Topical Therapy for GSM

After menopause, many women suffer from symptoms related to the thinning of the lining of the vaginal canal and the vulvar area (the tissue outside of the vaginal opening). This can lead to vaginal dryness, pain with intercourse, and scar tissue or adhesions forming in the labial area. Unlike other symptoms of menopause, which may subside over time, GSM tends to progress if left untreated.

Despite the fact that GSM affects over 50% of women after menopause, it goes unrecognized and untreated the large majority of the time. The largest survey of US women, called REVIVE (Real Women’s Views of Treatment Options for Menopausal Vaginal Changes), included over three thousand women with GSM. Shockingly, only 7% reported that their healthcare provider had initiated a conversation about GSM, and yet it was a condition that clearly had profound impact on their quality of life. 85% of women said they experienced loss of intimacy, and 59% indicated that it detracted from their enjoyment of sex (1). GSM is an important medical problem that deserves attention and treatment. In many cases, it can be treated with moisturizers or estrogen cream, which work locally to improve the quality of the tissue. The Mona Lisa Touch laser therapy also works very well, if topical therapy is ineffective, or contraindicated.

What works?

When the problem is lack of estrogen, replacing the estrogen in the vaginal area with a low dose cream, tablet, or ring is very effective at restoring the cell thickness and normal acidic vaginal pH. In fact, applying topical estrogen directly to the tissue can be more effective for relieving symptoms of GSM than systemic hormonal replacement therapy. Topical estrogen is extremely effective in reversing the underlying conditions that are creating the problem.

The other great benefit of vaginal estrogen therapy is that it can help with urinary symptoms as well. Because it improves the local circulation, as well as collagen, some women experience an improvement in incontinence due to the extra support around the urethra and bladder neck. It has also been shown to promote relaxation of the bladder smooth muscle, which helps with overactive bladder symptoms. For women who suffer from recurrent urinary tract infections, topical estrogen can restore the healthy microbiome to the vagina, which prevents UTI-causing bacteria from being able to reside near the vagina.

Other non-estrogen, hormonal based therapies include DHEA (dehydroepiandrosterone) and Osphemipene (a selective estrogen receptor modulator). These are FDA approved for postmenopausal women with dyspareunia (pain with intercourse) and vulvovaginal atrophy caused by GSM. For DHEA, two high quality studies showed significant improvement versus placebo in vaginal cell maturation, pH and dyspareunia (2).

Is topical estrogen safe?

The benefit of local estrogen use is that there is minimal to no systemic absorption of the estrogen. Therefore, it is considered safe and does not carry the same risk profile as systemic hormone replacement therapy with oral pills or a patch. However, if you have a history of breast, ovarian, or endometrial cancer, Dr. Kumar will discuss with your oncologist whether you are a candidate for using topical estrogen.

What if I am not comfortable using any hormonal options?

Many women wish to avoid using hormonal therapy, because of their own personal history, or sometimes because of an experience they went through with a friend or family member with breast or ovarian cancer. Dr. Kumar will work with you to ensure you are making informed decisions that you are comfortable with. There are many non-hormonal options for vaginal moisturization, such as hyaluronic acid and natural oils. Dr. Kumar can discuss options which are over the counter as well as those that she can have compounded specifically for you.


  1. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society
  2. The 2017 hormone therapy position statement of The North American Menopause Society