The Role of Estrogen in Lower Urinary Tract Conditions
Estrogen is responsible not only for reproductive and vulvovaginal function, but ALSO for a healthy urinary tract. We all know that estrogen levels decline in menopause, but they also can be affected by any surgery involving the ovaries, cancer treatment (chemotherapy, hormonal therapy, radiation), hormonal contraception, and during breast feeding. “Genitourinary Syndrome of Menopause” (GSM) is the condition of estrogen deficiency affecting vulvovaginal and urinary tract health. GSM affects over 50% of postmenopausal women and the symptoms can occur many years after then end of menstruation.
Genitourinary Syndrome of Menopause symptoms include:
- Vaginal dryness
- Vaginal itching
- Vaginal discharge
- Painful intercourse
- Urinary urgency, frequency, incontinence
- Recurrent urinary tract infections (UTIs, see Urinary Tract Infection Fact Sheet)
What is the Treatment for Vaginal Dryness?
There are many over-the-counter treatments for vaginal dryness. These involve moisturizers and lubricants (see Vulvar Skin Care). Prescription treatments include a vaginal estrogen cream, or vaginal inserts (tablet, capsule or silicone ring). The estrogen effect can take 6-12 months to become fully established, especially for conditions of the urinary tract. Vulvovaginal symptoms often respond more quickly, often by around 3 months. These treatments work as long as you use the treatment. Your symptoms will return when you stop.
Is Low-dose Vaginal Estrogen Safe?
Low doses of estrogen administered in the vagina can be used to treat vaginal dryness when used as a cream or an insertable tablet, capsule or ring. A small amount of hormone can be absorbed in the bloodstream (especially in “thin” vaginal tissues early after starting treatment), but when used on a regular basis, the level of estrogen in the blood is similar to the level in postmenopausal women who are not using topical low-dose vaginal estrogen. This means that the risk of side effects that can be associated with estrogen taken orally or applied transdermally (patch / gel) for Menopausal Hormone Replacement (MHR) or for contraception / birth control such as blood clots, breast cancer and heart attack is no different compared to someone not using vaginal estrogen. If you have a history or breast cancer or other gynecologic conditions, talk with your doctor about the risks and benefits of vaginal estrogen. Using topical estrogen will not protect against osteoporosis or stop hot flashes caused by menopause.
How Do I Use Vaginal Estrogen?
Cream: A tube of estrogen cream comes with an applicator and detailed instructions on how to use it. You can use the applicator to put the cream into the vagina or use it to measure the dose of cream for fingertip application which usually allows for better distribution of the cream over the vaginal and vulvar skin.
Vaginal tablet / suppository: The product comes in a one-time use cellophane-wrapped plastic applicator for the vagina.
For cream and vaginal tablet / suppositories, typically, you will be instructed to use the product 2-3 x per week. Under some circumstances a once daily “loading dose” is prescribed. Generally speaking, in our urological practice , the loading dose is not recommended in order minimize the risk of side effects. We are usually prescribing vaginal estrogen to provide benefits that come with long-term use (i.e. months – years). Although instructions are often to apply the cream before going to bed, any time of day that is convenient is best (e.g. immediately after showering) – using low-dose vaginal estrogen should easy and become part of your routine… like brushing your teeth! Also, although, it is not advised to use vaginal estrogen immediately prior to vaginal intercourse, it should be noted that there is no significant absorption through the male genitalia under these circumstances.
Ring: The flexible silicone ring is left in the vagina for 3 months. After 3 months, the old ring is removed and a new one put in its place. The ring does not need to be removed during toileting, sex or bathing. The ring cannot be felt by you or your sexual partner. In women who have had a hysterectomy or who have pelvic prolapse, the ring will sometimes fall out. It can be washed and re-inserted. If this occurring repeatedly, another option may need to be considered.
Selected References
https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause
Urology Care Foundation. https://www.urologyhealth.org/healthy-living/care-blog/2024/learn-about-womens-health-and-menopause
Facts on Menopause from Canada’s Experts. The Society of Obstetricians and Gynaecologists of Canada (SOGC). https://www.menopauseandu.ca/
Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023 Sep 1;142(3):660-668. Agrawal P, Singh SM, Able C, Dumas K, et al.
Association of vaginal oestradiol and the rate of breast cancer in Denmark: registry based, case-control study, nested in a nationwide cohort. BMJ Med. 2024 Feb 13;3(1):e000753. Meaidi A, Pourhadi N, Løkkegaard EC, et al.
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