INTRO

Good morning and welcome back to Mornings with Megan. I’m Megan Pfiffner, Certified Nutrition Specialist and perimenopause nutrition expert. This is part three of our series on sexual health in perimenopause, and I have been looking forward to this one. If you have not listened to parts one and two, please go back. We covered a lot of ground: what is happening hormonally, the cultural weight women carry around sex, chore play, the spontaneity myth, lubrication and why your lube choices actually matter, and the importance of solo sex as body literacy. Today builds on all of it. Today we are talking about vaginal estrogen. Let’s go.

ANATOMY: LET’S ACTUALLY KNOW WHAT WE ARE TALKING ABOUT

I want to start with anatomy. Most of us were never actually taught the correct names for our own body parts. We got euphemisms, we got vague gestures, we got the kind of sex ed that was more interested in scaring us than informing us. So before we talk about what estrogen does to this tissue, I want to make sure we are all working with the same vocabulary. Because you cannot advocate for yourself with a healthcare provider if you do not know what to call what you are describing.

First: there are three openings. The urethra, which is where urine comes out. The vaginal opening. And the anus. Second: what most people call their vagina is actually their vulva. The vagina is internal. It is the canal that connects the uterus to the outside of the body. What you can see from the outside is your vulva.

Here is what I want you to do. Get a hand mirror. Find a good light. And actually look. Knowing what your body looks like is useful. You cannot notice changes if you have no baseline.

The anatomy of the vulva. The labia majora: the outer lips, the larger often hair-bearing folds on either side that protect everything inside. The labia minora: the inner lips, smaller and hairless. They vary enormously from person to person. They can be barely visible or several centimeters long. They can be symmetrical or asymmetrical. They can be pink, red, purple, brown, or nearly black. All of that is completely normal. The clitoris: the visible part is actually just the tip. The full clitoral structure extends internally on either side of the vaginal canal and is much larger than what you can see. It is packed with nerve endings and as far as current science knows, it exists for pleasure. The urethra: a small opening just below the clitoris, above the vaginal opening. This is where urine exits. The urethral tissue surrounding it is also estrogen-sensitive, which is why vaginal dryness and recurrent UTIs are so closely connected.

YOUR VAGINA IS ALREADY DOING ITS JOB

Vaginal discharge and cervical mucus are normal. They are healthy. They are your body doing exactly what it is supposed to do. Your vagina is self-cleaning: think of it as a self-cleaning oven. It manages its own pH, its own microbiome, its own housekeeping. It does not need your help on the inside.

What that means in practice: you do not need to wash inside your vagina. You do not need to douche. The vagina cleans itself. What you can do is wash the vulva, the outside, gently with mild unscented soap and water. That is it.

Your vagina should not smell like flowers. Those are marketing inventions designed to make you feel like your normal, healthy body is a problem that needs to be solved. The scented products designed for use in or around the vaginal area contain fragrance chemicals that are endocrine disruptors. Meaning they interfere with your hormones. And putting endocrine disruptors on the most absorbent tissue in your body is not a great idea.

WHAT ESTROGEN DOES TO ALL OF THIS

Every structure we just named, the labia majora, the labia minora, the clitoris, the urethral tissue, and the vaginal walls, all of it is estrogen-sensitive. Estrogen maintains the thickness, elasticity, and moisture of all of that tissue. When estrogen declines during perimenopause, the tissue changes throughout the entire area.

This is Genitourinary Syndrome of Menopause, GSM. And I want to be very clear: GSM is not just a sexual health issue. It affects urinary health, comfort in daily life, the ability to exercise without discomfort, and quality of life in ways that have nothing to do with whether you are sexually active. It is progressive: meaning it tends to get worse over time if it is not addressed.

CLIENT STORIES

I want to share two client stories. The first came to me primarily for nutrition support. She had been dealing with recurrent UTIs for a couple of years, three or four times a year. She had no idea her UTIs were connected to her hormones. She was not experiencing pain during sex. She had not noticed significant dryness. She just kept getting UTIs and nobody had connected them to the tissue changes happening in her urethral area as her estrogen declined. Once she started vaginal estrogen, the UTIs stopped.

The second client described her vagina as, and I am quoting her directly, shriveled up and dead. She had essentially stopped having sex because it was uncomfortable, assumed this was just what happened now, and felt a mix of grief and resignation about it. She had not brought it up with her doctor because she felt embarrassed and genuinely did not think anything could be done. When we talked through what was actually happening, she almost cried with relief. The idea that this was addressable, that she did not have to accept it, was genuinely shocking to her. She started vaginal estrogen, gave it a few months, and reported back that things were dramatically better.

VAGINAL ESTROGEN: WHAT IT IS AND HOW IT WORKS

Vaginal estrogen is a low-dose estrogen applied locally, directly to vaginal tissue. It comes in several forms: a cream, a ring that sits inside the vagina and releases estrogen slowly over time, a suppository, or a tablet. The key word is local. According to the research, local vaginal estrogen does not affect blood levels of estrogen. This is why it has a completely different safety profile from systemic hormone therapy.

What it does: it restores thickness, elasticity, and moisture to vaginal and urethral tissue. It improves lubrication. It supports a healthier local microbiome, which reduces UTI risk. Research shows local vaginal hormones reduce the risk of UTIs by more than 50%. It makes sex more comfortable. It reduces urinary urgency and frequency for many women. Because it addresses the underlying tissue changes rather than just lubricating over them, the effects are cumulative. It typically takes six to twelve weeks to notice significant changes. Consistency is the key.

THE BLACK BOX WARNING: WHAT HAPPENED AND WHAT CHANGED

In 2002, the Women’s Health Initiative study looked at hormone therapy in postmenopausal women and found associations with increased risk of breast cancer, heart disease, blood clots, and stroke. The FDA put a black box warning, their most serious safety alert, on all estrogen products. All of them. Including low-dose vaginal estrogen, which was not even studied in that research. That black box warning stayed for over two decades. It scared patients. It scared providers. And the tissue changes of GSM went untreated in millions of women.

In November 2025, the FDA announced the removal of that black box warning from low-dose vaginal estrogen products, following a comprehensive review of the evidence. The science was clear. The warning was not supported by the data on this specific product. As of February 2026, the first batch of products with updated labeling has been approved, with more rolling out across manufacturers now. And FDA Commissioner Marty Makary has publicly stated that the agency is actively working to make vaginal estrogen available over the counter without a prescription.

WHO CAN USE IT AND HOW TO HAVE THE CONVERSATION

Vaginal estrogen is considered safe for the vast majority of vulva owners. Research also confirms it is safe for breast cancer survivors and those currently undergoing breast cancer treatment, though that is always a direct conversation to have with your oncologist given individual circumstances.

If you are experiencing any of the following, vaginal estrogen is worth asking your provider about: vaginal dryness or discomfort, pain or reduced pleasure during sex, changes in the time it takes to become aroused or reach orgasm, recurrent UTIs, urinary urgency or leaking, or any general tissue discomfort in the vulvar area. You do not have to be in crisis to ask. You do not have to be postmenopausal. If these changes are affecting your quality of life, this conversation is worth having now.

If your provider seems to be defaulting to outdated concerns about the old black box warning, you can gently let them know the warning has been removed and ask them to review the current evidence. Dr. Rachel Rubin has a prescriber guide available at rachelrubinmd.com/gsm that you can print and bring to your appointment.

MY PERSONAL STORY WITH VAGINAL ESTROGEN

When I was on birth control for twenty years, the dryness was significant, painful enough that using tampons was uncomfortable. When I finally got off birth control in my mid-thirties, I had about seven years of what I can only describe as glorious, very effective self-lubrication. So when things started shifting again in my early 40s, already in perimenopause and on MHT, the change was subtler. Sex was not painful. But there was more friction than there used to be, more awareness of discomfort in certain positions, a low-grade thing I had gotten so used to I had almost stopped consciously noticing it.

I went to my gynecologist and asked for vaginal estrogen. It was one of the best decisions I have made from a personal health perspective. Within a few months the tissue felt different. More resilient. More like itself. Sex was comfortable again. And that low-grade background awareness I had been quietly accommodating around was gone. That is how quietly GSM can develop. You adapt. You work around it. You think this is just what it is now. And then something changes and you realize how much you had normalized without ever naming it. You do not have to normalize it.

SERIES CLOSE

Your sexuality does not expire at perimenopause. Your pleasure matters, not as a bonus, not as something to get to when everything else is handled, but as a real, legitimate part of your health and your quality of life. The research supports it. The biology supports it. And you deserve a healthcare team that takes it seriously. The changes that come with perimenopause are real. And all, to a significant degree, addressable. You now have the vocabulary. You have the framework. You know what questions to ask and where to find the resources. Go have the conversations, with yourself, with your partner, with your provider. She matters. You matter. I will see you next week.