Vaginal dryness and painful sex
Estriol Cream for Vaginal Atrophy: Benefits, Safety and How to Use It
The short answer
Estriol is a weaker estrogen that, used as a vaginal cream or gel, relieves dryness, irritation and painful sex caused by menopause-related vaginal atrophy. A systematic review of 22 studies with 1,217 women found vaginal estriol effective with few side effects; in the US it is available only as a compounded prescription, not an FDA-approved product.
What is vaginal atrophy?
When estrogen falls during perimenopause and after menopause, the tissues of the vulva, vagina, urethra and bladder change. The vaginal lining becomes thinner, less elastic and drier, blood flow drops, and the normally acidic pH rises, which changes the balance of protective bacteria. Doctors now usually call this genitourinary syndrome of menopause (GSM), because it affects the urinary tract as well as the vagina.
GSM is very common, affecting an estimated 27% to 84% of postmenopausal women, and unlike hot flashes it tends to get worse over time without treatment (NAMS 2020). Typical symptoms include:
- vaginal dryness, burning or itching
- pain or discomfort during sex, and sometimes light bleeding afterward
- a need to urinate urgently or often, and repeat urinary tract infections (UTIs)
- discomfort with exercise, sitting or tight clothing
Our full guide to genitourinary syndrome of menopause covers causes, diagnosis and the full range of treatments.
What is estriol, and how is it different from estradiol?
The body makes three main estrogens. Estradiol is the most potent and dominates during the reproductive years. Estrone is the main estrogen after menopause. Estriol is the weakest and is made in large amounts mainly during pregnancy.
Because estriol binds estrogen receptors more briefly and is cleared quickly, it has been used for decades, mainly in Europe, as a vaginal treatment that acts on local tissue with little effect elsewhere. When applied vaginally, blood estriol levels rise briefly after a dose and then fall; a systematic review found no build-up in the blood after six months of use (Rueda 2017). For more on estriol as a hormone, see bioidentical estriol.
Does estriol cream work for vaginal atrophy?
Yes, the evidence supports it, though most studies are small and of low to moderate quality:
- A systematic review of 22 studies with 1,217 women found vaginal estriol preparations relieved vaginal atrophy symptoms with few side effects (Rueda 2017).
- In a 12-week phase 3 trial of 167 postmenopausal women, an ultra-low-dose 0.005% estriol gel improved dryness, vaginal pH and the health of the vaginal lining compared with placebo, with improvements seen as early as 3 weeks (Cano 2012).
- In a classic randomized trial in postmenopausal women with repeat UTIs, vaginal estriol cream sharply reduced UTI recurrences compared with placebo, likely by restoring protective lactobacilli and a lower vaginal pH (Raz 1993).
A Cochrane review of 30 trials found no clear difference in symptom relief between the various vaginal estrogen products (creams, tablets and rings) when compared with each other (Lethaby 2016). In practice, that means estriol is one reasonable option among several, not uniquely better.
By the numbers
Vaginal estriol: the evidence
Is estriol cream safe?
Blood levels and the uterus
At the low doses used vaginally, estriol and other vaginal estrogens keep blood estrogen levels low. The Menopause Society's position is that a progestogen (progesterone) is not needed with low-dose vaginal estrogen, but it also notes that endometrial safety hasn't been studied in trials longer than about a year (NAMS 2020). Any bleeding after menopause, even if you think it's from the cream, needs to be checked by a clinician.
Cancer and heart risk
In the Women's Health Initiative Observational Study, which followed more than 45,000 postmenopausal women for a median of about 7 years, women who used vaginal estrogen did not have higher rates of breast cancer, endometrial cancer, stroke or blood clots than non-users (Crandall 2018). Package inserts for vaginal estrogen products still carry class warnings that come largely from studies of systemic estrogen, so your clinician will review those with you.
If you've had breast cancer
This needs an individual decision with your oncologist. Expert consensus recommends non-hormonal treatments first; for women whose symptoms don't respond, low-dose vaginal estrogen may be considered depending on the type of cancer and treatment, with extra caution for women taking aromatase inhibitors (Faubion 2018).
Side effects
How do you use estriol cream?
Your prescriber will set the exact dose and schedule, because compounded strengths vary. A common pattern with vaginal estrogen creams is:
Step by step
A common vaginal estrogen schedule
- Starting phase:A small measured amount inserted into the vagina nightly, usually for about two weeks.
- Maintenance:The same amount about twice a week, long term.
Tips that help:
- Apply at bedtime so the cream stays in place.
- Use the applicator or a clean fingertip as directed; some women are also told to apply a little to the vulva.
- Wash the applicator with warm, soapy water and let it air dry.
- Avoid using it right before sex, since a partner can absorb a small amount.
- Keep using a lubricant for sex until the tissue has had time to improve.
Most women feel some relief within a few weeks, but the lining takes about 8 to 12 weeks to rebuild. Because GSM is a long-term condition, symptoms typically come back if treatment stops.
Estriol cream vs other vaginal atrophy treatments
| Treatment | FDA status | Best for |
|---|---|---|
| Vaginal moisturizers and lubricants | Over the counter | Mild symptoms; anyone avoiding hormones |
| Compounded estriol cream | Not FDA-approved (compounded) | Moderate to severe symptoms when a clinician prefers estriol |
| Estradiol cream, tablet/insert or ring | FDA-approved products available | Moderate to severe symptoms |
| Conjugated estrogens vaginal cream | FDA-approved | Moderate to severe symptoms |
| Vaginal DHEA (prasterone) insert | FDA-approved for painful sex due to menopause | Painful sex; an alternative to estrogen |
| Ospemifene (oral pill) | FDA-approved for painful sex and dryness due to menopause | Women who prefer a pill over vaginal products |
| Systemic hormone therapy | FDA-approved products available | Women who also have hot flashes and other whole-body symptoms |
| Vaginal laser | Not FDA-approved for GSM | Evidence too limited to recommend |
Local estriol or whole-body hormone therapy?
If dryness, painful sex or urinary symptoms are your only menopause problems, a local vaginal treatment is usually the first choice. If you also have hot flashes, night sweats or poor sleep, systemic hormone therapy may make sense, and it often improves vaginal symptoms too, though some women still need a vaginal product on top. We explain the trade-offs in local vs systemic HRT.
Amie offers one systemic option: Amie HRT+, a single compounded cream containing estradiol and progesterone, with the strength chosen by the clinician, for hot flashes, night sweats, sleep and other menopause symptoms. It is not a vaginal estriol product, and it is not FDA-approved. A licensed clinician reviews your health history, including any history of breast cancer, blood clots, stroke, heart disease or unexplained bleeding, to decide whether it's appropriate and whether you'd also benefit from local vaginal treatment.
When to see a clinician
- Any vaginal bleeding after menopause
- Pain with sex that doesn't improve with lubricants and moisturizers
- Repeat UTIs, or burning with urination
- Itching, sores, white patches or skin changes on the vulva, which can signal other conditions such as lichen sclerosus
- Symptoms that persist after 12 weeks of treatment
If painful sex is your main concern, our guide to painful sex after menopause covers pelvic floor therapy and other approaches as well.
Common questions
Is estriol cream FDA-approved?
No. In the US, estriol is available only from compounding pharmacies with a prescription. Several FDA-approved vaginal estrogen products contain estradiol or conjugated estrogens instead, and estriol products are approved in some other countries.
How long does estriol cream take to work?
Many women notice less dryness and irritation within a few weeks, with fuller improvement in the vaginal lining over about 8 to 12 weeks. Symptoms usually return if treatment stops, so most women continue a lower maintenance dose.
Is estriol cream safer than estradiol cream?
Both are considered low-risk at low vaginal doses, and trials show similar symptom relief from different vaginal estrogens. Estriol is weaker and blood levels stay low, but there is no strong evidence that it is safer than low-dose vaginal estradiol.
Can I use estriol cream if I've had breast cancer?
Possibly, but only after discussing it with your oncologist. Expert groups say non-hormonal options come first and that vaginal estrogen may be considered for some survivors whose symptoms don't respond, depending on cancer type and treatment.
Do I need progesterone with vaginal estriol?
Usually not. The Menopause Society says a progestogen is not indicated with low-dose vaginal estrogen, though long-term endometrial safety hasn't been studied beyond about a year. Any vaginal bleeding after menopause should be checked.
Sources
- Rueda C et al. Efficacy and safety of estriol to treat vulvovaginal atrophy: systematic review. Climacteric 2017
- Cano A et al. Ultra-low-dose 0.005% estriol vaginal gel for postmenopausal vaginal atrophy. Menopause 2012
- The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause 2020
- Lethaby A et al. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev 2016
- Raz R, Stamm WE. Intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 1993
- Crandall CJ et al. Vaginal estrogen and cancer and cardiovascular events in the WHI Observational Study. Menopause 2018
- Faubion SS et al. Management of GSM in women with or at high risk for breast cancer. Menopause 2018
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