Many women suffering from vaginal dryness find relief by using locally-applied, natural estrogen products. As opposed to oral hormone replacement therapy (HRT), locally-applied bioidentical estrogen can help relieve persistent vaginal dryness without passing large amounts of estrogens throughout the rest of your system.
For most of the products below (with the exception of the Femring), only minimal amounts of estrogen enter your body’s circulation, so they are generally considered a safer option than oral (systemic) hormone therapy.
Of course, it’s important to have proper evaluation and monitoring by your gynecologist to rule out other possible causes for vaginal dryness. But before you go to the doctor, be aware that the first-line approach for vaginal dryness by many conventional doctors involves a prescription for Premarin Vaginal Cream. This product contains conjugated equine estrogens, hormones that are not natural to the human female body. Fortunately, there are many safe biodentical estrogen options for localized treatment of vaginal dryness that are equally if not more effective.
The three main bioidentical estrogens are estrone (E1), estradiol (E2), and estriol (E3). Currently pharmaceutical companies manufacture estradiol-based bioidentical vaginal products, but you need to know which ones to ask for. The charts below list the vaginal dryness treatments along with a few nonhormonal, over-the-counter products that can be used on their own or in addition to bioidentical estrogen or on their own to soothe delicate vaginal tissues.
Treatment options for vaginal dryness
In all my years of practice, I have mainly prescribed only Estriol vaginal cream and/or vitamin E suppositories with great success. I believe the combination of these two options is the safest choice for women, and my patients report significant symptom relief.
That said, this chart is intended to help you understand your options when talking to your healthcare provider about topical bioidentical estrogen for vaginal dryness.
PRESCRIPTION ESTROGEN PRODUCTS* for VAGINAL DRYNESS
| Estriol vaginal cream | |
|---|---|
| Contents | One common form of estriol is a vaginal cream in a pH-balanced base in concentrations of 0.6 mg/g or 0.8 mg/g. |
| Typical use | One gram is applied to the vagina nightly for 7 nights (sometimes 10 nights if there is very severe atrophic vaginitis); then the dosage is reduced to 2–3 times per week for long-term maintenance. A small amount can be used on the vulva and opening to the vagina (introitus). |
| Pros | Estriol vaginal cream is a good first choice, since it is the gentlest option and may be safest where there are breast cancer concerns. This low-potency cream will gradually help tissue both inside and outside the vagina, and can also be applied directly to the vulva and urethral tissue. Results may be seen in just 1–2 weeks. Estriol vaginal cream can also be custom-compounded to include a small amount of testosterone. Many women respond best to this combination. |
| Cons | You have to remember to use it to maintain results, and it’s not intended as a personal lubricant for sexual intercourse. |
| Availability | Estriol vaginal cream is custom-compounded only by special prescription order from your provider. Women’s International Pharmacy is a great source and offers very affordable pricing, since insurance companies do not always cover this product. |
| Vagifem vaginal inserts | |
|---|---|
| Contents | Vagifem estradiol vaginal tablets are small, white, film-coated tablets containing 25.8 mcg of 17ß-estradiol hemihydrate, equivalent to 25 mcg of estradiol. They are provided in boxes of 8 or 18 tabs with an applicator. |
| Typical use | One insert is used in the vagina each night for 7–14 nights, and then reduced to one insert two nights per week for maintenance. |
| Pros | This product is not messy, is easily inserted, and is effective for rejuvenating the vaginal tissues. In time, the vulva should also respond. |
| Cons | Vagifem may not work as quickly as creams do to the external tissues of the vulva and outer portion of the vaginal opening. You have to remember to use it regularly to maintain results. It is not intended for use as a lubricant prior to sexual intercourse. |
| Availability | This brand name product is available by prescription through regular pharmacies. |
| Estrace vaginal cream | |
|---|---|
| Contents | Estradiol vaginal cream, USP, 0.01% |
| Typical use | One gram is applied to the vagina nightly for 7 nights (sometimes 10 nights for very severe atrophic vaginitis), then reduced to 1–3 times per week for long-term maintenance. Massaging small amounts to the vulva and inner labia can also be very helpful, though this may not be mentioned on the prescription or insert directions. |
| Pros | Results are seen in just 1–2 weeks, but it may take longer for peak results. This product is very good to use prior to trying the Vagifem inserts or 90-day rings, since it can also be applied to the vulva. |
| Cons | Some complain that it feels messy, especially that first week of nightly use. You have to remember to use it to maintain results, and it isn’t intended for use just prior to sex. Some women report burning from the base ingredient used in this product. (A compounding pharmacy can duplicate this cream in a more hypoallergenic, pH-balanced base for improved comfort.) |
| Availability | This brand name product is available by prescription through regular pharmacies. |
| Estring 90-day vaginal ring | |
|---|---|
| Contents | Estring (estradiol vaginal ring) is a silicone-based ring containing 2 mg estradiol. Estring releases estradiol (approximately 7.5 mcg/24 hours) in a consistent stable manner over 90 days. |
| Typical use | One ring is inserted into the vagina and remains there for 90 days. After 90 days, it is removed and replaced with new ring. |
| Pros | This device delivers a nice low dose of estradiol for 90 days of use without any adjustments needed. It can help provide support to the vaginal walls in women whose pelvic floor muscles are weak. |
| Cons | It does require some degree of dexterity to insert and remove. Some women are not comfortable with insertion or removal and choose to see their practitioner every 90 days to have it done for them. While some women find an Estring comfortable, others don’t like the feel of wearing this or any ring-like device. The use of Estrace vaginal cream for one month prior to initial insertion of an Estring can improve comfort level. |
| Availability | This brand name product is available by prescription through regular pharmacies. |
| Femring 90-day vaginal ring | |
|---|---|
| Contents | Femring (estradiol acetate vaginal ring) is a soft, flexible silicone-based ring containing time-released estradiol acetate. Two strengths are available for Femring: 0.05 mg/day and 0.10 mg/day, the latter usually requiring special order. Both strengths release estradiol acetate every day for 3 months for system-wide estrogen replacement therapy (not just vaginal treatment). |
| Typical use | One ring is placed into the vagina for 90 days and then removed and replaced as needed. |
| Pros | The Femring is softer and more pliable than the Estring, and thus easier to insert and remove for some women. It can provide support to the vaginal walls where pelvic floor muscles are weakened. |
| Cons | Because it requires insertion and removal, women who aren’t comfortable doing so have to visit their practitioners every 90 days to have it done for them. The feeling of wearing a ring-like device can also be uncomfortable for some women. For women with a history of endometriosis, the Femring may cause flare-ups of endometriosis discomfort because of the strong estrogen delivery directly within the pelvis. |
| Note | The Femring product supplies estradiol to the vagina and the general circulation at a potency similar to an estradiol patch for treatment of both vasomotor (e.g., hot flashes) and vaginal symptoms. It is not a low-dose treatment localized to the vagina tissues only, but a form of systemic (system-wide) hormone replacement therapy. A prescription-strength progesterone product, such as Prometrium, must be used in conjunction with this product. |
| Availability | This brand name product is available by prescription through regular pharmacies. |
| * Note: Since pharmaceutical companies’ brand name products are all FDA-approved and regulated, they come with the same intimidating warnings that the FDA insists go on all estrogen products. There is growing evidence that suggests that delivery of low-dose estradiol either percutaneously (“across the skin”) or transvaginally (through the walls of the vaginal tissue) does not increase the risk for blood clotting to the degree that oral estrogen does. Yet the warning labels are still required on all estrogen products. | |
Non-hormonal products for vaginal dryness
There are several nonhormonal products available that women with vaginal dryness may find soothing. Over-the-counter products for vaginal dryness can be used intermittently as needed, in-between or in addition to prescription bioidentical estrogen. Some women seem to have tried everything without success, and for them, or for the breast cancer patient who is too fearful of trying vaginal estrogen, we suggest a manual massage with some type of lubricant.
Remember to check the product labels to be sure the one you choose contains no harsh chemical ingredients, petrochemicals, endocrine disruptors, or irritants to which you may have a sensitivity, such as alcohol, parabens, or propylene glycol. The chart below lists several options.
We find women’s responses to vaginal bioidentical estrogen and other products vary widely so they may need to try several before their vaginal dryness resolves. Whether you have mild, severe, occasional or chronic vaginal dryness, it’s good to know your options.
While some women are pleased to find that improving their nutrition and using a personal lubricant cures their vaginal dryness, others may need stronger, long-term treatments. We encourage you to try the above options. If one or two do not resolve your vaginal dryness, stay open to trying another one, or shift to a combination approach until you get relief.
1 Scarabin, P., et al. Effects of oral and transdermal estrogen/progesterone regimens on blood coagulation and fibrinolysis in postmenopausal women. A randomized controlled trial. Arterioscler. Thromb. Vasc. Biol., 17 (11), 3071–3078. URL: https://atvb.ahajournals.org/cgi/content/full/17/11/3071 (accessed 06.25.2007).
2 Giardinelli, M. 1952. Effect of alpha–tocopherol in some disorders of the menopause and in atrophy of the vaginal mucosa. Minerva Ginecol., 4, 579–587.
Further reading
This webpage offers instructions and a diagrammatic representation of manual vaginal massage. Some women find success with this method even when all other options have failed, and massage may also be helpful for a breast cancer patient who is fearful of trying vaginal estrogen. URL: https://www.a-womans-touch.com/article/40/157/Vaginal_Penetration_Problems.html (accessed 07.09.2007).
