30: IT Just Got a Whole Lot Better – Vaginal Estrogen, the FDA, and What Changes Now Part 3

[INTRO MUSIC]

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. What it is, what it does, why it has been dramatically underused for decades, and why that is finally starting to change. We are also going to spend some time on anatomy, because I think understanding what we are actually working with makes everything else in this series land differently. And I am going to share some client stories that I think are going to feel very familiar.

Let’s go.

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

I want to start with something that might seem basic but I promise is not: 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.

Dr. Rachel Rubin, board-certified urologist and sexual medicine specialist, says it best: when you give women information about how their bodies work, they make great decisions for themselves. That is exactly what we are going to do right now.

So. For those of you with this anatomy, let’s talk about what you actually have.

First: there are three openings. The urethra, which is where urine comes out. The vaginal opening. And the anus. I mention this because a surprising number of people are genuinely not sure which is which, and that is not a personal failing. That is a failure of education.

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. You cannot see it from the outside. If you want to actually see your vagina, your gynecologist uses a speculum to do that. What you can see from the outside is your vulva. And both the vulva and the vagina are significantly affected by the hormonal changes of perimenopause — we will get into exactly how in a few minutes.

Here is what I want you to do. Get a hand mirror. Find a good light. And actually look. I know that might feel strange or uncomfortable if you have never done it. But knowing what your body looks like is useful. You cannot notice changes if you have no baseline.

So, the anatomy of the vulva. Working from the outside in:

The labia majora: the outer lips. These are the larger, often hair-bearing folds on either side. They protect everything inside.

The labia minora: the inner lips. These are the smaller, hairless folds inside the labia majora. And here is something worth knowing: 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. All of it.

The clitoris: most people know the clitoris as a small external nub at the top of the vulva, where the labia minora meet. But 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 — more than anywhere else in the human body — and as far as current science knows, it exists for pleasure. That deserves a moment of appreciation.

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. More on that shortly.

The vaginal opening: the entrance to the vaginal canal itself.

Now here is something I want to address directly, because it comes up more than you might think. Vulva owners do a lot of comparing. And in the absence of accurate information and images of real, diverse bodies, that comparing tends to happen against pornography or other highly curated images — which represent an extraordinarily narrow slice of what vulvas actually look like.

The research documents labiaplasty procedures being performed on girls in early adolescence, some before they have even finished puberty. Vulva owners are having surgery to reshape their labia because they have never seen a vulva that looks like theirs and concluded that something must be wrong with them. That is heartbreaking. And it is entirely a product of inadequate education and distorted media representation.

Your vulva is normal. Whatever it looks like.

I want to send you to two resources I think are genuinely wonderful. The Vulva Gallery at thevulvagallery.com: illustrated portraits of real vulvas with personal stories, used by the NHS and in sex education programs. And The Labia Library at labialibrary.org.au, by Women’s Health Victoria: photographs of real labia in all their variety, created specifically to counter the pressure toward labiaplasty. Read the testimonials on that site. Vulva owners in their 60s saying it is the first time they ever felt normal. I will link both in the show notes.

And while we are on the subject: there is an art installation called The Great Wall of Vulva by British artist Jamie McCartney. Plaster casts of 400 vulvas. Four hundred. All different. Also in the show notes. Just go look at it.

[YOUR VAGINA IS ALREADY DOING ITS JOB]

Before we move on, I want to address two things that come up constantly and that nobody talks about clearly enough.

The first is discharge. Vaginal discharge and cervical mucus are normal. They are healthy. They are your body doing exactly what it is supposed to do.

Here is the quick version: cervical mucus is produced by the cervix and changes throughout your cycle in response to estrogen. Around ovulation, when estrogen peaks, it becomes clear, stretchy, and abundant — what you may have heard described as egg white consistency. That is your fertile window signaling itself. Outside of ovulation it tends to be thicker, less noticeable, or absent. This is completely normal cycle variation.

Self-lubrication during arousal is a different process entirely — that is the vaginal walls producing fluid in response to arousal. Both are normal. Both are your body functioning correctly.

I want to mention this specifically because when my hormone levels shifted in perimenopause, I noticed my cervical mucus became very sparse. It was actually one of the things that tipped me off that something hormonal had changed. And once I adjusted my MHT and estrogen stabilized, it came back — and has actually lasted longer through my cycle than it used to, because estrogen is what drives that mucus production. Your hormones show up in ways you might not expect.

I also want to name something I hear from vulva owners regularly: shame and confusion around having any discharge at all. Women worry they are dirty or gross. They are not. A healthy vagina produces discharge. It 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. You do not need any internal cleansing products — and in fact, doing so disrupts the very ecosystem that keeps things healthy. The vagina cleans itself. What you can do is wash the vulva — the outside — gently with mild, unscented soap and water. That is it.

And this brings me to something I want to say very directly, and I will be saying it in much more depth in a future episode on environmental exposures and endocrine disruptors: your vagina should not smell like flowers. It should not smell like a summer breeze or fresh linen or tropical fruit. 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 — sprays, wipes, douches, scented pads — 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.

Your vagina has a scent. It is supposed to. That scent can change throughout your cycle, after sex, and during perimenopause as the tissue and microbiome shift. If something smells significantly different or off to you, that is worth mentioning to your provider as a potential sign of infection or pH disruption. But the answer is never a scented product. It is never a scented product.

More on all of this when we do a dedicated episode on personal care products and endocrine disruptors. For now: gentle soap on the outside, leave the inside alone, and your vagina should not smell like a candle.

[WHAT ESTROGEN DOES TO ALL OF THIS]

Now that we know the parts and how they work normally, let’s talk about what happens to them when estrogen declines.

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.

The labia may become thinner and less full. The clitoris can become less sensitive over time, which can affect arousal, the time it takes to get there, and the ability to orgasm. The urethral tissue thins, losing its natural protective thickness, which shifts the local microbiome and makes infection more likely. And the vaginal walls become thinner, less elastic, drier, and more vulnerable to micro-tears and irritation.

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 affects most vulva owners going through perimenopause and menopause to some degree. And it is progressive — meaning it tends to get worse over time if it is not addressed.

One more thing worth mentioning that most people have never heard of: GSM is not exclusive to menopause. Dr. Rachel Rubin has been instrumental in naming and documenting what is called Genitourinary Syndrome of Lactation. Postpartum, breastfeeding people can experience the same GSM-like symptoms because birth temporarily sends the body into a menopause-like hormonal state — estrogen drops dramatically after delivery. This can make postpartum tissue changes and discomfort significantly worse, on top of everything else the body is already recovering from. Local vaginal estrogen can be used to treat this as well. It is a conversation worth having with your provider if you are postpartum and struggling, and one that is rarely offered.

[CLIENT STORIES]

I want to share two client stories here, because they illustrate very different entry points into this conversation.

The first client 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 was on antibiotics repeatedly. She was doing everything right from a hydration and hygiene standpoint and nothing was breaking the cycle. 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. Vaginal estrogen was not on her radar at all because she did not think she had a vaginal estrogen problem. She thought she had a UTI problem. 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, she had assumed this was just what happened now, and she felt a mix of grief and resignation about it. She had not brought it up with her doctor because she felt embarrassed and because she genuinely did not think anything could be done. When we talked through what was actually happening — the tissue changes, why they were happening, what vaginal estrogen does — 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. Not immediately perfect. But dramatically better. And more importantly: she felt like herself again.

Both of these women had something addressable that nobody had told them about. That is exactly the problem we are trying to solve.

[VAGINAL ESTROGEN: WHAT IT IS AND HOW IT WORKS]

So let’s get into the treatment itself.

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 inserted with a small applicator, or a tablet. Your provider can help you figure out which format works best for your life and preferences.

The key word is local. Vaginal estrogen works where it is applied. 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 — and why the warnings that kept so many women and providers away from it for decades were not actually based on evidence about this specific product.

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 reduces friction and the micro-tears that lead to irritation and infection. It makes sex more comfortable. It reduces urinary urgency and frequency for many women. And one analysis found that using preventative local vaginal estrogen therapy could save Medicare patients between $1,200 and $4,900 annually in reduced infections and related treatments. Because it addresses the underlying tissue changes rather than just lubricating over them, the effects are cumulative — it tends to keep working better over time.

It typically takes six to twelve weeks to notice significant changes. Consistency is the key.

[THE BLACK BOX WARNING: WHAT HAPPENED AND WHAT CHANGED]

Here is the history, because it matters.

In 2002, a large study called the Women’s Health Initiative looked at hormone therapy in postmenopausal women and found associations with increased risk of breast cancer, heart disease, blood clots, and stroke. That study made enormous headlines. Women stopped taking hormone therapy in huge numbers. And 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. Many gynecologists became reluctant to prescribe vaginal estrogen or even bring it up. Women who asked about it were sometimes actively discouraged. And the tissue changes of GSM, which are progressive and much easier to address early than late, went untreated in millions of women who either did not know the option existed or were afraid of it.

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 major medical societies — urology, gynecology, urogynecology — had been pushing for this for years. The science was clear. The warning was not supported by the data on this specific product. And it was actively harming women by keeping them from a safe and effective treatment.

As of February 2026, the first batch of products with updated labeling has been approved, with more rolling out across manufacturers now.

And there is more coming. FDA Commissioner Marty Makary has publicly stated that the agency is actively working to make vaginal estrogen available over the counter, without a prescription, citing its profound benefits for preventing UTIs and reducing painful sex. That would be a significant shift in access, particularly for women who do not have easy access to a gynecologist or whose providers have been reluctant to prescribe it.

[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. You do not have to be at a certain age. 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 on her website that you can print and bring to your appointment. It gives clinicians the information they need to diagnose and prescribe treatment for GSM. There is a whole generation of providers who were never taught what GSM is or how to treat it. You can help educate yours.

For finding a perimenopause-informed provider, The Menopause Society has a provider finder at menopause.org. Dr. Kelly Casperson’s podcast, You Are Not Broken, and her book by the same name are also excellent resources for understanding this space more broadly.

If your provider dismisses you — if you are told this is just aging or just something to accept — that is a signal to find someone who is current on the research. The research is clear. You deserve a provider who knows it.

[MY PERSONAL STORY WITH VAGINAL ESTROGEN]

I want to close the clinical section with my own experience, because I think it makes the abstract concrete.

I had a complicated starting point with this. When I was on birth control for twenty years, the dryness was significant — painful enough that using tampons was uncomfortable because they would catch and pull on the vaginal walls. That was my baseline for a long time. 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. It was revelatory after what I had known.

So when things started shifting again in my early 40s, already in perimenopause and on MHT, the change was subtler than what I had experienced before. This was not the extreme dryness of my birth control years. Things were still lubricated. But less so. 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.

My partner noticed some of these things before I had fully processed what was happening, and asked questions. We tried adjusting foreplay, slowing down, giving things more time. We eventually added lube, which helped. But it was not the same as it had been. So 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

So that is the series. Three episodes on something that affects most vulva owners going through this transition and that almost nobody is talking about clearly enough.

Here is what I want you to walk away with.

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. The hormonal shifts, the tissue changes, the libido fluctuations – all real. And all, to a significant degree, addressable. You do not have to white-knuckle through this. You do not have to accept it. You do not have to suffer in silence.

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.