Written by: Sarah Lunsford, MPH, PhD,
TABLE OF CONTENTS
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Perimenopause and menopause don’t just mean hot flashes and night sweats. Up to 87% of women experience disruptive symptoms below the belt: vaginal dryness, burning, itching, pain with sex (dyspareunia), micro-tears, and urinary incontinence or recurrent infections. Collectively, these changes are part of Genitourinary Syndrome of Menopause (GSM), a condition caused by declining hormones that normally keep your vaginal and urinary tissue healthy, cushioned, and well lubricated.
How Do Hormones Support Vaginal and Pelvic (Below-the-Belt) Health?
Hormones — especially estrogen — play a major role in keeping the pelvic tissues healthy. Estrogen helps maintain natural lubrication, elasticity, and thickness in the tissues of the vulva, vagina, urethra, and perianal area. It also supports blood flow, collagen production, and a balanced vaginal microbiome, all of which are essential for comfort and sexual health.
Why Does Vaginal and Urinary Discomfort Happen During Perimenopause and Menopause?
During perimenopause and menopause, estrogen levels decline. As a result, the skin and tissues in these areas can become thinner, less elastic, and less naturally lubricated. This can lead to:
- Vaginal dryness and irritation
- Burning or itching
- Pain with sex (dyspareunia)
- Micro-tears or discomfort with movement
- Pelvic pressure or soreness
- Urinary urgency, leakage, or recurrent UTIs
What is Menopause Hormone Therapy (MHT)?
MHT — also called systemic hormone therapy — supplements the estrogen, progesterone, or testosterone that drop when you enter perimenopause and menopause.
Unlike vaginal estrogen that works only in the pelvic area, MHT travels through the bloodstream and supports the whole body. It is used to relieve common menopause symptoms such as:
- Hot flashes
- Night sweats
- Brain fog
- Mood changes
- Sleep disruption
MHT can also help support bone health, cognitive function, and overall well-being as hormones change with age.
How Is MHT Delivered?
There are several ways to take MHT, depending on your needs and preferences:
- Oral pills
- Transdermal patches
- Topical gels or sprays
Your healthcare provider can help determine which form and dose are best for you based on your symptoms, medical history, and health goals.
How Is Menopause Hormone Therapy (MHT) Different from Vaginal Estrogen?
For vaginal dryness, pain with sex, or urinary symptoms, local vaginal estrogen may be recommended, either alone or alongside MHT.
Vaginal estrogen works right where the tissue needs support, with minimal absorption into the bloodstream, and is available as:
- Vaginal cream
- Vaginal tablet
- Vaginal ring
- Vaginal insert or suppository
How do I Choose Between Vaginal Estrogen and Menopause Hormone Therapy (MHT)? Can I Use Both?
Vaginal estrogen and MHT are both effective options for managing GSM.
If your main symptoms are vaginal dryness, irritation, pain with sex, or urinary urgency, vaginal estrogen is often the first-line treatment. It works locally in the vaginal and vulvar tissues, making it a targeted option for below-the-belt discomfort.
MHT may be recommended if you are also experiencing whole-body symptoms such as hot flashes, night sweats, brain fog, mood changes, or sleep disruption.
You can absolutely use both. Many women benefit from combining vaginal estrogen with MHT for comprehensive relief.
Always work with a menopause-trained clinician to determine the safest and most effective plan for your individual health history and goals.
Is Menopause Hormone Therapy (MHT) Safe?
The latest position statement from The Menopause Society, the leading U.S. medical organization on menopause care, education, and treatment guidelines, concludes that hormone therapy is the most effective treatment for hot flashes and GSM.
Like any medical therapy, MHT does come with potential risks, but for many women, especially those who start it near the menopause transition (within 10 years of their last period), the benefits often outweigh the risks. And importantly, our understanding of menopause and hormone therapy has advanced dramatically over the last 20 years, leading to safer dosing, better delivery methods, and more personalized care than before.
Today, hormone therapy is about the right treatment, for the right person, at the right time, in the right formulation, for the right duration.
Some Considerations When Exploring MHT:
- Breast cancer risk
- Combined estrogen + progesterone therapy may slightly increase breast cancer risk
- Estrogen-only therapy for women without a uterus does not appear to increase breast cancer risk
- Blood clots + stroke
- Oral estrogen may increase risk of blood clots. Transdermal estrogen (estrogen patch, gel, or cream) may be safer.
- Cervical cancer
- MHT does not increase your overall risk of cervical cancer, but some research suggests certain hormone regimens may be associated with a slightly higher risk of specific cervical cancer subtypes. This is why it is important to work with a clinician to personalize your care based on your health and family history.
Like any therapy, safety depends on the type, dose, route, timing, and personal risk factors. It is important to consult with your healthcare provider to determine the best intervention for your specific situation.
Can I Get MHT for Menopause Over-the-Counter?
No, you cannot get true MHT over-the-counter. Hormone therapy must be prescribed and monitored by a licensed healthcare provider. This ensures the right dose, delivery method, and safety screening based on your health history.
To start MHT, you’ll typically work with an OB/GYN, menopause-trained primary care provider, nurse practitioner, or another licensed provider.
What About “Hormone-Free” Menopause Supplements?
Some over-the-counter supplements claim to balance hormones or relieve perimenopause and menopause symptoms. While some women find relief, these products:
- Do not replace hormones
- Vary widely in quality and evidence
- Are not regulated for safety
Always check with your healthcare provider before starting supplements.
What If I Don’t Want to Treat My Menopause Symptoms with Hormones?
There are effective non-hormonal strategies to help manage symptoms!- Vaginal moisturizers and lubricants for routine comfort and sex.
- Pelvic floor physical therapy for pain, urinary symptoms, and tissue support.
- Ospemifene (oral SERM) and vaginal DHEA (prasterone) are prescription options for moderate to severe GSM when moisturizers aren’t enough.
- Prasterone works locally to nourish and restore vaginal tissue. Though it is often described as a “non-estrogen” option, it’s technically a hormone precursor, meaning the body can convert it into small amounts of estrogen and testosterone right where it’s needed.
How to Choose a Clean Vaginal Moisturizer or Lubricant
| LOOK FOR | AVOID |
|---|---|
| pH balanced (3.8-4.5) - supports healthy vaginal flora | Glycerin or propylene glycol - can sting or feed yeast |
| Gentle hydrators - hyaluronic acid, vitamin E, squalane | Parabens or phenoxyethanol - preservatives that irritate thin tissue |
| Short ingredients list - simple, transparent, free of fragrance or alcohol | Fragrance, essential oils, or “tingling” ingredients like menthol, peppermint, or cinnamon |
| The right texture for you: Water-based for everyday comfort Silicone-based for long-lasting moisture Oil-based for external soothing (not condom-safe) | Petroleum or mineral oil - traps bacteria, damages condoms |
| Products with “freshening” or “tightening” claims - disrupt vaginal and vulvar balance |
How To Talk To Your Clinician About Your Perimenopausal Below the Belt Symptoms
Too many women report feeling dismissed or gaslit when they bring up menopause or GSM. If your doctor minimizes your symptoms or says, “That’s just part of aging,” you have the right to seek care elsewhere. Here’s how to find a more supportive provider:
- Look for a menopause-certified specialist. The Menopause Society maintains a directory of clinicians certified in menopause care. These providers receive additional training in hormone therapy, perimenopause, and GSM.
- Ask the right questions up front. When booking an appointment, ask:
- Do you treat women in perimenopause or menopause?
- Are you comfortable prescribing hormone therapy or local estrogen?
- Do you screen for pelvic floor or vulvovaginal changes?
- Bring notes and data. Track your symptoms like dryness, irritation, urinary urgency, libido changes, or pain with sex. Clinicians respond better to clear patterns and specifics than to general discomfort.
- Don’t hesitate to get a second opinion. If you feel unheard, remember this is your body. You deserve care that’s evidence-based, safe, and compassionate.
- Consider a provider that offers integrative care. Many types of clinicians can help manage GSM and menopause symptoms including OB/GYNs, pelvic floor therapists, women’s health nurse practitioners, and functional medicine clinicians. The most effective care plan often combines multiple interventions including hormonal, non-hormonal, and supportive therapies that address pelvic health, tissue resilience, and overall wellbeing.
The Bottom Line
You don’t have to just live with below the belt discomfort during perimenopause and menopause. Work with a clinician who listens, considers your personal history and risk, and offers a stepwise plan that includes clean, supportive topicals, pelvic floor care, and, when appropriate, hormone therapy.