been advocating for the removal of this warning for as ACOG as the risks do not apply to local estrogen.

What if I’m a breast cancer survivor or at a higher risk of breast cancer?

Vaginal estrogen is still considered safe for you, although as with any medication, it’s recommended to seek personalized medical advice from your healthcare provider (oncologist and/or gynecologist). The same goes for cervical, ovarian, and endometrial cancer.

Unfortunately, there is still a black box warning that warns it can lead to an increased of stroke, heart attack and dementia or affect lab values and that it requires an opposing progestin. The removal of this warning has been advocated for years by providers as well as ACOG as the risks do not apply to local estrogen.

What if I’ve had a hysterectomy?

Women who have had hysterectomies are excellent candidates for vaginal estradiol, especially if they have had their ovaries removed as well. Estradiol helps to support the production of collagen and elastin in the walls of the vagina, which can be beneficial for structural support after a surgical procedure to remove the uterus.

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What if I’m on systemic hormone therapy?

If you’re on another form of hormone therapy, you can still use local estrogen to treat vaginal symptoms, especially if you’re on a very low dose.

What if I have a history of blood clots?

Since vaginal estradiol works locally, it does not raise blood levels of the hormones and, for this reason, is very safe to use in women with a history of blood clots (DVTs/PEs) or a history of a blood clotting disorder.

What are my options?

There are many, including vaginal estrogen creams, moisturizers, tablets, inserts, and suppositories:

Vaginal tablets: Vagifem, Vuvafem, Yuvafem
Vaginal inserts: Imvexxy
Vaginal creams: Estrace, Premarin, Estradiol from Odela
Vaginal rings: Estring (rings need to be replaced every three months).
Vaginal suppositories: Intrarosa (the only DHEA option)

Key takeaways

Vaginal estrogen is an effective treatment option for vaginal symptoms of menopause and it’s still considered safe for women with a history of or at high risk of breast cancer. Elektra’s board-certified, menopause-trained clinicians can work with you to optimize sexual health and address symptoms impacting quality of life.

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