Not Your Grandma's Crotch Cream
Legit things to use vaginally for GSM
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The last two weeks have been exciting for me personally and professionally, but I’m also excited about the new recommendations from the American Urological Association on the Genitourinary Syndrome of Menopause (GSM).
I know, right?! Aren’t you excited too?!
Why does this matter?
It matters because we now have updated formal guidelines for physicians (urologists, first and foremost, but other physicians also look to these guidelines) to treat the symptoms of the vaginal and urological changes that occur during perimenopause and menopause.
If you’re unsure what the Genitourinary Syndrome of Menopause (GSM) is, you can read my articles Urine Luck! Peeing Problems in Perimenopause and Papaya Dryness.
The guidelines are very clear on screening, diagnosis, and treatment, and give physicians a basis from which to work from. This information is also a catalyst for continuing education for physicians on menopause topics and is being widely discussed in the medical community.
The Menopause Society has endorsed these guidelines and also updated its consumer health brochure based on this information.
In addition to treatment, it also clarifies whether things like CO2 laser or radiofrequency are effective based on evidence (they get a C grade for evidence of effectiveness). Although the FDA has cleared these options for safety in vaginal use, they haven’t been approved specifically for GSM.
The purpose of this article isn’t to delve deeply into the recommendations. Instead, I want to share some information on evidence-based products that are available vaginally to help with pain, discomfort, or those pesky urinary symptoms that can pop up around this age.
Grandma’s Crotch Cream
We’re so lucky to be living now when we have so many available options to help with the vaginal discomfort and urinary symptoms of GSM and other vaginal issues.
Premarin vaginal cream was first approved by the FDA in 1946 and is still being manufactured. This cream is made from conjugated estrogens. Conjugated means combined, so this is a mixture of different types of estrogen1 .
Premarin is also available as an oral pill and is the type of estrogen most often used in the major hormone therapy studies. If you’d like to learn more about conjugated estrogens vs. estradiol estrogen, I wrote about it here.
Grandma had this one option.
A World of Choices for Us
Prescription Options:
We can work with our doctors to pick from these prescription options to help with GSM.2 Some of these options are only approved for postmenopause. None of them are considered contraceptive.
For all of these options, follow your doctor’s and prescription instructions.
These options are available in the US. The last I checked, Canada does not have an available vaginal estradiol estrogen cream, and I’m sure there are more differences between all countries.
The below listed estrogen products can help with both vaginal and urinary GSM complaints.
Premarin (vaginal cream) - as discussed above, this option is still available
Estradiol Estrogen (vaginal cream; also called Estrace) - This one seems to be the most popular option and the least costly option overall. Some complain about the applicator, but there are other ways to get the job done.
Estring (vaginal ring) - A fairly small “soft, flexible” ring (although I’ve seen it in person and was actually surprised how large it was) that you fit into your vagina where it stays for 3 months. This is convenient but may be an expensive option.
Vagifem (vaginal tablet) - an estradiol tablet inserted vaginally
Imvexxy (vaginal softgel) - an estradiol softgel inserted vaginally
Intrarosa (vaginal suppository) - a non-estrogen option (DHEA; drug name prasterone) that comes as a vaginal suppository that is converted into estrogen by your body. This product helps with vaginal GSM complaints and may help with urinary symptoms like UTIs (it hasn’t been studied enough).
Any prescription that does not have a generic equivalent will most likely be more expensive. When pharmaceutical companies develop a drug, it stays under a patent for 20 years, which means that generic pharmaceutical companies cannot make a cheaper version of the drug until the patent expires and the FDA approves a generic version.3
I advise you to check your health insurance coverage while working with your physician on which option is right for you.
Note: A big question that comes up is whether you can use estrogen vaginal products in addition to HRT (systemic estrogen with or without progesterone). The American Urological Association’s guidelines recommends that clinicians “should offer the option of local low-dose vaginal estrogen or DHEA” in patients experiencing GSM even if the patient is on systemic estrogen.
Non-Prescription Choices:
Vaginal Lubricants - vaginal lubricants are used during sexual activity to reduce friction and pulling of vaginal skin which can become delicate. Vaginal lubricants do not help repair or rebuild tissue.
When selecting vaginal lubricants, I opt for versions without warming ingredients or flavors. In my book, less is more. You’ll also see recommendations to pick one without propylene glycol, which is good advice, but the problem is that prescription vaginal creams contain it, so it gets confusing which advice to follow. I avoid it in my lube, but can’t avoid it in my vaginal cream.
Lubricants come in different versions: water-based, silicone-based, and oil-based. Some lubricants work better with condoms than others, so do your research (I can help!). Plus, some lubricants are better suited for certain locations (like the shower).
Vaginal Moisturizers - vaginal moisturizers help hold in moisture and can help keep tissue plump. Moisturizers are used as a part of your daily care routine and not for sex.
While the gold-standard of GSM care is estrogen-based vaginal products, moisturizers are a good option for those looking for a hormone-free over-the-counter option and they help best with mild GSM vaginal symptoms. Dr. Monica Christmas, OB/GYN, recommends hyaluronic acid-containing moisturizers, so look for this as an ingredient. If you need brand names or help picking one, contact me.
Vaginal Dilators - The Menopause Society offers vaginal dilators as another option to help stretch and enlarge the vagina. The vagina goes through many changes during this time which some may be helped by dilators. These are different from vibrators and should be used in combination with guidance from a clinician. However, vibrators (or a penis) can be helpful in improving blood flow and getting the juices flowing.
What Shouldn’t I Use Vaginally?
Dr. Lauren Streicher, a leading menopause MD specialist and one of the first doctors to really tell us how it is, wrote this great article:
As a GYN, she’s seen it all. And, I’ll never see a toothbrush the same way again.
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Be well, stay cool…
Shelby Tutty, MHA
Certified Perimenopause Educator
Founder of The Periprofessional, LLC
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Made from a mixture of “sodium estrone sulfate and sodium equilin sulfate and other components: 17α-dihydroequilin, 17α-estradiol, and 17β-dihydroequilin.” And, yes, it’s true that it’s derived from pregnant horse urine. https://www.pfizermedicalinformation.com/patient/premarin-vaginal-cream/what-are-the-ingredients-in-premarin-vaginal-cream
MenoNote, Genitourinary Syndrome of Menopause, The Menopause Society, May 2025. and Levy-Gantt, Rebecca. Perimenopause for Dummies. John Wiley & Sons, 30 Nov. 2023.
Although Premarin has been around for decades, it does not have a generic equivalent.
Thanks for keeping us up to date with the new guidelines! 😍
I saw these new guidelines hit the other day and said 'it's about damn time'!