Vaginal Estrogen & DHEA for Menopause Dryness (GSM): Estriol, Estradiol & DHEA
Summary: Genitourinary syndrome of menopause (GSM) — vaginal dryness, irritation, painful intercourse, and some urinary symptoms — is caused by dropping estrogen after menopause. Low-dose vaginal estrogen (estradiol or estriol) and vaginal DHEA are effective, well-established treatments that work locally in the vaginal tissue with minimal absorption into the rest of the body. Compounded versions let a prescriber tailor the hormone, strength, and cream base to the individual patient.
GSM is extremely common, under-treated, and very responsive to the right therapy. Here’s what you should know.
What is genitourinary syndrome of menopause (GSM)?
GSM is the modern term for the collection of symptoms caused by the loss of estrogen in the tissues of the vagina, vulva, and lower urinary tract after menopause. Unlike hot flashes, which often fade over time, GSM tends to be progressive and doesn’t improve on its own. Common symptoms include:
Vaginal dryness, burning, or irritation
Pain or discomfort during intercourse (dyspareunia)
Light bleeding or spotting after sex
Urinary urgency, frequency, or recurrent urinary tract infections
What are the treatment options for GSM?
According to The Menopause Society’s 2020 GSM Position Statement, low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are all effective treatments for moderate to severe GSM. For mild symptoms, non-hormonal moisturizers and lubricants are often enough. (The Menopause Society, 2020)
Vaginal Estradiol — low-dose estrogen applied locally. Notes: effective for dryness and painful sex; minimal systemic absorption.
Vaginal Estriol — a milder estrogen, commonly compounded. Notes: frequently used in Europe and compounded in the U.S.
Vaginal DHEA (prasterone) — a hormone precursor converted locally in the tissue. Notes: improves dryness, pain, and bother from GSM.
Non-hormonal moisturizers and lubricants — over-the-counter symptom relief. Notes: best for mild symptoms.
A 2024 International Menopause Society systematic review found that, compared with placebo, vaginal estrogen improved dryness, painful sex, and overall satisfaction, and vaginal DHEA improved dryness, pain, and GSM-related distress. (International Menopause Society, 2024)
Why compound vaginal estrogen or DHEA?
Compounding is valuable for GSM because it allows individualization that off-the-shelf products don’t:
Choice of hormone. Estradiol, estriol, or a combination, at the strength your prescriber selects.
A cream base that suits sensitive tissue. Important for patients irritated by preservatives or additives.
Combination formulas. For example, an estriol-and-DHEA preparation, or a formula that adds ingredients for tissue comfort.
Precise low dosing. GSM responds to very small local doses.
Because these hormones act locally, absorption into the bloodstream is low, which is part of why local vaginal therapy is considered a well-tolerated approach for isolated GSM.
Is vaginal estrogen safe for breast cancer survivors?
This is a common and important question. It must be individualized with the patient’s oncology team, but the research is encouraging: one 2024 analysis found vaginal estriol, vaginal DHEA, and ospemifene improved GSM symptoms in breast and gynecologic cancer survivors and were not associated with cancer recurrence over the follow-up period. (PubMed) Any survivor considering vaginal hormone therapy should discuss it with their oncologist and prescriber.
How do I get compounded vaginal hormone therapy?
Vaginal estrogen and DHEA are prescription-only. Your prescriber evaluates your symptoms and history and selects the right hormone, strength, and form; we compound it to their specifications.
Why patients trust Restorative: we’re a 503A compounding pharmacy with NABP Healthcare Merchant Accreditation and .pharmacy verification, shipping to eligible states nationwide, with every preparation made by licensed pharmacists to your prescriber’s exact specifications.
Providers: Partner with Restorative →
Patients: Start a prescription or transfer →
Explore women’s health compounding →
Frequently asked questions
Does vaginal estrogen get absorbed into the whole body?
Low-dose vaginal estrogen is designed to act locally, and systemic absorption is minimal compared with pills or patches — which is why it’s often used specifically for isolated vaginal and urinary symptoms.
What's the difference between estradiol and estriol?
Both are estrogens; estriol is weaker. Estriol is very commonly compounded, and some prescribers prefer it or a blend for local vaginal therapy. Your provider will choose.
Can vaginal DHEA help with painful sex?
Yes — vaginal DHEA has been shown to improve dryness and dyspareunia (painful intercourse) in GSM. (IMS 2024)
Do I need a prescription?
Yes. Compounded vaginal hormone therapy is prescription-only and directed by your provider.
Reviewed by the Restorative clinical pharmacy team. Educational only; not a substitute for medical advice. Compounded medications are prepared pursuant to a valid prescription for uses your prescriber determines are clinically appropriate.
References
The 2020 Genitourinary Syndrome of Menopause Position Statement — The Menopause Society. https://menopause.org/wp-content/uploads/default-document-library/2020-gsm-ps.pdf
Hormonal Treatments and Vaginal Moisturizers for GSM: A Systematic Review — International Menopause Society (2024). https://www.imsociety.org/2026/03/19/hormonal-treatments-and-vaginal-moisturizers-for-genitourinary-syndrome-of-menopause-a-systematic-review/
Treatment of GSM in Breast and Gynecologic Cancer Survivors: Vaginal Estriol, DHEA and Ospemifene — PubMed. https://pubmed.ncbi.nlm.nih.gov/39829194/
