Alternatives to Estrogen Vaginal Cream for Vaginal Dryness

First-Line: Non-Hormonal Topical Options

The American College of Obstetricians and Gynecologists recommends applying vaginal moisturizers 3-5 times per week to the vagina, vaginal opening, and external vulvar folds for optimal symptom control 1, 3
Vaginal moisturizers provide daily maintenance of vaginal tissue health and can be as effective as low-dose estrogen for mild to moderate symptoms 1, 3
Water-based lubricants are recommended specifically during sexual activity to reduce friction and discomfort 1, 2
Silicone-based lubricants last longer than water-based products and may provide more effective relief during intercourse 1, 2
Topical vitamin D or E can provide supplementary symptom relief for vaginal dryness 1, 2
Topical lidocaine applied to the vulvar vestibule before penetration helps with persistent introital pain and dyspareunia 4, 1

Pelvic floor physical therapy significantly improves sexual pain, arousal, lubrication, orgasm, and overall satisfaction 1, 2, 3
Vaginal dilators benefit women with vaginismus, vaginal stenosis, or pain during sexual activity, particularly those treated with pelvic radiation 4, 1, 2
Cognitive behavioral therapy may decrease anxiety and discomfort related to sexual activity and improve overall sexual functioning 4, 3

Vaginal DHEA is FDA-approved for vaginal dryness and dyspareunia, improving sexual desire, arousal, pain, and overall sexual function 1, 2
Vaginal DHEA is particularly useful for women on aromatase inhibitors who have not responded to non-hormonal treatments 4, 1
Ospemifene is FDA-approved for moderate to severe dyspareunia in postmenopausal women without current or history of breast cancer 4, 1, 2

For women with hormone-positive breast cancer, non-hormonal options must be tried first before considering any hormonal therapy 4, 1, 2
Vaginal DHEA is the preferred hormonal option for women on aromatase inhibitors who haven't responded to non-hormonal treatments 4, 1

Begin with vaginal moisturizers 3-5 times weekly plus lubricants during sexual activity 1, 3
If symptoms persist after 4-6 weeks, add pelvic floor physical therapy and/or vaginal dilators 1, 3
If still inadequate after 4-6 weeks or symptoms are severe at presentation, consider prescription options: vaginal DHEA or ospemifene 1, 2