From vaginal dryness to frequent UTIs, declining estrogen can affect more than you think. We asked women’s health expert and Antha founder Dr. Natalie Barnett to explain what’s happening and what can help.
We talk a lot about menopause these days. Hot flashes, sleep disruptions, brain fog and mood changes are finally getting the attention they deserve. But there’s another side of menopause that doesn’t get nearly enough airtime: what happens to our vaginal and urinary health as estrogen levels decline.
If you’ve noticed more frequent trips to the bathroom, vaginal dryness, discomfort during intimacy or even recurring urinary tract infections, you’re not alone. And these symptoms aren’t necessarily something you have to accept as part of getting older.
I recently caught up with my friend Dr. Natalie Barnett, PhD, founder and CEO of Antha, a women’s health company focused on making evidence-based vaginal estrogen treatment more accessible. With a background in quantitative and molecular genetics and years of clinical research experience, Natalie brings a scientist’s perspective to a topic that deserves more attention.
We discussed what happens to our bodies during menopause, why vaginal estrogen is gaining attention and what women should know before considering treatment.
What Happens to Vaginal Health During Menopause?
Estrogen does much more than regulate our menstrual cycles. It also helps maintain the health of the vagina, vulva, urethra and bladder.
As estrogen levels decline during perimenopause and menopause, these tissues can become thinner, drier and less elastic. Blood flow decreases, and the vaginal environment changes in ways that can make irritation and urinary problems more common.
“Estrogen does a lot of quiet work below the belt,” Natalie explains.
One particularly important change involves the vaginal microbiome. Estrogen helps support beneficial bacteria called lactobacilli, which maintain the vagina’s naturally acidic environment. When estrogen declines, those bacteria may decrease and vaginal pH can rise, potentially making it easier for bacteria associated with urinary tract infections to thrive.
These changes have a medical name: genitourinary syndrome of menopause, or GSM.
What Is Genitourinary Syndrome of Menopause (GSM)?
GSM describes the vaginal, vulvar and urinary symptoms associated with declining estrogen levels. Estimates suggest that at least half of postmenopausal women experience symptoms, although many never discuss them with their healthcare providers.
Some symptoms are familiar, while others are surprisingly easy to overlook.
Common symptoms of GSM include:
- Vaginal dryness and reduced natural lubrication
- Burning, itching or irritation
- Pain or discomfort during intimacy
- Frequent or urgent urination
- Recurrent urinary tract infections
- UTI-like symptoms even when tests are negative
- Light spotting or small tears after intimacy
That last group is especially important. Many women don’t realize that urinary urgency, recurrent UTIs or persistent irritation may be connected to hormonal changes.
Rather than addressing each symptom individually, recognizing GSM can help women have more productive conversations with their healthcare providers.
Of course, these symptoms can have other causes, too. Persistent discomfort, urinary symptoms or vaginal bleeding deserve a proper medical evaluation rather than an assumption that menopause is responsible.
Can Vaginal Estrogen Help Prevent UTIs and Frequent Urination?
This may be one of the most compelling reasons to learn about vaginal estrogen.
Low-dose vaginal estrogen works directly on estrogen-sensitive tissues in and around the vagina. By improving tissue health and supporting a healthier vaginal microbiome, it may help reduce the risk of recurrent urinary tract infections in peri- and postmenopausal women.
In fact, the American Urological Association recommends offering vaginal estrogen to appropriate peri- and postmenopausal women with recurrent UTIs to reduce the risk of future infections.
What about that frustrating feeling of constantly needing to use the bathroom?
Natalie explains that vaginal estrogen may also improve urinary urgency and frequency for some women, although the evidence is stronger for preventing recurrent UTIs.
Nighttime bathroom trips are more complicated because sleep patterns, fluid intake, medications and other medical conditions can all play a role.
For some women, a combination of vaginal estrogen and pelvic floor physical therapy may be especially helpful. The estrogen addresses tissue changes, while physical therapy focuses on muscle function and coordination.
Vaginal Estrogen vs. Hormone Replacement Therapy: What’s the Difference?
One common source of confusion is the difference between vaginal estrogen and systemic menopausal hormone therapy, often called HRT or MHT.
Systemic hormone therapy, delivered through options such as patches, pills, gels or sprays, circulates throughout the body. It is commonly used to manage symptoms including hot flashes and night sweats and, in appropriate patients, can help prevent bone loss.
Low-dose vaginal estrogen is different. It delivers estrogen locally, primarily targeting the vaginal and surrounding tissues, with relatively little entering the bloodstream.
That means vaginal estrogen can help address dryness, irritation and certain urinary symptoms, but it isn’t intended to treat hot flashes or other whole-body menopause symptoms.
And here’s something many women don’t realize: using systemic hormone therapy doesn’t necessarily eliminate the need for vaginal estrogen.
Some women taking HRT continue to experience vaginal dryness or urinary discomfort. In those cases, a healthcare provider may recommend adding a local vaginal treatment.
Is Vaginal Estrogen Safe?
For many women, safety is the biggest question.
Estrogen has been the subject of confusing and sometimes alarming headlines for decades. But it’s important to distinguish low-dose vaginal estrogen from systemic hormone therapy because their absorption, benefits and risk profiles are different.
Low-dose vaginal estrogen generally results in minimal systemic absorption, and professional medical guidelines support its use for appropriate women experiencing GSM symptoms.
Still, treatment decisions should always account for personal medical history.
Women with a history of breast cancer or other estrogen-sensitive cancers should discuss treatment with their healthcare team. This is particularly important for women taking aromatase inhibitors.
Anyone experiencing unexplained vaginal bleeding should be evaluated before starting treatment. Bleeding after menopause should always be brought to a healthcare provider’s attention.
The takeaway? Vaginal estrogen has an established role in menopause care, but the right treatment is a personalized medical decision.
How Long Does Vaginal Estrogen Take to Work?
Don’t expect overnight results.
According to Natalie, some women notice improvements in dryness, burning or irritation within a few weeks. More substantial tissue changes and improvements in comfort during intimacy may take longer.
Many women need approximately two to three months of consistent treatment to experience the fuller benefits.
Urinary improvements, particularly a reduction in recurrent UTIs, may take longer to assess because they’re measured over time.
Consistency matters. GSM is generally a chronic condition, meaning symptoms can return after treatment is discontinued.
A healthcare provider can help determine whether ongoing maintenance treatment is appropriate.
Vaginal Estrogen Cream vs. Tablets: Which Is Better?
Vaginal estrogen is available in several formulations, including creams and vaginal tablets or inserts. Both can deliver low doses of estrogen directly to the affected tissues, but they differ in application and convenience.
Vaginal Estrogen Cream
Cream can be applied inside the vagina and, when prescribed for that purpose, to external areas such as the vulva and vaginal opening.
This flexibility may be particularly useful for women experiencing external irritation or discomfort alongside internal vaginal dryness.
Vaginal Estrogen Tablets
Vaginal tablets or inserts are placed inside the vagina and offer a convenient, low-mess option.
They’re designed to deliver estrogen directly to vaginal tissue, making them appealing to women who prefer a simple maintenance routine.
Neither formulation is universally better. The right choice depends on symptoms, personal preferences and medical guidance. Some patients may be prescribed more than one formulation, but combining products should be done only under a clinician’s direction.
How Often Do You Use Vaginal Estrogen?
Treatment schedules depend on the specific product and prescription.
Some formulations begin with a short period of more frequent use, often daily for approximately two weeks, followed by a maintenance schedule such as twice weekly.
Other formulations have different instructions.
Because estrogen-related tissue changes may persist after menopause, some women continue treatment long-term with periodic medical review.
The important thing is finding a routine that is effective, comfortable and sustainable.
Meet Antha: Making Vaginal Estrogen Easier to Access
For Natalie, the science behind vaginal estrogen was only part of the inspiration for launching Antha.
The other issue was access.
Women often feel uncomfortable bringing up vaginal or urinary symptoms, struggle to find providers who understand GSM or face challenges maintaining treatment once they’ve received a prescription.
Antha was created to make that process more straightforward.
Through Antha.health, women can access an online medical evaluation by a licensed physician to determine whether vaginal estrogen is appropriate for them.
The company offers a 0.01% estradiol cream and a 10 mcg estradiol vaginal tablet, with discreet medication delivery and the ability to communicate with a physician by text.
Natalie says Antha’s founding team was motivated by personal experiences navigating barriers to vaginal estrogen treatment.
Her goal is to combine accessible care with clear, evidence-based education so women can make informed decisions about their health.
The Bottom Line: Menopause Care Should Include Vaginal and Urinary Health
We’ve made meaningful progress in talking openly about menopause, but vaginal and urinary health still tend to be left out of the conversation.
That needs to change.
Vaginal dryness, discomfort during intimacy, urinary urgency and recurrent UTIs can have a significant impact on everyday life. Women deserve to know that effective treatment options exist and that these symptoms are worth discussing with a qualified healthcare provider.
What I appreciate about Natalie’s approach is her commitment to making the science understandable and helping women feel comfortable seeking care.
Whether you’re navigating perimenopause, well into menopause or simply curious about your options, understanding the role of estrogen in vaginal and urinary health is a smart place to start.
Learn more about vaginal estrogen treatment and Antha’s approach to women’s healthcare at Antha.health.
About the Expert
Dr. Natalie Barnett, PhD, is the founder and CEO of Antha, a women’s health company focused on expanding access to evidence-based vaginal estrogen treatment. She holds a PhD in quantitative and molecular genetics and has extensive experience leading clinical research at healthcare technology companies.
Medical note: This article is for educational purposes and is not a substitute for individualized medical advice. Consult a licensed healthcare professional about symptoms, diagnosis and treatment options.
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