Already on HRT? Why You Might Still Need Vaginal Oestrogen
Understanding the connection between menopause, vaginal health, bladder symptoms and your pelvic floor.
When we talk about menopause, we often hear about hot flushes, night sweats, mood changes and disturbed sleep, but what about the changes happening to our vaginal tissues, bladder and pelvic floor? These are symptoms that many women experience but don't always feel comfortable discussing.
One thing that often surprises women is that even if you're already taking hormone replacement therapy (HRT), you may still benefit from vaginal oestrogen.
It's something I wish I'd understood much earlier in my own menopause journey.
My Own Experience of Menopause and HRT
My experience of menopause was far from straightforward. I experienced significant joint pain, disturbed sleep, anxiety, mood changes and overwhelming fatigue. At one point, I genuinely thought I was developing rheumatoid arthritis because my joints were so painful.
I remember sitting outside the bank in my car, unable to face going inside to carry out a simple task, something that would normally have been completely manageable suddenly felt overwhelming. For me, starting HRT made an enormous difference. Of course, HRT is a personal decision, and what works for one woman may not be suitable for another, but my experience highlighted just how widely fluctuating and declining hormone levels can affect our physical and emotional wellbeing.
What I didn't fully appreciate at the time was how these hormonal changes could also affect my pelvic health.
What's the Difference Between HRT and Vaginal Oestrogen?
Systemic HRT works throughout the body and can help manage symptoms such as hot flushes, night sweats, sleep disturbances and mood changes. However, some women continue to experience vaginal dryness, soreness, discomfort during sex, bladder irritation or recurrent urinary tract infections (UTIs), even while taking systemic HRT. This is because the tissues around the vagina, vulva and urinary tract are particularly sensitive to changes in oestrogen. As oestrogen levels decline, these tissues may become thinner, drier, less elastic and more easily irritated.
These changes are often referred to as Genitourinary Syndrome of Menopause (GSM), a term that includes what was previously commonly called vaginal atrophy. GSM can affect women during perimenopause and after menopause, and symptoms may persist without appropriate treatment.
How Can Vaginal Oestrogen Help?
Unlike systemic HRT, low-dose vaginal oestrogen acts mainly on the tissues where it's applied, with minimal absorption into the bloodstream.
It can help improve the health and comfort of vaginal tissues and relieve symptoms such as:
Vaginal dryness, soreness and irritation
Discomfort during sexual activity
Burning or irritation around the vulva
Some menopause-related urinary symptoms
Recurrent UTIs in peri- and post-menopausal women
NICE guidance recommends offering vaginal oestrogen for genitourinary symptoms associated with menopause, including for women already using systemic HRT.
NICE also recommends considering vaginal oestrogen to help prevent recurrent UTIs during perimenopause and menopause where appropriate.
Importantly, you don't need to be taking systemic HRT to discuss vaginal oestrogen with your GP.
There are several preparations available, including creams, vaginal tablets, pessaries and rings. I personally use estriol cream, and I've noticed a significant improvement since starting treatment. As with any medication, the preparation, dosage and treatment schedule should be discussed with your prescribing healthcare professional.
Vaginal oestrogen does not treat an active UTI, and persistent or unexplained symptoms should always be appropriately assessed.
What About Your Pelvic Floor?
As an Osteopath and Pelvic Health Coach, I regularly see women experiencing bladder symptoms, pelvic discomfort and changes in pelvic floor function during peri and post menopause. One thing I always emphasise is that pelvic health is about much more than muscle strength alone.
You can be performing pelvic floor exercises regularly, improving your breathing and working on your core strength, yet still experience symptoms associated with low oestrogen.
That's because pelvic health involves several interconnected factors, including:
Pelvic floor muscle strength, relaxation and coordination
Vaginal and vulval tissue health
Bladder and bowel function
Breathing and abdominal pressure management
Hormonal changes and lifestyle factors
For some women, pelvic floor rehabilitation may be beneficial alongside medical treatment for menopause-related tissue changes. Understanding the bigger picture helps us identify which approaches may be most appropriate, rather than assuming every symptom can be resolved by strengthening the pelvic floor.
Not Sure How to Discuss Vaginal Oestrogen With Your GP?
Talking about vaginal dryness, discomfort during sex or recurring urinary symptoms can feel uncomfortable, particularly if you're unsure how to describe what you're experiencing.
To make that conversation a little easier, I've created a free, one-page guide:
🌸 Let's Talk About Your Lady Bits! – Vaginal Oestrogen: What to Ask Your GP
It includes simple prompts to help you identify your symptoms, consider how they're affecting everyday life and prepare useful questions for your appointment.
You can complete it beforehand or print it out and take it with you.
Looking at the Bigger Picture
Whether you're already taking HRT, considering your options or managing menopause without hormone treatment, changes in vaginal, bladder and pelvic health deserve attention.
Not every symptom is caused by menopause, but understanding the possible influence of hormonal changes can help guide the right conversations, assessments and treatment.
Pelvic health isn't simply about strengthening muscles. It's about understanding how your body works as a whole.
If you're experiencing pelvic floor symptoms and would like individual guidance, I offer pelvic health consultations both in clinic at Denham Osteopathy and online through Balance & Beyond UK.
Jayne 🌸
Denham Osteopathy | Balance & Beyond UK
Find It · Feel It · Connect With It.
References and Further Reading
NICE NG23 – Menopause: Identification and Managementhttps://www.nice.org.uk/guidance/ng23
NICE NG112 – Urinary Tract Infection (Recurrent): Antimicrobial Prescribinghttps://www.nice.org.uk/guidance/ng112
This article provides general educational information and does not replace individual medical advice. Symptoms such as recurrent urinary infections, unexplained bleeding or persistent pelvic discomfort should be assessed by an appropriate healthcare professional.
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