Hot flashes get most of the attention, but vaginal dryness, irritation and painful sex are among the most common and persistent effects of menopause. Unlike hot flashes, they often get worse over time rather than fading. The good news is that effective treatments exist, several of them low-dose and local, and most can be started through an online visit.
Key Takeaways
- Genitourinary syndrome of menopause (GSM) covers vaginal dryness, burning, irritation, painful sex and some urinary symptoms caused by lower estrogen.
- Non-hormonal moisturizers and lubricants are first steps for mild symptoms.
- Low-dose vaginal estrogen (cream, tablet or insert, ring) acts locally and is a mainstay of treatment for moderate to severe symptoms.
- Vaginal DHEA (prasterone) and oral ospemifene are other FDA-approved prescription options.
- In late 2025 the FDA moved to remove boxed warnings from menopausal hormone therapy labels and condense safety information for low-dose vaginal estrogen.
What is genitourinary syndrome of menopause?
As estrogen falls around and after menopause, the tissues of the vulva, vagina, urethra and bladder change. They become thinner, less elastic and less lubricated. The Menopause Society (formerly NAMS) uses the term genitourinary syndrome of menopause, or GSM, to describe the resulting symptoms, which can include:
- Vaginal dryness, burning or itching
- Pain or discomfort with sex, and sometimes light bleeding afterward
- Urinary urgency, discomfort, or more frequent urinary tract infections
The Society's 2020 position statement notes that GSM is common, is often underreported because people are embarrassed to raise it, and tends to be progressive without treatment. Our menopause telehealth overview covers the broader picture.
Treatment options, from gentlest to strongest
| Option | How it works | Prescription? | Best for |
|---|---|---|---|
| Vaginal moisturizers | Used regularly to hydrate tissue | No | Mild, everyday dryness |
| Lubricants | Used during sex to reduce friction | No | Discomfort mainly with intercourse |
| Low-dose vaginal estrogen (cream, tablet/insert, ring) | Restores local tissue with minimal whole-body absorption | Yes | Moderate to severe symptoms, recurrent UTIs related to GSM |
| Vaginal DHEA (prasterone) | Converted locally to estrogens and androgens | Yes | Painful sex due to menopause |
| Ospemifene (oral) | Acts like estrogen on vaginal tissue | Yes | Painful sex due to menopause in people who prefer a pill |
| Pelvic floor physical therapy | Addresses muscle tension and pain | Referral often helpful | Pain that persists despite treating dryness |
Non-hormonal first steps
Moisturizers and lubricants are not the same thing. Moisturizers are used several times a week regardless of sexual activity, while lubricants are used during sex. Water-based and silicone-based lubricants are both options; avoid products with fragrances, warming agents or other irritants if your tissue is sensitive. For many people with mild symptoms, consistent use of both is enough.
Low-dose vaginal estrogen
When non-hormonal products are not enough, low-dose vaginal estrogen is the treatment the Menopause Society's position statement describes as highly effective. It is applied directly to the vagina as a cream, a small tablet or insert, or a soft ring that stays in place for months. Because doses are low and the effect is local, systemic absorption is minimal compared with hormone therapy taken for hot flashes.
People with a history of breast cancer or other estrogen-sensitive cancers should discuss options with their oncology team; the decision is individual, and non-hormonal approaches are often tried first.
Other prescription options
Vaginal DHEA (prasterone) is a nightly vaginal insert approved for moderate to severe painful sex due to menopause. Ospemifene is an oral medication that acts like estrogen on vaginal tissue, approved for the same indication. A prescriber will weigh your history, preferences and other medications in choosing among them.
How telehealth handles GSM
Many menopause-focused telehealth services, and general women's health platforms, prescribe GSM treatments after a questionnaire or video visit. A good intake covers:
- Your symptoms, how long you have had them, and how they affect sex and daily life
- Bleeding history, especially any bleeding after menopause
- Personal and family history of breast or uterine cancer, blood clots and stroke
- Current medications, including any systemic hormone therapy
Our guide to telehealth menopause and hormone therapy explains how programs differ, and women's telehealth in 2026 covers related care like UTIs.
What using vaginal estrogen looks like in practice
Prescriptions usually start with a short loading phase, often daily use for a couple of weeks, followed by maintenance use a few times a week. The ring is replaced on a schedule set by the product. Your prescriber's instructions take priority over any general pattern.
- Give it time. Many people notice improvement within weeks, but full benefit can take longer as tissue recovers.
- Keep using moisturizers and lubricants as needed while treatment takes effect.
- Treatment is often long-term. Symptoms tend to return when local estrogen stops, so plan follow-up rather than a one-time prescription.
- Report bleeding after menopause promptly, whatever you are using.
If sex remains painful despite improved dryness, muscle tension or pelvic floor problems may be involved. A referral to pelvic floor physical therapy can help, and that part of care typically happens in person.
Recurrent UTIs after menopause
The Menopause Society notes that GSM is linked to recurrent urinary tract infections in some people, and that vaginal estrogen can reduce recurrences. If you are getting repeated UTIs, mention it during your visit rather than treating each one in isolation. Our article on telehealth for UTIs explains how online care handles individual episodes.
Starting the conversation
Many people wait years before mentioning vaginal dryness, assuming it is just part of aging. It is common, but it is also treatable. If typing it into an online form is easier than saying it out loud, that is a perfectly good reason to use telehealth. Be specific about what bothers you most, whether that is daily discomfort, pain with sex, or urinary symptoms, because that shapes which treatment fits best.
Frequently Asked Questions
Is vaginal estrogen the same as hormone replacement therapy?
Not quite. Low-dose vaginal estrogen acts locally with minimal absorption into the bloodstream. Systemic hormone therapy, taken for hot flashes, delivers estrogen throughout the body.
Will vaginal dryness go away on its own after menopause?
Usually not. GSM symptoms tend to persist or worsen over time without treatment, which is different from hot flashes.
Can I get vaginal estrogen through telehealth?
Yes, many telehealth services prescribe it after an intake that covers your history and symptoms. Bleeding after menopause or other concerning symptoms still require an in-person exam.
Are there non-hormonal prescription options?
Ospemifene is an oral non-estrogen medication that acts on vaginal tissue. Vaginal DHEA is a hormone precursor rather than estrogen itself. Moisturizers and lubricants are non-hormonal and available without a prescription.
Did the FDA remove the black box warning on vaginal estrogen?
In November 2025 the FDA announced plans to remove boxed warnings from menopausal hormone therapies and to condense safety information for low-dose vaginal estrogen. Check your product's current label with your pharmacist.
Sources
- The 2020 Genitourinary Syndrome of Menopause Position Statement of NAMS (PubMed)
- RAPS: FDA to remove boxed warnings from menopausal hormone therapies (Nov. 2025)
Medical guidance and labeling change. We link primary sources so you can check the current version yourself.