There are no data—none—showing that local vaginal estrogen causes cancer, cardiovascular problems, stroke, dementia, or any other issues. In fact, two decades of research show just the opposite. Even studies in women who have gynecological cancers show no issues using local vaginal estrogens.^10,11 We prescribe and encourage this therapy in our patients with breast cancer or a family history of breast cancer as well as those who are worried about breast cancer.

Let’s Look at a Quick Example

At one point during gestation, pregnant patients will have systemic estrogen levels of roughly 3,000 pg/mL. At the same time, if we measured the estrogen level in the biological fathers of these pregnancies, we would expect levels of roughly 25 pg/mL. Menopausal women’s systemic estrogen levels are less than 5 pg/mL, and on vaginal estrogen, they remain at roughly 5 pg/mL. Our point? Local vaginal estrogen does not impact the amount of estrogen in your bloodstream. How is it going to cause tumor growth, dementia, or blood clots? It’s not, and it doesn’t.12 A birth control pill has different risks than an IUD, which has very different risks from local vaginal estrogen. All hormones are not the same.

Perhaps now you are sold on this diagnosis and its treatment, but how do you do it because standard emergency medicine training does not include this particular therapy? Starting local vaginal hormone therapy is easy and should be started in the emergency department. There are some key points to remember when explaining the therapy to patients:

1. There are lots of options out there, including inserts, gels, and rings.
2. If cost and insurance coverage are issues, generic estradiol 10-mcg inserts are typically $40/month with a cash price and GoodRx coupon. Advise one vaginal insert daily for two weeks, then twice weekly indefinitely.
3. It may take as long as two to three months to see maximal benefit (remember the tissue must heal, which takes time).
4. It will only keep working if you keep using the therapy. For a woman who needs vaginal estrogen therapy, asking when the therapy should stop is like asking, “When can I stop brushing my teeth?” or “When can I stop wearing my seat belt?” Never. The answer is never.

The next time you encounter a postmenopausal women with recurrent UTIs, think about GSM, an essential and easily treatable diagnosis for emergency physicians who care for older women.

Dr. Ashley Winter (@AshleyGWinter) and Dr. Rachel Rubin (@drrachelrubin), two renowned urologists who focus on sexual medicine, joined forces with emergency physician Dr. Howie Mell (@drhowiemell) to compose this article after a productive conversation sparked on Twitter about a better approach to patients presenting with recurrent urinary tract infections.