Hi friends! You’ve probably heard of hormone replacement therapy in menopause, but have you ever heard of vaginal estrogen? Vaginal estrogen is often deemed to be a safer option for some individuals that systemic estrogen (which is often taken as a pill by mouth). Vaginal estrogen comes in several forms and can often help improve pelvic floor muscle function and associated symptoms. Let’s talk about why estrogen is important, what it can do, and treatment options.
Keep in mind that this blog is not intended to serve as individual medical advice. Consult your healthcare provider before making any medication changes. The information in this blog is for educational purposes and may help with conversations with your providers.
Let’s start with what estrogen does and why it’s important. Estrogen is a hormone. While it is present in both males and females, it is found in higher concentrations in females. As females age and enter the perimenopausal and menopausal states, the amount of estrogen circulating in the blood often decreases. Estrogen plays a big role in female sexual function and urinary function. This is in part because the female genitals, bladder, and urethra (where pee exits the body) have high numbers of estrogen receptors (Khanjani, 2019).
As we age and estrogen levels decline, we can see several side effects. Blood flow can be reduced in the tissues around the genitals which often causes the tissue of the vulva become thin and fragile (Khanjani, 2019; Krychman, 2011). The thin tissue can become painful and even bleed. Vaginal dryness is another common symptom and is reported by 1 in 4 females (Khanjani, 2019; Krychman, 2011). Changes in estrogen can impact the vaginal pH which makes the vagina more susceptible to infection (Khanjani, 2019). Higher levels of estrogen help the tissues to stay strong, lubricated, and free from infections.
Along with the vulva and genitals, the urinary system is often impacted by lower estrogen levels. This can cause symptoms of needing to pee frequently, strong sudden urges to pee, getting up at night to pee, pain with peeing, and urinary incontinence (Khanjani, 2019). The tissue thinning caused by decreased estrogen can lead to frequent urinary tract infections (UTIs) in 20% of postmenopausal women (Khanjani, 2019). Higher levels of estrogen can help prevent all of these urinary symptoms as long as the pelvic floor muscles are functioning well.
So what are the options if estrogen is low? You can discuss several options with your healthcare provider.
Trying to replace estrogen is one option. One of the concerns with estrogen is the potential for increasing estrogen throughout the body which can cause side effects like an increased risk of cancer, especially endometrial cancer. However, many studies showing the increased risk looked at systemic or oral estrogen replacement and not at vaginal estrogen. The increased risk may be because the systemic estrogen is absorbed by the digestive tract and release into the bloodstream, meaning it impacts the entire body. The topical or vaginal estrogen primarily impacts the tissue to which it is applied. Low dose topical or vaginal estrogen therapies cause low to negligible levels of estrogen in the blood stream (Santeen, 2020).
The British Menopause Society recommends topical or vaginal estrogen to as treatment if the symptoms are primarily vaginal or urinary (Khanjani, 2019). This can come in the form of creams, tablets, and rings (Khanjani, 2019). In some studies, creams showed the highest rise in blood estrogen levels compared with tablets, rings, and inserts (Crandall, 2020). It is recommended for most individuals to use systemic or oral hormone replacement therapy if vasomotor symptoms or osteoporosis are present (Khanjani, 2019).
Applying estrogen vaginally, has demonstrated numerous benefits including improving vaginal pH and vaginal flora (Fernandes, 2016). It can improve the ability of the pelvic floor muscles to work well and decrease symptoms of dysfunction. Estrogen can also improve symptoms of urinary frequency, urgency, nighttime peeing, incontinence, and frequent UTIs (Rahn, 2014).
Estrogen use may help improve comfort and ease of pessary use (Dessie, 2016). Pessaries are medical devices that can provide support to the vaginal walls to decrease symptoms of pelvic organ prolapse. To learn more about pessaries, read our blog here.
What if vaginal estrogen is not an option? You may not want to use vaginal estrogen, or your provider may decide that this is not a good treatment option for you. There are other options to help alleviate symptoms. Vaginal lubricants and moisturizers are god option for women who are not suitable to take estrogen (Khanjani, 2019; Rahn, 2014).
Lubricants provide short-term relief for dryness with activities like intercourse (Khanjani, 2019; Krychman, 2011). However, not all lubricants are created equally, read our blog here to learn more about which lubricants are best. Moisturizers tend to have a longer-lasting effect on symptoms—imagine it being a special lotion for the vagina (Khanjani, 2019; Krychman, 2011).
Lasers may be another effective treatment option, but studies have been limited (Khanjani, 2019).
Along with all of these treatment options, pelvic floor therapy can be a great help to any sexual or urinary symptoms. The great news about therapy is that it can be done alongside some of these other treatment options to help you achieve the best outcomes and live your best life. To find a pelvic floor physical or occupational therapist go to www.mypfm.com/find-a-pt.
Ready to learn more about pelvic health? Here are some helpful resources:
Watch Netflix for Your Pelvic Floor at Pelvic Flicks
Watch our YouTube playlist on Pelvic Physical Therapy
Learn more about the pelvic floor muscles with our book: My Pelvic Floor Muscles The Basics
Order myPelvic Bra perineal support
Sign up for our email newsletter!
Visit our Instagram page for more on pelvic health.
For providers, check out myPFM Academy to learn more so you can better help your clients. With two membership options, you have access to courses, a growing library of patient handouts, hundreds of custom sharable images and infographics, and multilingual resources. At myPFM Academy you’ll find courses like:
Birth Control, Hormones, and your Vulva with Dr. Jill Krapf, MD, Med, FACOG
Postpartum, Hormones, and the Pelvic Floor with Dr. Jill Krapf, MD, Med, FACOG
Pregnancy, Hormones, and the Pelvic Floor with Dr. Jill Krapf, MD, Med, FACOG
Hormones, Menopause, and Pelvic Health with Dr. Jill Krapf, MD, Med, FACOG
Hormone Therapy-The Who, When, Why, and How with Dr. Sarah Boyles, MD, MPH, FACOG, FPMRS
Written by Emily Reul, PT, DPT
References
Crandall CJ, Diamant A, Santoro N. Safety of vaginal estrogens: a systemic review. Menopause. 27(3):339-360.
Dessie SG, Armstrong K, Modest AM, Hacker MR, Hota LS. Effect of vaginal estrogen on pessary use. Int Urogynecol J. 2016;27:1423-1429.
Fernandes T, Costa-Paiva LH, Pedro AO, Baccaro FC, Pinto-Neto AM. Efficacy of vaginally applied estrogen, testosterone, or polyacrylic acid on vaginal atrophy: a randomized controlled trial. Menopause. 2016;23(7):792-98.
Khanjani S, Panay N. Vaginal estrogen deficiency. The Obstetrician and Gynaecologist. 2019;21:37-42.
Krychamn ML. Vaginal estrogens from the treatment of dyspareunia. J Sex Med. 2011;8:666-674.
Rahn DD et al. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol. 2014;124(6):1147-1156.
Santen RJ, Mirkin S, Bernick B, Constantine GD. Systemic estradiol levels with low-dose vaginal estrogens. Menopause. 2020;27(3):361-370.