Use of vaginal estrogens in urogynecology: current evidence, controversies and clinical applications

PURPOSE OF REVIEW: Genitourinary syndrome of menopause (GSM) is a prevalent yet underrecognized condition in postmenopausal women, characterized by progressive vulvovaginal and lower urinary tract symptoms from estrogen deficiency. Vaginal estrogen therapy is the first-line pharmacologic treatment for GSM. However, as new evidence emerges, understanding of its efficacy, safety, and use in special populations continues to evolve. This review summarizes current evidence on vaginal estrogen formulations, clinical effectiveness, safety, and therapeutic applications. RECENT FINDINGS: Recent randomized controlled trials confirm that low-dose vaginal estrogen significantly improves GSM symptoms - including vaginal dryness, dyspareunia, and irritation - while restoring epithelial integrity and normalizing pH. Evidence also supports its role in reducing recurrent urinary tract infections by restoring lactobacilli-dominant flora, reinforced by a 2025 multisociety clinical guideline recommending topical, but not systemic, estrogen for this indication. Comparative studies show similar efficacy across creams, tablets, inserts, and rings, differing primarily in convenience and absorption rather than effectiveness. Large cohort studies indicate no increased risk of cardiovascular disease, venous thromboembolism, or malignancy. Use in breast cancer survivors remains controversial, but emerging data suggest minimal systemic absorption and no clear increase in recurrence risk, supporting shared decision-making. In addition, long-term outcomes show that adjunctive vaginal estrogen does not improve anatomic surgical success after native tissue apical prolapse repair. Nonhormonal therapies and agents like ospemifene or prasterone offer alternative options, though they demonstrate lower or more variable efficacy than vaginal estrogen. SUMMARY: Vaginal estrogen therapy is the most effective, evidence-based treatment for GSM and helps prevent recurrent urinary tract infections in postmenopausal women. Its favorable safety profile and multiple formulations enable individualized care. Recent evidence clarifies that while overall safety is reassuring, caution is necessary for breast cancer survivors using aromatase inhibitors. Additionally, longer-term perioperative trial data temper expectations regarding surgical-recurrence benefits, while confirming its value for local tissue optimization. Ongoing research should focus on long-term safety in high-risk groups and the effectiveness of emerging non-estrogen alternatives.