Estrogen Ring vs Cream vs Inserts for Menopause HRT

Hormone replacement therapy (HRT), also known as menopause hormone therapy (MHT), is used to alleviate the symptoms of decreasing estrogen and progesterone production. Estrogen vaginal rings, inserts, and vaginal creams are forms of local hormone therapy used to treat vaginal dryness, irritation, or itching, urinary urgency or leaks, and discomfort or pain during sex.

This article outlines the differences between estrogen vaginal rings, inserts, and estrogen vaginal creams for treating vaginal menopause symptoms.

Why Women Need More Estrogen During Menopause?

As women approach midlife and reproduction is no longer likely to occur, the body naturally starts to produce less of the sex hormones estrogen and progesterone. This stage of life is known as perimenopause. It can last 4-12 years, and the symptoms of declining hormone production are experienced differently by every woman. 

Menstruation typically becomes irregular due to these hormone changes, and because estrogen supports almost every body tissue; the skin, muscle mass, bone density, heart health, vaginal lubrication, and brain function may also experience changes. 

These changes can manifest in the body as hot flashes, night sweats, interrupted sleep, brain fog, increased anxiety or depression, vaginal dryness, and pain during sex. 

Once hormone levels have permanently stabilized, and menstruation has not occurred for a year, menopause has been reached. Afterward, women are considered postmenopausal for the remainder of their lives, and although most menopause symptoms ease or stop for many, some women continue to experience symptoms.

Local vs Systemic MHT

Because each woman experiences menopause differently, with varying symptoms and levels of intensity, hormone therapy to alleviate menopause symptoms also varies. 

Local MHT (vaginal rings, inserts and creams) is prescribed to relieve symptoms affecting only one area of the body, typically the vaginal area, urinary tract, and pelvic floor muscles. Systemic MHT (pills, patches, gels, rings, or sprays) is absorbed throughout the entire body to alleviate menopause symptoms affecting several body parts. 

Due to the localized nature of vaginal estrogen, the risk of side effects is much lower compared to systemic estrogen therapy. 

With systemic estrogen therapy being absorbed throughout the body, a progestin or bioidentical progesterone pill is typically taken at the same time to prevent hyperplasia of the uterine lining and the risk of uterine cancer linked to estrogen-only MHT. This is not necessary when taking local MHT only.

That said, women who have undergone a hysterectomy can safely take estrogen-only MHT (systemic and local) because there is no uterus to protect.

When correctly prescribed according to each woman’s needs, the benefits of MHT greatly outweigh the risks. And after 80 years of research, findings reveal that determining the correct type of MHT for each woman requires consideration of their age, medical history, whether they’ve had a hysterectomy, and where they are on their menopause journey (perimenopause or postmenopause). 

How Does Menopause Affect the Vagina?

Due to the lowered levels of estrogen passing through the skin tissues and muscles during the menopause transition, a loss of moisture, skin elasticity, and decreased blood flow is common.

The vaginal skin can become dry due to a lack of natural lubrication linked to low estrogen levels, and the pelvic floor muscles and urinary tract can lose elasticity. Ensuing symptoms include; vaginal itching and vulvar skin irritation (Vaginal Atrophy), discomfort or pain during sex (Dyspareunia), and a sudden or frequent urge to pee, sometimes involving urine leaks (Overactive Bladder or Urge Incontinence). Additionally, some women experience recurrent bladder infections.

Collectively known as Genitourinary Syndrome of Menopause (GSM), local hormone therapy in the form of estrogen vaginal rings, inserts orcreams are used to ease symptoms, improve quality of life, and enhance sexual pleasure. 

The most common form of estrogen used in MHT is estradiol. 

What is Estradiol?

Estradiol (E2) is a specific type of estrogen. In essence, estrogen is a broad term for several hormones, including estradiol, estriol, and estrone. Although each plays a role in supporting the female reproductive system, estradiol is the most powerful form of estrogen naturally found in the body, particularly during the reproductive years. 

Estradiol is bioidentical, meaning it is derived from plants and is chemically identical to the estradiol naturally produced in the body. 

Estrogen Ring vs Cream vs Inserts: Similarities and Differences

Estrogen vaginal rings, creams or insertsall contain estradiol. They are considered effective and safe methods of local hormone therapy for treating GSM symptoms, including vaginal dryness, itching, and irritation, in addition to pain during sex, a frequent need to pee, or urinary leaks. 

While they differ in some ways, estrogen vaginal rings, creams and inserts are designed to restore moisture, improve elasticity, and reduce discomfort.

Due to minimal absorption into the bloodstream, the uterine lining is not at risk of hyperplasia with local estrogen therapy, meaning synthetic progestin or bioidentical progesterone are never required. 

Estrogen Vaginal Rings 

Vaginal rings are similar in size to a hair tie/elastic and are inserted and then changed out y every three months. Most women do this themselves, but if dexterity issues exist, an appointment can be made every 3 months for a clinician to exchange the ring. Considered long-lasting and convenient, they are designed to release a low and steady dose of estrogen to the vaginal area every day without systemic absorption. 

Although convenient, vaginal rings are pricier than vaginal creams, and require replacing every 3 months. 

Estrogen Vaginal Creams

Vaginal estrogen creams are administered with a vaginal applicator or with a finger. Once inserted, the cream adheres to the vaginal walls and releases estradiol into the skin tissue, delivering a low and steady dose of estradiol to the vaginal area, with minimal absorption into the bloodstream. 

Even though they might seem less convenient to vaginal rings or inserts, estrogen vaginal creams are easily applied, cost effective, and don’t involve leaving a foreign object long-term in the vagina. Vaginal creams are usually inserted nightly for two weeks, and then the dose is decreased to 2-3 times weekly. Unlike rings or inserts, creams can be applied directly to the skin that needs it most, including the opening of the vagina, clitoris and labia. 

Vaginal Estrogen Inserts

Estrogen vaginal inserts are also inserted in the vagina with the help of a clean finger or an applicator into which the suppository tablet or gel cap fits. When inserted, the tablet begins to dissolve, and estradiol is released into the skin, once again with minimal to no absorption into the bloodstream. 

Similar to estrogen vaginal creams, estrogen vaginal inserts are inserted daily for two weeks, then decreased to two to threetimes per week, depending on each individual’s needs.

Each of the above forms of local MHT is safe and effective, with the choice coming down to each individual’s preference, overall health, vaginal comfort, and price range. 

Are There Side Effects Linked to Vaginal Estrogen?

Common side effects of vaginal estrogen include some vaginal sensitivity or discharge.

Can Every Woman Use Vaginal Estrogen to Treat Menopause Symptoms?

Vaginal estrogen is safe for almost all women experiencing GSM during perimenopause and postmenopause, however, women with certain conditions should discuss further with their clinician. If you suffer from any of the conditions mentioned below, consult with a menopause expert to determine which type of MHT is right for you. 

• Allergic reaction -you may have an allergy to an inactive ingredient in the cream, insert, or ring. In these cases, compounding pharmacies can be utilized to mix estrogen into a hypoallergenic base. 
  
• Unexplained vaginal bleeding- the source of bleeding should be determined before starting vaginal estrogen
• History of uterine sarcoma- these cancers can recur in the vagina and are often estrogen-sensitive. We have limited studies on the safety of vaginal estrogen in this population. A risk vs. benefit conversation is needed before starting vaginal estrogen in this group.

Not Sure Which Type of MHT Is Right for You?

Given the myriad of menopause symptoms and the varying intensity with which they are experienced, not to mention the exaggerated media coverage on the apparent risks, it can be tricky to comprehend if MHT is right for you, and if so, which type or dose.

Added to that, most PCPs lack basic education and training about the effects of menopause on the body, the associated symptoms, and the various types and doses of MHT that ease them with minimal risk. 

To help women understand their hormonal needs throughout the menopause transition, Intimate Rose, a leading American female health company, has launched a telehealth platform to provide MHT and menopausal care.

After filling out a free and confidential assessment that includes your age, menopause symptoms, and medical history, you’ll receive MHT recommendations from one of their menopause experts before your hormone treatment is discreetly shipped to your door within days. 

Follow-up consultations are also available to monitor symptom relief and dose adjustments.

Are There Non-Hormonal Methods of Treating GSM?

Yes, there are. Vaginal dryness and vulvar irritation can be eased by using an organic vaginal moisturizer that is free from harmful synthetic ingredients that could further irritate the vaginal skin. 

Frequent peeing, urine leaks, and a loss of elasticity in the vaginal muscles during menopause can be treated non-hormonally by re-toning the vaginal and pelvic floor muscles with Kegel Weights made from body-safe, medical-grade silicone. Pelvic floor physical therapy is a very effective treatment option for urinary issues, and Intimate Rose is proud to offer pelvic floor physical therapy telehealth appointments nationwide. 

To relieve discomfort during sex, a personal silicone-based lubricant moistens the vaginal opening and vaginal canal for less friction and more pleasure. In more severe cases of dyspareunia, where the vaginal muscles tighten due to pain, a set of vaginal dilators, ideally made from body-safe, medical-grade silicone, are recommended to gently stretch the vaginal tissues and pelvic floor muscles. 

Conclusion 

Estrogen rings, creams, or inserts are a form of local hormone therapy used to treat the Genitourinary Syndrome of Menopause (GSM). Affecting the vulva, vagina and bladder, GSM can include vaginal dryness, urinary frequency or leaks, and pain during sex. 

While each is designed to release a low and steady dose of estradiol into the vaginal area to relieve GSM symptoms, rings stay in the vagina for up to three months estrogen vaginal creams or inserts are administered a few times per week using a clean finger or applicator.

For more insight into the types of MHT and the benefits they can provide, complete this free menopause assessment at Intimate Rose for guidance and recommendations based on your unique needs. 

References 

Intimate Rose – Menopause Hormone Therapy Administration Methods - https://www.intimaterose.com/blogs/womens-health/menopause-hormone-therapy-administration-methods?

Verywell Health - The Difference Between Estradiol and Estrogen - https://www.verywellhealth.com/estradiol-vs-estrogen-why-hormone-levels-matter-7566712

Mayo Clinic – Vaginal Atrophy - https://www.mayoclinic.org/diseases-conditions/vaginal-atrophy/symptoms-causes/syc-20352288

National Library of Medicine – Dyspareunia - https://www.ncbi.nlm.nih.gov/books/NBK562159/

Johns Hopkins Medicine - Genitourinary Symptoms of Menopause - https://www.hopkinsmedicine.org/health/conditions-and-diseases/genitourinary-syndrome-of-menopause