Vaginal Estrogen: Pearls for the Practitioner A Practical Review of Evidence, Guidelines, and Prescribing Strategies for Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM) is a chronic, progressive condition resulting from estrogen and androgen deficiency that affects 27–84% of postmenopausal individuals. Symptoms include vaginal dryness, dyspareunia, urinary urgency, dysuria, and recurrent urinary tract infections. Despite strong evidence supporting the safety and efficacy of local vaginal estrogen (VE) therapy, treatment remains underutilized due to clinician uncertainty, misconceptions regarding systemic risk, and regulatory warnings. Recent clinical guidelines emphasize vaginal hormones as first-line therapy for GSM. This review summarizes the pathophysiology of GSM, evidence supporting local hormone therapy, safety considerations, and practical prescribing strategies for clinicians. Pearls for clinical practice are discussed, including dosing regimens, formulation selection, patient counseling, and strategies to overcome barriers to treatment adherence.