Vaginal Dryness, Painful Sex and Bladder Changes

What is happening

The tissue of the vulva, vagina, urethra and bladder depends on estrogen to stay thick, moist and elastic. As estrogen falls, that tissue thins and dries out. The vaginal pH rises, the healthy bacteria shift, and infections come easier. The medical name for this is genitourinary syndrome of menopause, or GSM. You may also see it called vulvovaginal atrophy.

At least half of postmenopausal women have it. But very few bring it up. You should.

Signs of GSM

Step one: vaginal moisturizers

Moisturizers are used on a routine schedule, usually two to three times a week, whether or not you are sexually active. They rehydrate the tissue the way a face moisturizer does for skin.

Step two: lubricant for sex

Lubricant is used in the moment to reduce friction. It does not repair the tissue, so most women do best using both a moisturizer and a lubricant.

Step three: prescription treatment

When over-the-counter products are not enough, local prescription therapy treats the cause instead of the symptom. These treatments work right where they are placed, and very little reaches the bloodstream.

• Low-dose vaginal estradiol. Available as a cream, a small tablet, a soft insert, or a ring that stays in place for three months. The most widely used and best studied option.
• Conjugated estrogen vaginal cream. Another FDA-approved estrogen cream.
• Vaginal DHEA (prasterone). A nightly insert that the vaginal cells convert to estrogen and testosterone locally.
• Ospemifene. A daily pill for women who prefer not to use anything vaginally. It acts like estrogen on vaginal tissue only.
• Compounded estriol or testosterone. Custom preparations from a compounding pharmacy. These are not FDA-approved, and we review that with you before prescribing.

Pelvic floor physical therapy is another strong option, especially for pain with sex or leaking, and it pairs well with any of the above.

Low-dose vaginal estrogen is a different product from the hormone therapy you take as a pill, patch or gel. And the warnings on the box were written for the higher-dose systemic products, not for local use. Your prescription and how often to use it are written for you individually.

If you have had breast cancer

This is the question we hear most, and the evidence is more reassuring than many women are told.

• The American College of Obstetricians and Gynecologists (2021) states that non-hormonal options come first, and vaginal estrogen can be considered for women with a history of breast cancer whose symptoms do not respond, as a shared decision with their oncologist.
• A 2023 study of more than 42,000 women with a breast cancer history found no increase in recurrence over five years among those using vaginal estrogen.
• A 2024 study of nearly 50,000 women found no increase in breast cancer deaths among vaginal estrogen users.
• Extra caution applies if you take an aromatase inhibitor (such as anastrozole, letrozole or exemestane), since even small amounts of estrogen work against that medication. Some data show a higher recurrence risk in that group.

If you have a breast cancer history, we walk through the research with you, review the non-hormonal options first, document your decision, and keep your oncologist informed. You do not have to choose between your cancer care and a comfortable, functioning body.

This page is general education, not medical advice, and it does not replace a visit with your own clinician. Your diagnosis, treatment and any medication instructions come from your individual care plan. Reviewed by Jessica Boggs, MSN, APRN, FNP-C, ENP-C.