 In my last video, I explained how the first line treatment for mild to moderate vaginal dryness due to menopause are lubricants and moisturizers, and called out the safest brands. If over-the-counter lubricants and moisturizers are insufficient to control the agendo-urinary symptoms of menopause, low-dose local estrogen therapy is recommended unless women have a history of hormone-dependent cancers like endometrial or breast. Local, meaning applying vaginally as opposed to taking orally, vaginal application is considered safer, more effective than systemic hormone therapy. A meta-analysis of 58 studies comparing vaginal to systemic estrogens found that vaginal estrogen therapy offered better symptom relief than estrogen pills, patches, or implants. In fact, many women who are on systemic menopausal hormone therapy have to add on supplemental vaginal estrogens to control symptoms. Vaginal estrogens are available as a variety of creams, repositories, and rings. 30 randomized controlled comparative trials have been performed, and there appears to be no difference in efficacy between the various preparations. However, they may take weeks before a noticeable alleviation of symptoms is detected and two to three months before the full effect is achieved. Although year-long studies can clearly demonstrate vaginal estrogen's benefit, studies as long as 12 weeks have failed to manifest superiority to placebo. Some of the estrogen applied to the vulva or vagina is systemically absorbed, and therefore can fade the same black box FDA notice that oral estrogens carry, in all caps, a warning of increased risk of endometrial cancer, cardiovascular disorders, breast cancer, and probable dementia. Vaginal estrogen is considered safer, though, since it can be used at a much lower dose, as low as one-hundredth the oral dose. The Harvard nurses' health study did not find any increased risk associated with vaginal estrogen use over 18 years of follow-up. Randomized controlled trials lasting up to a year appear to confirm its safety, but there have been observational studies leaking vaginal use to about a doubling of odds for endometrial cancer. But this was done back in the 1970s when higher estrogen doses were used, and a more recent study out of Denmark that found the same thing may have been confounded by concurrent oral estrogen exposure. Not of an abundance of caution, though, even low-dose localized estrogen may be contraindicated in hormone-dependent cancer survivors to be on the safe side. Breast cancer survivors suffering from GSM may want to consider vaginal DHEA instead. Oral DHEA doesn't appear to offer any benefit, but in 2016 the FDA approved vaginal DHEA suppositories for pain during intercourse due to menopause. It's converted locally into estrogen and does not significantly affect systemic hormone levels. A downside is that it has to be administered nightly, whereas estrogen preparations are typically twice a week, or even every few months with the vaginal rings. For those who would rather an oral treatment, there is osmophen, a tamoxifen-type drug that has pro-estrogenic effects on the vaginal lining. However, it can actually double the rate of hot flashes and urinary tract infections in the short term, and insufficient data is available for long-term safety.