What are the alternatives to vaginal estrogen?
There are several good alternatives to vaginal estrogen, and the right one depends on your goals and on whether you want to avoid hormones entirely. Genitourinary syndrome of menopause (GSM), once called vaginal atrophy, is the group of symptoms low-dose vaginal estrogen treats: dryness, irritation, and pain with sex. More than one approach can relieve these symptoms, and the best choice is made together, weighing the evidence against your own preferences and goals.
Nonhormonal moisturizers and lubricants
Nonhormonal vaginal moisturizers and lubricants are first-line, and they are the starting point for everyone, especially anyone who wants to avoid estrogen. A moisturizer is used on a regular schedule, roughly one to three times a week, to keep the tissue hydrated over time. A lubricant is used at the time of sex to reduce friction and pain. Neither contains hormones. Guidelines recommend moisturizers and lubricants, alone or combined with other therapies, to improve vaginal dryness and painful sex. For many people with milder symptoms, this is enough.
Vaginal DHEA (prasterone)
Vaginal DHEA, sold as prasterone (Intrarosa), is a nonestrogen prescription option and a vaginal insert used once a day. DHEA is an inactive precursor that vaginal cells convert locally into small amounts of estrogen and testosterone; blood levels of these hormones stay within the normal postmenopausal range. It improves vaginal dryness and pain with sex, and the guideline gives it a moderate recommendation. It is a reasonable fit if you prefer a hormonal option that is not estrogen, or a simple once-a-day insert.
Ospemifene
Ospemifene (Osphena) is an oral pill, a selective estrogen receptor modulator, taken as a 60 mg tablet once a day. It acts like estrogen on vaginal tissue and is approved for moderate to severe pain with sex and vaginal dryness. It is the only oral product approved specifically for these symptoms, which makes it worth considering if you would rather not use a vaginal product. It carries an FDA boxed warning about the risk of blood clots and stroke, so that risk is worth discussing before you start.
Neither vaginal DHEA nor ospemifene requires routine monitoring of the uterine lining. Pelvic floor physical therapy can also help as an adjunct when pelvic floor muscle dysfunction is adding to the pain.
What the evidence does not support
Some popular options are not backed by evidence. Over-the-counter herbal and phytoestrogen supplements are not supported for GSM, and no vitamin substitutes for estrogen; a one-year randomized trial of black cohosh, a multi-botanical supplement, and soy found no change in vaginal dryness. Energy-based treatments such as vaginal laser are also not supported by current evidence, which I cover elsewhere.
How I approach it
When patients want to avoid vaginal estrogen, I recommend starting with a nonhormonal moisturizer and a lubricant, because they are low-risk and inexpensive. If dryness and pain persist and you want to stay away from estrogen, vaginal DHEA and ospemifene are both good next steps, and I match the choice to what fits your life: a daily vaginal insert, or a daily pill. Low-dose vaginal estrogen itself remains the option with the strongest evidence, so choosing an alternative is usually about your preferences and goals rather than about safety. Whatever we choose, we can change course if it is not working, and it is common to combine a moisturizer with a prescription therapy.
References
- Kaufman MR, Ackerman AL, Amin KA, et al. Genitourinary Syndrome of Menopause: AUA/SUFU/AUGS Guideline. American Urological Association. 2025.
- Faubion SS, Kingsberg SA, Clark AL, et al. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020. doi:10.1097/GME.0000000000001609
- Ringel NE, Iglesia C. Common Benign Chronic Vulvar Disorders. American Family Physician. 2020.
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