Vaginal hormones: what you need to know

Vaginal hormones are an effective treatment for menopausal and postmenopausal women, but others may benefit too

• Vaginal hormones include oestrogen and prasterone
• They are available in cream, gel, pessary and silicone ring formats
• Your healthcare professional can help to determine the right dose and type to manage your symptoms

Around 80% of menopausal women vulvovaginal symptoms and lower urinary tract symptoms related to low hormone levels [1]. Genitourinary Syndrome of the Menopause (GSM) is a collective term to describe symptoms, which can include vaginal dryness, discomfort or pain during sex, irritation or burning of the vulva or vagina, needing to go to the toilet more often and feeling very desperate to go, without much notice, and urinary tract infections such as cystitis.

RELATED: Managing genitourinary syndrome of the menopause (GSM)

NICE menopause guidelines recommend vaginal oestrogen to help manage GSM in menopausal and postmenopausal women [2]. Vaginal DHEA (prasterone) can also help to alleviate symptoms. You don’t need to have all the symptoms to be prescribed vaginal hormones – some women may be prescribed them to treat recurrent UTIs and not suffer from vaginal dryness, for example. 

It’s important to note that it’s not just menopausal women who can benefit from using vaginal hormones if they are experiencing these symptoms. Younger women, especially those taking contraceptives, and some women with diseases such as diabetes and inflammatory bowel disease, can also experience these symptoms, which often improve with vaginal hormones. 

RELATED: More than a little vaginal dryness: how vaginal hormones can transform lives

Most vaginal hormones are prescribed by a healthcare professional, and they will be able to advise you on how to take them. However, there are two over-the-counter preparations – Gina, a vaginal oestrogen tablet, and Ovesse, a vaginal oestrogen cream – that are available to some women without a prescription.

If you have been prescribed vaginal hormones to treat or manage your symptoms, it can be confusing to see all the different brands available, and the different hormones and formulations available. This overview can help.

Vaginal creams

In the UK there are two brands of vaginal oestrogen cream available – Estriol and Ovesse. Both contain oestriol, which is a type of oestrogen made naturally in your ovaries. While Estriol is a prescription-only cream, Ovesse is available over the counter – it can be bought by women aged 50 and above who have not had a period for at least a year. A pharmacist will ask you a few questions from a checklist to make sure that it’s suitable and some women may still need a prescription from a healthcare professional. This includes women who have had breast, endometrial or ovarian cancer, blood clots, heart disease, liver disease or stroke. Also, younger women will need a prescription.

Estriol

Estriol cream is available as a 1mg/g cream preparation and each applicator contains 0.5g of cream, which is 0.5mg oestriol. You screw the clear plastic applicator onto the neck of the tube, which makes it easy to squeeze the cream into the applicator up to the red ring mark. To dispense the cream, it’s best to lie down, put the applicator into your vagina and slowly push the plunger all the way in.

Ovesse

Ovesse contains 1mg of oestriol per 1g of cream. Like with Estriol, you apply the cream directly in your vagina using a reusable applicator. Fill the applicator up to the red ring mark with Ovesse, then apply as you would a tampon. Again, usually a good time to do this is before going to bed.

Vaginal Gel

Blissel

Blissel is a clear, water-based gel. It contains a lower dose of oestriol than most other creams or pessaries (50 micrograms of oestriol per gram of gel). This makes it a gentler option – it is less likely to cause irritation and can be used to treat external soreness.  

It comes with an applicator that you can screw onto the neck of the tube of gel. You squeeze the tube to fill the applicator up to the filling mark. To apply the gel, simply lie down, insert the applicator into your vagina, and push the plunger all the way in to release the gel. It’s usually best to do this before you go to bed. Alternatively, you may be recommended to use the gel externally on your vulva or other areas in which case you gently apply with your fingertips.

As it’s water based, Blissel is not as thick and sticky as creams so is often less messy to use. The water-based formulation means it’s safe to use if you rely on latex condoms or a diaphragm for contraception.

RELATED: Contraception during the menopause and perimenopause

Vaginal Pessaries

In the UK, there are numerous brands of vaginal hormonal pessaries. Most of these contain the hormone oestrogen (which will appear on the leaflet as either oestriol or oestradiol), but pessaries containing prasterone are also available.

Imvaggis

Imvaggis pessaries contain 30 micrograms of oestriol, which makes it the lowest-dose topical oestrogen product available in the UK. The pessaries are small, waxy and bullet shaped. Unlike other pessaries, Imvaggis doesn’t come with a plastic applicator – it’s designed to be inserted with your finger, which reduces plastic waste. The waxy texture makes it easy to insert, and adds some extra moisture to your vagina as it melts. As Imvaggis is oil-based, it shouldn’t be used alongside condoms or a diaphragm as it could damage the latex.

Vagifem

Each dose of Vagifem, which contains 10 micrograms of oestradiol, comes in a foil-wrapped, pre-dosed, single-use applicator, which looks similar to a tampon applicator. You can insert it when you’re standing up or lying down, and it’s best to use it before you go to bed. As Vagifem pessaries stick well to the vaginal walls, they aren’t as messy to use as some other creams and pessaries and don’t leave a sticky residue.

The main downside is that Vagifem can only be used internally, unlike creams and gels which can be used around the vaginal opening and vulva. You should avoid having sex straight after using Vagifem as your partner will be exposed to the oestrogen from the pessary.

Vagirux

Vagirux is a similar product to Vagifem. Each pessary contains 10 micrograms of oestradiol but unlike Vagifem, it comes with a single reusable applicator in each pack, which should be cleaned after each use. Simply load the pessary into the applicator before use, then insert it in the same way that you would when using a tampon, either standing up or lying down.

It’s best to use Vagirux before you go to bed, so the pessary stays in place for several hours and you should avoid having sex straight after using Vagirux as your partner will be exposed to the oestrogen from the pessary.

Vagirux pessaries aren’t as messy to use and don’t leave a sticky residue. However, it can only be used internally, unlike creams and gels that can be used around the vaginal opening and vulva.

RELATED: Vaginal dryness: why you don’t need to suffer

Intrarosa

Intrarosa is one of the newest treatments available in the UK and is the only vaginal non-oestrogen treatment available. It contains plant-derived form of the hormone dehydroepiandrosterone (DHEA, also known as prasterone), which your body produces naturally. Each pessary contains 6.5mg of prasterone, and once inserted into your vagina, this hormone is released and converted to both oestrogen and testosterone. These hormones lubricate and improve the condition of affected vaginal and surrounding tissues, and research has shown that women using Intrarosa have a lower future risk of developing urinary tract infections and symptoms too [3].

RELATED: UTIs and menopause: what’s the link?

Vaginal tablet

Gina

Gina is a small vaginal tablet that contains 10 micrograms of oestradiol, and you insert it into your vagina using a pre-loaded, single-use applicator. This is the same as Vagifem. Gina is available without a prescription in the UK to women aged 50 and over, who haven’t had a period for at least a year. As it’s available over the counter, stricter rules apply when buying Gina. The pharmacist will need to ask you a few questions to make sure that it’s suitable, and some women will still need a prescription of this preparation from a healthcare professional.

RELATED: Gina vaginal oestrogen available over the counter: what you need to know

Vaginal silicone ring

Estring

Estring is a soft, flexible, silicon ring that contains 2mg of oestradiol. Once inserted into the upper third of your vagina, Estring slowly and continuously releases oestradiol (at an average amount of 7.5micrograms per 24 hours) directly to the area where it’s needed most to relieve symptoms. It works for three months, at which point it needs to be replaced.

You shouldn’t be able to feel Estring once it’s in place – if you can, this means it’s too low in your vagina and needs to be inserted a little higher up. If you’re not confident about inserting Estring yourself, a healthcare professional can do it for you.

There’s no need to remove it before sex. If you prefer to take it out, it should be rinsed in lukewarm water and reinserted as soon as possible. If you rely on barrier forms of contraception such as condoms or a diaphragm, there’s no risk of Estring damaging the latex, unlike oil-based creams and pessaries.

Some people prefer Estring to creams, gels and pessaries, which can be messy to use as they leave a sticky residue when they leak out of your vagina.

What other vaginal treatments are there?

Women with vaginal dryness can also use non-hormonal vaginal moisturisers and lubricants alone or in addition to vaginal oestrogen.

Are vaginal hormones safe?

Vaginal hormones are different to HRT as they are very low dose and do not get absorbed into your body. Vaginal oestrogen is safe to use and can usually safely be prescribed for women who have had any type of breast cancer [4,5,6,7].

Vaginal hormones are safe to use alongside other forms of HRT, including gels, sprays and patches.

RELATED: Gaslighting of genitourinary symptoms of the menopause

Resources

NHS: About vaginal oestrogen

BNF: Estradiol

BNF: Estriol

BNF: Prasterone

References

1. Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic. Sarmento ACA, Costa APF, Vieira-Baptista P, Giraldo PC, Eleutério J Jr, Gonçalves AK. 2021, Front Reprod Health., p.15; 3:779398. doi: 10.3389/frph.2021.779398. PMID: 36304000; PMCID: PMC9580828.
2. NICE: Menopause: identification and management (ng23)
3. Rubin R., Sanaee M., Yee A., Moyneur E., Dea K., Dury A.Y. (2025), ‘Prevalence of urinary tract infections in women with vulvovaginal atrophy and the impact of vaginal prasterone on the rate of urinary tract infections. Menopause. doi: 10.1097/GME.0000000000002485. Epub ahead of print. PMID: 39774900.
4. Agrawal P. et al. (2023), ‘Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer’, Obstet Gynecol,142(3):660-668. doi: 10.1097/AOG.0000000000005294
5. McVicker L. et al (2024), ‘Vaginal estrogen therapy use and survival in females with breast cancer’, JAMA Oncol, 10(1):103-108. doi: 10.1001/jamaoncol.2023.4508
6. The 2022 hormone therapy position statement of the North American Menopause Society advisory panel (2022), ‘the 2022 hormone therapy position statement of The North American Menopause Society’, Menopause, 29(7):767-794. doi: 10.1097/GME.0000000000002028
7. Hussain I., Talaulikar V.S. (2023), ‘A systematic review of randomised clinical trials – the safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors’, Post Reprod Health, 29(4):222-231. doi: 10.1177/20533691231208473