Qhen it comes to hormone therapy during menopause, the question is often the same: “Is a local treatment or a systemic one better?”. But they are not two overlapping alternatives, because they respond to different needs. “They told me about local estrogens, but I was thinking about hormone therapy.” Or, on the contrary: “I’m having hormone therapy, so I shouldn’t also have dryness or intimate discomfort.” These are very common doubts, and arise from a frequent misunderstanding: think that local and systemic estrogens/hormones do the same thing. Actually, they are not the same therapy and do not meet the same objectives.
What are local estrogens
Local estrogens are treatments that work especially at the vulvovaginal and urinary level. They are mainly used for symptoms such as:
- vaginal dryness
- burning
- pain in relationships
- recurrent irritation
- urinary discomfort related to menopause
Their goal is not to treat the “general” symptoms of menopause, but improve the health of local tissues. They only have a local action, and that’s exactly why with mine Menopauseboost association we are collecting signatures to present a petition to AIFA to modify the leaflets of topical therapies, as has already been done in other countries, in light of the many clinical studies on the safety as well as the effectiveness of these therapies.
Local estrogens: they are not all the same
When we talk about local therapy, we often tend to simplify by saying “vaginal estrogens”. Actually, they are not all the same.
The two main ones used are:
- estradiolmore powerful and with a more marked action on tissues
- estriolmore delicate, with a predominantly local effect
The choice depends on symptoms, age, clinical picture and individual response. But clarifying this difference is important, because not all formulations have the same impact.
Because sometimes it’s not enough
Many women start local estrogen therapy and obtain an improvement: less dryness, less burning, more elastic tissues. Yet, it is not uncommon for a specific symptom to persist:
pain at the vaginal entrance (superficial dyspareunia). This is a much more common situation than you might think.
The (often forgotten) role of androgens
This happens for a precise reason, linked to the distribution of receptors in the tissues. Inside the vaginal canal, the effects of estrogen prevail. But approaching the vulvar entrance and the vestibulechange the situation:
- they increase androgen receptors
- increases the presence of nerve fibers (nociceptive)
- the tissues become more sensitive and reactive
This means that, in that area, estrogen alone may not be sufficient.
The result in clinical practice
This is why a very large proportion of women who only use vaginal estrogen report general improvement but persistence of pain localized to the entrance. A pain often described as: burning, pinpoint discomfort, initial difficulty in penetration.
What changes in management
Understanding this mechanism is fundamental, because it completely changes the approach. It’s not about “therapy that doesn’t work”, but about: partial therapy with respect to the distribution of receptors. In these cases, it may also be useful to consider the role of local androgens, always within a personalized evaluation.
Local estrogens are a very effective tool, but not always sufficient on their own.
Vulvo-vaginal health is not regulated by a single hormone or a single therapy but often by a therapeutic multimodality, and the symptoms at the entrance often have a different basis than the deeper vaginal ones.
Recognizing this difference allows us to avoid incomplete treatments and, above all, to give a more targeted response to a very frequent but often poorly explained symptom.
What systemic therapy does instead
Systemic hormone therapy acts throughout the body (since estrogen receptors are ubiquitous) and is used especially when broader symptoms are present, such as:
- flushes
- night sweats
- sleep disorders
- brainfog
- osteoarticular pain
- swings related to the menopausal transition
- in some cases, even bone protection in selected women.
So the point is this: systemic therapy treats menopause as a whole; the local one mainly treats genitourinary symptoms.
One does not replace the other
This is the most important aspect to clarify. A woman can have vaginal/urinary symptoms onlyand therefore benefit above all from local therapy, or important systemic symptomsand therefore have an indication for systemic therapy. But a third, very frequent thing can also happen: be on systemic therapy and still need local support.
Because the benefit on vaginal tissues is not always sufficient, or is not the same for everyone.
How to decide the right choice
The choice is not based on “what is best in general”, but on a very concrete evaluation:
- what symptoms are present
- how much they impact the quality of life
- age and years since menopause
- personal and family history
- any contraindications or precautions.
For this reason, comparing the two options as if they were competitors is often misleading.
Therefore the right question is not: “Is local or systemic estrogen better?”
The right question is: “What problem am I trying to treat?”
Because during menopause the most effective therapy is not the “strongest” or “most complete” one, but that more suited to the real symptom of the woman in front of you.
Understanding this difference helps you make more informed, more personalized and often even more effective choices.
Doctor Cinzia Polo
Specialist in Gynecology and Obstetrics, Menopausologist, la Doctor Cinzia Polo for years it has been carrying out dissemination and training work on the physical and psychological transformations that accompany menopause, with the aim of giving women a freer, more informed and positive approach.
Co-founder and vice-president of the Association Menopauseboost, Dr. Polo is also part of the parliamentary commission established for women’s rights which brought the revision of the leaflets to the attention of both the Chamber of Deputies and Montecitorio.
In this column, the expert answers the most current and useful questions to help women better experience the delicate period of menopause through the sharing of scientific information.
Doctor Cinzia Polo.