It relieves painful symptoms and helps prevent recurrent UTIs. Yet outdated fears, uninformed doctors, and decades of neglect still stand between us and our prescriptions.

Fewer than 1 in 10 women 65 and older diagnosed with genitourinary syndrome of menopause (GSM) ever fill a prescription for vaginal estrogen, even though it’s safe past 60. 

When PROVOKED founder Susan Dabbar talked to her doctor about getting a prescription for vaginal estrogen, she’d done her homework. She knew her symptoms—severe vaginal dryness and, in her case, urinary hesitancy, although urinary frequency is a more common symptom—were consistent with GSM. Her sister, a nurse, couldn’t believe she wasn’t already using it.

At age 65 and more than 10 years past menopause, Dabbar knew she wasn’t a good candidate for systemic estrogen therapy. But low-dose, local vaginal estrogen seemed like a no-brainer, and she expected to have a prescription in hand within minutes of bringing it up with her primary care physician.

She still can’t believe what came next.

“My doctor said, ‘I tend to favor optimizing vitamin D before chasing HRT. Have you checked your vitamin D levels?’” said Dabbar, who pushed back, replying that she takes 1,000 IU of vitamin D daily and didn’t see how that would address her symptoms of GSM.

Then, her doctor doubled down on vitamin D, and it took multiple email follow-ups to finally get a prescription for the treatment of her symptoms.

“Imagine if I weren’t well versed in this topic or wasn’t so vocal and able to advocate for myself,” said Dabbar. “I would’ve walked out of there with no prescription for vaginal estrogen. How many women who have symptoms like mine are walking away from their doctors without a prescription?”

Why Doctors Still Aren’t Prescribing It

So, why aren’t more of us being prescribed this safe, effective, and relatively inexpensive treatment? Why does it often feel like a fight to get a prescription or such a struggle to find a clinician who’s up to speed on the American Urological Association’s (AUA) guidelines for treating GSM, which say that clinicians should offer the option of low-dose vaginal estrogen to patients with GSM?

“Good f-ing questions,” said urologist Dr. Kelly Casperson. “I think it’s a Venn diagram of dismissal of older people, dismissal of anything that remotely smells like sexual health, and a dismissal of hormones as actual medicine and not some sort of trendy longevity fad.” 

Dr. Melissa Kaufman, Ph.D., FACS, a urologist and lead author of the AUA’s guidelines, also pointed to the years-long black box warning on all estrogen products, including vaginal estrogen, as a reason why it’s still underprescribed. The product labeling that came with vaginal estrogen warned women of an increased risk of cardiovascular disease, breast cancer, and dementia—warnings the FDA later said needed to be updated to reflect current evidence—and it slowed current efforts to spread the word about vaginal estrogen’s safety and efficacy, said Dr. Kaufman.

“It was just in November 2025 that the FDA initiated the removal of that black box warning,” said Dr. Kaufman. “Unfortunately, information about vaginal estrogen’s safety hasn’t penetrated into our collective consciousness yet.”   

What Is Genitourinary Syndrome of Menopause?

Of course, it’s hard to ask for a treatment when you don’t know you have the condition it treats. And that’s a big part of the problem with GSM: Too many women have never heard of it, don’t recognize the symptoms, and never get diagnosed.

GSM is a chronic, progressive condition most often caused by declining estrogen levels that can affect the vulva, vagina, and lower urinary tract. These tissues are filled with estrogen and testosterone receptors. After menopause, these hormone levels decline sharply, and those tissues don’t get the hormones they need. The result can be dryness, itching, burning, and irritation in the vulva and vagina; pain or discomfort during sex; difficulty reaching orgasm; decreased libido; and/or urinary symptoms, such as burning when urinating, frequent or urgent need to urinate, changes in urinary stream, incontinence, and/or recurrent UTIs.

“We have data that women wait years before going to their doctor for bladder leakage,” said Dr. Casperson, if they seek care at all. She added that women are also likely putting off getting help for the other symptoms of GSM given how much shame they can prompt.

There’s another reason many of us aren’t getting a diagnosis of GSM and a prescription for its treatment: Vulvar exams can become less common after menopause. 

“Women often avoid having a vulvar exam because of pain, or they don’t think they need one because they’re past their childbearing years or had a hysterectomy,” said Dr. Kaufman. “What’s more, many clinicians aren’t comfortable performing these types of exams, even though it’s an important part of being able to give an accurate diagnosis of GSM. I think this is a major obstacle to beginning treatment for many patients.”

How Does Vaginal Estrogen Work?

The vagina is lined with layers of cells that help keep the tissue plump, elastic, and resilient. Estrogen plays a critical role in maintaining the health of these cells. The vulva—the external genitalia, including the labia, clitoris, and vaginal opening—is similarly hormone sensitive and responds to both estrogen and testosterone.

When hormone levels fall after menopause, the vaginal lining thins, blood flow decreases, and the tissues can become drier and less elastic, said Dr. Kaufman. This, in turn, can shorten and narrow the vagina, which is one reason sex can hurt.

The assault doesn’t stop there. Beneficial bacteria called lactobacilli that live in the vulvovaginal region thrive on estrogen, Dr. Kaufman continued. When estrogen is low, it can change the acidity of the vagina, and those helpful lactobacilli can’t colonize as effectively, which may help explain why UTIs can become more common after menopause.

Vaginal estrogen gives those hormone-dependent cells what they need to stay healthy and protect you from both symptoms and infection. And because the dose is low and there are so many hormone receptors in the tissues where it’s being applied, systemic absorption is generally very low, said Dr. Casperson.

This is why it’s considered safe for nearly all women, said Dr. Kaufman, including those who are more than 10 years past menopause and may not be candidates for systemic hormone therapy. 

The Price of Doing Nothing

The fact that so many women who could benefit from vaginal estrogen aren’t using it isn’t just an unfortunate gap in healthcare. When left untreated, GSM can have serious consequences that extend beyond vaginal dryness and painful sex.

One 2026 study of nearly 2 million women with recurrent UTIs found that just 5% were prescribed vaginal estrogen, and those who were had substantially lower rates of sepsis, hospitalization, and death than women who weren’t prescribed it. Another analysis of randomized controlled trials also found vaginal estrogen can help reduce the risk of recurrent UTIs in postmenopausal women.

There are also the literal healthcare costs of these highly preventable health outcomes. Treating a single uncomplicated UTI (a bacterial infection in the lower urinary tract in an otherwise healthy person) costs an average of about $1,300 in healthcare expenses and about $500 in lost productivity and other costs, according to a recent study. When a complicated UTI (an infection where the patient is at higher risk of complications) leads to hospitalization, the costs climb quickly. The median cost of a UTI-related hospitalization was nearly $10,000 in a 2022 study using 2017-2018 claims data. And when a complicated UTI requires hospitalization, the median cost of treatment is about $27,800—though the average is $42,000, skewed upward by the most expensive cases. For sepsis survivors, the bills may keep climbing after discharge, with nearly $29,000 in median healthcare costs during the first year alone. 

“We have the data proving that not treating GSM is incredibly expensive and that vaginal estrogen saves money and saves lives,” said Dr. Casperson. “We don’t need more data. We need to implement the data we have.”

How to Ask for Vaginal Estrogen (and What to Say If Your Doctor Says No)

Convinced of the benefits of vaginal estrogen but haven’t had a conversation about it with your healthcare provider? Bring it up at your next appointment and be honest about the symptoms that may feel tough to talk about. “You have to lay it on the table,” said Dr. Kaufman.

Feel free to outright ask, “Am I a good candidate for vaginal estrogen?” You might even have the link to the guidelines pulled up on your phone so you can hand it to your clinician if you experience any pushback. If that happens, Dr. Casperson recommends saying something like this:

“I’m experiencing X, Y, and Z and I would like to trial vaginal estrogen cream. Please call the prescription in to the pharmacy where I found the best price. I’ll schedule a follow-up so we can adjust the plan as needed.” If your doctor still isn’t on board with that, ask why.

“What you’ve done here is gave your clinician a diagnosis, told them the prescription, shared the pharmacy where you found the best price, and gave them a follow-up plan as well,” said Dr. Casperson. “This is what self-advocacy looks like.”

That’s how Dabbar ended up with her prescription for vaginal estrogen. Eight months later, she’s an evangelist.

“I tell everyone, ‘It’s so easy. You put it on your finger, you rub it all over, and it’s like you go back in time,’” she said. “My vagina is so lovely now. Eight months ago it was atrophied and wrinkled. Now, my vagina looks like it did when I was in my 40s, and my symptoms are gone. 

“It’s like magic.”

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