5 Estrogen Creams and Inserts for Vaginal Menopause Symptoms
Key takeaways:
Genitourinary syndrome of menopause (GSM) includes symptoms such as vaginal dryness, frequent urination, and painful sex.
Vaginal estrogen products can help treat GSM symptoms without the same risks of oral or topical estrogens that are absorbed into the bloodstream. Common examples include estrogen-based vaginal creams, tablets or capsules, and rings.
All vaginal estrogen products work similarly well for GSM symptoms. The decision of which to choose comes down to personal preference and cost. GoodRx can help you find ways to save on vaginal estrogen products.
Table of contents
Hot flashes and night sweats are some of the most well-known symptoms of menopause. But it can also cause urinary and vaginal symptoms, such as vaginal dryness and painful sex. These symptoms are known as the genitourinary syndrome of menopause (GSM).
When GSM symptoms are mild, over-the-counter (OTC) vaginal lubricants and moisturizers often work well. Prescription vaginal estrogen creams and inserts can help with severe GSM symptoms or when OTC options aren’t effective. But keep in mind that most of these products only help with GSM symptoms — they aren’t effective for hot flashes or night sweats.
So what are the different estrogen creams and inserts available, and how are they different? Here, we’ll look at five options to help you find the best treatment for your needs. We’ll also review how to use these vaginal estrogen products.
1. Estradiol vaginal cream (Estrace)
Estradiol vaginal cream (Estrace) contains 0.1 mg of estradiol per gram of cream. Estradiol is a form of estrogen that’s naturally found in the body. But the estradiol found in menopause hormonal therapies is lab-mad. In most cases, you’ll insert estradiol vaginal cream daily for 2 to 4 weeks. Then you’ll use it just 1 to 3 times per week thereafter.
Common estradiol vaginal cream side effects include vaginal burning or irritation, headache, and sore breasts. You may also notice some leakage after inserting the cream. Using it at bedtime can help reduce this side effect.
How to save: Estradiol vaginal cream is available as both a brand-name medication and a lower-cost generic. Generic estradiol cream’s price at certain pharmacies is as low as $24.00 per tube with a free GoodRx discount.
Natural menopause treatments: Learn more about supplements and over-the-counter options for menopause, including which ones are worth a try and which you should avoid.
Is menopause hormone therapy safe? Here’s what to know about the risks and benefits of taking hormones to treat your menopause symptoms.
What does menopause feel like? Read these first-hand accounts to help you determine if your symptoms might be menopause-related.
2. Estradiol vaginal tablets (Vagifem)
Estradiol vaginal tablets (Yuvafem, Vagifem) contain 10 mcg of estradiol per tablet. You’ll insert 1 tablet daily for 2 weeks. After that, you’ll insert 1 tablet twice a week, about 3 to 4 days apart.
Common side effects of estradiol vaginal tablets include back pain, diarrhea, and vaginal yeast infections.
How to save: Estradiol vaginal tablets come under the brand name Vagifem as well as in two different lower-cost generic forms. GoodRx can help you save over 75% off the average retail price of the generic versions.
3. Imvexxy vaginal capsules
Estradiol vaginal capsules (Imvexxy) come in two different doses: a 10 mcg capsule and a 4 mcg capsule. They both follow the same dosage schedule as the estradiol vaginal tablets. But Imvexxy is only FDA approved for painful sex due to menopause (dyspareunia). They aren’t approved for other GSM symptoms.
Headache was the most common Imvexxy side effect reported in clinical studies. Vaginal discharge is also possible.
How to save: Imvexxy is available as a brand-name medication. Anyone with a valid prescription, regardless of insurance status, can use GoodRx to purchase 8 capsules of Imvexxy at an exclusive cash price of $85. If you have commercial insurance, you may be eligible to pay as little as $35 per prescription using a savings card from the manufacturer.
4. Premarin Vaginal Cream
Conjugated estrogens vaginal cream (Premarin Vaginal Cream) is another type of vaginal estrogen cream. But instead of estradiol, Premarin contains 0.625 mg of conjugated estrogens per gram of cream. This is a combination of estrogens that come from the urine of pregnant horses (pregnant mare urine).
The recommended Premarin Vaginal Cream dosage for vaginal dryness is 0.5 g to 2 g applied daily for 21 days, followed by a 7-day break. But your prescriber may also recommend using it just twice a week instead. For painful sex, the recommended dosage is 0.5 g applied inside the vagina twice a week for 3 weeks, followed by a 1-week break.
Common Preparin Vaginal Cream side effects include headache, sore breasts, and pelvic pain.
How to save: Premarin Vaginal Cream is available as a brand-name medication. If you have commercial insurance, a copay savings card can help reduce your cost to just $25 per tube. GoodRx also offers exclusive savings on the out-of-pocket cost if insurance isn’t an option for you. A patient assistance program is also available.
5. Estring
Estring is a vaginal ring that releases 7.5 mcg of estradiol per day. You’ll insert 1 ring into the vagina every 90 days.
Common Estring side effects include headache, vaginal irritation or infection, and back pain. If you have a narrow or short vaginal canal, Estring may not be the best choice for you.
How to save: Estring is available as a brand-name medication. Anyone with a valid prescription, regardless of insurance status, can use GoodRx to purchase a 3-month supply (1 ring) of Estring at an exclusive cash price of $249. A copay card can lower your cost to $25 per ring (90-day supply) if you have commercial insurance. A patient assistance program is also available.
Good to know: Femring is another estradiol vaginal ring that treats menopause symptoms. But unlike Estring, it also treats full-body symptoms, such as hot flashes and night sweats. So we won’t be including it in this list.
How to use estrogen creams and tablets
Vaginal estrogen creams and tablets are both inserted with an applicator. Estradiol vaginal tablets come preloaded in individual disposable applicators. But Estrace and Premarin creams come with a reusable applicator you’ll use to measure your dose. Although your prescriber may recommend using your finger instead in some cases.
To place your dose:
Wash and dry your hands.
Relax in a comfortable position, such as on your back with your knees bent.
Insert the applicator (with medication) into the vagina. Make sure to stop if it becomes painful or uncomfortable.
Push the plunger down on the applicator, leaving the dose in the vagina.
Withdraw the applicator.
After placing your dose:
Remain in a reclined position after placing Estrace or Premarin Vaginal Cream. This can help lessen the amount of cream that leaks out.
You can discard the applicator if you’re using estradiol vaginal tablets. Otherwise, remove the plunger from the applicator and wash all parts in warm, soapy water. Allow it to air-dry before putting it back together.
Wash and dry your hands.
How to use Imvexxy
Imvexxy capsules don't come with an applicator. Instead, you’ll insert the capsule with your hands.
To place your dose:
Wash and dry your hands.
Push one capsule through the foil backing, and hold the large end (smaller end should be pointing up).
Choose a relaxed, reclined position or stand with your knees apart and bent.
Insert the capsule into the vagina, and use one finger to push it about 2 inches deep.
Wash and dry your hands.
How to use Estring
Estring also doesn’t require an applicator for insertion.
To place Estring:
Wash and dry your hands.
Pick a comfortable position, such as lying on your back or standing with one foot up on a chair.
Pinch the sides of the vaginal ring together in one hand.
With the other hand, open the skin around your vagina.
Insert the folded ring into the vagina. Then use one finger to push it as far into the vagina as is comfortable. The deeper you insert it, the less likely the ring is to fall out.
Wash and dry your hands.
To remove Estring:
Wash and dry your hands.
Stand or lie in a similar position to when you placed it.
Slide one finger into the vagina and hook it through the center of the ring.
Slowly pull the ring out. If you’re going to continue using the medication, insert a new ring.
Discard the used vaginal ring, then wash and dry your hands.
How do you choose the best vaginal estrogen cream or suppository?
With so many vaginal estrogen options available, you may be asking yourself how to choose between them. The good news is that all of the products we’ve discussed are similarly effective for GSM symptoms. The best option for you depends largely on personal preference.
For example, you may prefer Estring if the possible leakage of creams or tablets is bothersome for you. And if you have trouble remembering to insert a vaginal estrogen cream twice a week, Estring may be an easier option for you, since it lasts for 90 days. However, creams can be applied externally as well as internally. So they may be a better choice if you have vulvar irritation.
Cost can also be an issue, since not all vaginal estrogen creams and inserts come as lower-cost generics. Keep in mind that GoodRx can help you compare the costs of different menopause treatments to find the best fit for your needs.
Are estrogen creams and inserts safe?
All prescription estrogen products carry a boxed warning about the risk of serious side effects. This includes a higher risk of:
Uterine or breast cancer
Heart attacks
Strokes
Blood clots in the lung or legs
Dementia
That being said, the risk of these side effects with vaginal estrogen creams and inserts (other than Femring) is lower than other forms of menopause hormone therapy. In fact, current research suggests that the risk of these side effects is the same for those who use vaginal estrogen and those who don’t use menopause hormonal therapy at all. That’s because vaginal forms mainly work in the vagina where they’re inserted. They don’t enter the bloodstream in large amounts.
Still, it’s best to discuss the risks and benefits of estrogen creams and inserts with your prescriber. And you should use them for the shortest amount of time needed.
Who shouldn’t use vaginal estrogen cream or inserts?
Talk to your prescriber if you have any of the following conditions:
Unexplained vaginal bleeding
History of breast cancer
History of estrogen-dependent cancer
History of blood clots or a related condition, such as a stroke or heart attack
Liver problems
In some cases, it may still be OK for you to use a vaginal estrogen product. But in other cases, it may be best to avoid them. Your prescriber can assess your risk based on your personal history.
Frequently asked questions
Not typically. Weight changes aren’t associated with vaginal estrogen creams and inserts. That’s because they aren’t absorbed into your bloodstream in large amounts. So their effects are mainly localized to the vaginal area. However, weight gain can happen during menopause. So be sure to maintain a balanced diet and regular exercise to reduce the risk of this side effect.
There isn’t a set amount of time you can use vaginal estrogen products. In general, it’s best to use them for the shortest amount of time possible. And they’re safest if you start them when you’re under the age of 60 or within 10 years of menopause.
The bottom line
Genitourinary syndrome of menopause (GSM) includes symptoms such as vaginal dryness, urinary urgency, and pain during sex. Vaginal estrogen creams and inserts can help treat GSM symptoms. They aren’t effective for body-wide menopause symptoms, such as hot flashes and night sweats. But vaginal estrogen products are less likely to cause serious side effects than oral or topical estrogen products that are absorbed into the bloodstream.
Vaginal estrogen products come as creams, tablets or capsules, and rings. All vaginal estrogen products work similarly well. The best option for you is based on your personal preference when it comes to the dosage form and frequency of use. Be sure to discuss the risks and benefits of vaginal estrogen with your healthcare team.
Why trust our experts?
References
Christmas, M., et al. (2024). Clinical practice guidelines for managing genitourinary symptoms associated with menopause. Clinical Obstetrics and Gynecology.
Delgado, B. J., et al. (2023). Estrogen. StatPearls.
Harper-Harrison, G., et al. (2024). Hormone replacement therapy. StatPearls.
Hill, A. D., et al. (2016). Hormone therapy and other treatments for symptoms of menopause. American Family Physician.
Imvexxy. (n.d.). How to use Imvexxy.
Manson, J. E., et al. (2014). Why the product labeling for low-dose vaginal estrogen should be changed. Menopause.
Mayne Pharma. (2023). Imvexxy- estradiol insert [package insert].
MedlinePlus. (2022). Estrogen vaginal.
Palacios, S., et al. (2019). Hormone therapy for first-line management of menopausal symptoms: Practical recommendations. Women’s Health.
Pfizer Laboratories Div Pfizer. (2024). ESTRING- estradiol system [package insert].
The Menopause Society. (n.d.). Symptoms.
