Women’s Health Insights
Why This Matters
There’s a lot of confusing and outdated information out there about women’s hormones and sexual health. Too many women are told their symptoms are “normal” and something to just live with.
I don’t agree with that.
Women deserve to feel comfortable in their bodies and to enjoy intimacy at every stage of life—not just during their reproductive years. Hormonal changes don’t mean your needs go away, and your care shouldn’t either.
I share these insights to bring clarity (and a little honesty) to topics that deserve more attention—so you can better understand your body and feel more like yourself again.
Why More Women Should Be Using Vaginal Estrogen
Vaginal estrogen is one of the most effective—and most underused—treatments in women’s health.
So many women are told that vaginal dryness, discomfort with sex, irritation, or recurrent urinary tract infections are just a “normal” part of aging, postpartum recovery, or hormonal changes. While these symptoms are common, they are not something you have to simply live with—and in many cases, they are very treatable.
Vaginal estrogen is a low-dose, localized form of estrogen that is applied directly to the vaginal tissue, usually as a cream, tablet, or ring. Estrogen plays a critical role in maintaining the health of the vaginal and vulvar tissue. It helps keep the tissue thick, elastic, well-lubricated, and resilient. It also supports the natural vaginal environment by maintaining an acidic pH, which helps protect against irritation, infection, and imbalance.
When estrogen levels drop, the vaginal tissue becomes thinner, drier, and more sensitive. The pH becomes less acidic, which can make the vagina more susceptible to irritation, infections, and changes in the normal flora. This is when symptoms like dryness, burning, pain with sex, and recurrent UTIs can start to appear.
Most people associate this with menopause—and it absolutely is common then—but there are several other times in a woman’s life when ovarian estrogen production is significantly reduced or essentially “turned down.”
This includes:
Postpartum and breastfeeding, when prolactin suppresses ovarian estrogen production
Use of certain hormonal contraceptives, particularly birth control pills, which suppress ovulation and therefore natural estrogen production
Perimenopause and menopause, when ovarian hormone production becomes inconsistent or declines
In all of these states, the vaginal tissue is experiencing a relative estrogen deficiency—even if blood hormone levels are considered “normal” for that stage of life.
This is why vaginal estrogen can be helpful not just for menopausal women, but also for younger women who are postpartum, breastfeeding, or using hormonal contraception and experiencing symptoms.
Vaginal estrogen can significantly improve:
dryness
pain with sex
irritation or burning
recurrent urinary tract infections
urinary urgency or frequency
Many women also notice an overall improvement in comfort and a return to feeling more pleasure and sensation during sex.
There is often concern about safety, but vaginal estrogen is very different from systemic hormone therapy. It is a low-dose, localized treatment with minimal absorption into the bloodstream and is considered very safe for most women, even with long-term use. In many cases, even women who are not candidates for systemic estrogen can still use vaginal estrogen, depending on their individual history. Vaginal estrogen is safe for everyone!
One of the biggest reasons this treatment is underused is that women’s sexual health has historically been understudied and often minimized. Many providers don’t routinely ask about these symptoms, and many women don’t realize that what they’re experiencing is both common and treatable.
The bottom line is this: if you’re experiencing dryness, discomfort, or changes that don’t feel like before, it’s worth talking about. These symptoms are not something you have to accept as inevitable.
Vaginal estrogen is a simple, effective, and often life-changing treatment that deserves to be talked about more.
If you’re wondering whether it might be a good fit for you, I’d be happy to help you explore your options.
Hormone Therapy: The Story We Got Wrong
If you’ve ever heard that “hormones are dangerous,” you’re not alone.
For years, women have been told to fear hormone therapy—especially estrogen. Many patients come in already hesitant, sometimes even apologetic for wanting relief from symptoms that are significantly affecting their quality of life.
That fear didn’t come out of nowhere, but the full story is nuanced.
Before 2002: Estrogen Was Widely Used
Before the early 2000s, hormone therapy (HRT) was commonly prescribed.
Women were often started on estrogen at menopause
Many stayed on it for years or decades
It was even promoted as a way to preserve youth and prevent chronic disease
At the same time, we lacked large, high-quality randomized trials to fully understand long-term risks.
2002: The WHI Study Changes Everything
The Women’s Health Initiative (WHI) was a large, randomized controlled trial designed to evaluate whether hormone therapy could prevent chronic disease in postmenopausal women.
Initial results reported increased risks of:
Breast cancer
Blood clots
Stroke
Heart disease
Following publication:
Prescriptions dropped dramatically
Many patients stopped hormones abruptly
Clinicians became more hesitant to prescribe
Hormone therapy quickly shifted from routine to avoided.
What We Later Learned
Over time, a more nuanced understanding of the WHI emerged.
The population studied was older
Average age was 63
Many participants were more than 10 years past menopause
Baseline cardiovascular risk was already higher due to age
This differs significantly from women in their 40s and 50s entering menopause.
The type of hormones matters
The WHI used:
Oral conjugated equine estrogen (aka Premarin aka estrogen from pregnant horse urine!)
Medroxyprogesterone acetate (a synthetic progestin)
These differ from commonly used modern “bioidentical” options such as:
Transdermal estradiol (patch or gel)
Micronized progesterone
Different formulations have different risk profiles.
Route of delivery matters
Oral estrogen passes through the liver first, increasing clotting factors
This contributes to higher risks of blood clots and stroke
Transdermal estrogen bypasses the liver and is associated with lower clot risk.
Timing matters
We now recognize the “timing hypothesis”:
Starting hormone therapy closer to menopause appears safer
It may even have cardiovascular benefits
Starting therapy later (more than 10 years after menopause) may increase risk
The Impact of the WHI
After the WHI, hormone therapy use declined sharply.
Many clinicians stopped prescribing it altogether, and many women were left without effective treatment for:
Hot flashes and night sweats
Sleep disruption
Mood changes
Vaginal dryness and pain with sex
Bone loss and fracture risk
A generation of women were often told to tolerate symptoms rather than treat them.
What We Know Now
Over the past two decades, further research and reanalysis of the WHI have clarified the risks and benefits of hormone therapy.
For healthy women under 60 or within 10 years of menopause:
Hormone therapy is considered safe and effective for managing menopausal symptoms, including:
Vasomotor symptoms (hot flashes, night sweats)
Sleep disturbances
Mood changes
Genitourinary symptoms
Transdermal estrogen is often preferred
Lower risk of blood clots
Less impact on liver metabolism
Micronized progesterone is commonly used
More physiologic than older synthetic progestins
May have a more favorable safety profile
Vaginal estrogen is very low risk
Minimal systemic absorption
Appropriate for many women, including those who cannot use systemic estrogen
Should Everyone Use Hormone Therapy?
Not necessarily. There are still absolute contraindications to hormone replacement therapy, but they are few.
Hormone therapy is not appropriate for every patient, and it is not a one-size-fits-all treatment.
However, it also should not be avoided due to outdated or oversimplified interpretations of risk.
Hormone therapy is a tool that can be used thoughtfully and individually based on:
Symptoms
Medical history
Risk factors
Personal goals
A More Balanced Approach
The history of hormone therapy reflects a broader pattern in women’s health, where care has often shifted between overuse and underuse.
Current practice is moving toward a more individualized, evidence-based approach that considers both risks and quality of life.
How I Approach Hormone Therapy
When discussing hormone therapy, the focus is not simply on whether it is “safe” or “dangerous.”
The goal is to understand:
What symptoms are affecting quality of life
What individual risk factors are present
How to use the safest and most appropriate formulations
The emphasis is on tailoring treatment to the individual while minimizing risk and maximizing benefit.
Final Thoughts
Hormone therapy did not suddenly become dangerous in 2002.
Our understanding of the data evolved.
With more nuanced evidence and improved formulations, hormone therapy can now be used in a more thoughtful, individualized, and effective way.