Hormone replacement therapy often relieves vaginal dryness. But if the combination of hormones in the regimen isn’t suitable for an individual woman, vaginal dryness, burning, uncomfortable intercourse, or stress incontinence persist.

HRT regimens frequently include estradiol and estrone, two types of estrogen. A third type of estrogen, estriol, can often relieve vaginal dryness where other types have failed. Frequently called the “weak” or “forgotten” estrogen, estriol has a good track record in relieving genitourinary symptoms such as vaginal dryness and stress incontinence. Estriol is good for hot flashes too.

Although estriol is commonly used in Europe, it isn’t made in mass quantities in the United States. Many health care providers are unfamiliar with this natural form of estrogen. Each estriol prescription is compounded individually by a pharmacist as an oral capsule, vaginal cream, vaginal suppository, or topical skin cream or gel. Estriol suppositories are dry and need to be moistened before inserting, they aren’t waxy or messy like some vaginal suppositories. Some women prefer to use an estriol skin cream or gel, which is also a prescription medication that must be compounded by a pharmacist.

Dana, a reserved woman with a careful way of speaking, came to see me with this report: “My friends complain about hot flashes, moodiness, and memory lapses. I have none of those problems. What I notice is that lovemaking has become painful, and my friends aren’t talking about that.” She paused for a moment. “Well, I suppose I wouldn’t talk about it even if someone did bring it up.”

“These are deeply personal issues,” I said to Dana. “Many women are uncomfortable talking about their private lives, and besides, it hasn’t exactly been common knowledge that these changes can happen in our forties.”

As we talked more, Dana said that the vaginal discomfort and dryness didn’t happen only during lovemaking. She thought it had started at least a year ago; she is now 47. We talked about her options to manage this symptom, vitamin E or another over-the-counter lubricant and estriol.

After Dana and I discussed her family history and her questions and concerns about HRT, she consulted with her health care provider. Given her symptoms and her overall health profile, neither she nor her healthcare provider thought HRT was necessary for her now. She did, however, decide to try estriol cream, smoothing a very small amount (0.05 mg) on her hands twice a day for thirty consecutive days. She was also going to use vitamin E oil, which can be applied directly to the vagina. As we have discussed, estriol does not affect breast or uterine tissue. Unlike other estrogens, it can be taken without natural progesterone or synthetic progestin, because it does not stimulate the uterine lining. Dana had good results with estriol cream and vitamin E. When I saw her last and asked how she was doing, she said, “There has been a complete turnaround.” I took that to be her circumspect way of saying that her vaginal symptoms had improved and, I hope, that she was much more able to enjoy lovemaking again.

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