Written by Dr. Laura Kelly, DAOM, L.Ac, Dipl. OM
Let’s be honest—menopause might be natural, but that doesn’t make it comfortable. For many women, the years leading up to menopause usher in more than just hot flashes. Declining estrogen—and, critically, though almost always forgotten, androgen—levels trigger vaginal dryness, discomfort, pain during sex, urinary leakage, and a dip in libido that feels anything but subtle. These changes fall under the umbrella of Genitourinary Syndrome of Menopause (GSM), a term that better captures what’s actually happening: widespread tissue and sensory shifts in the vagina, vulva, urethra, and bladder.
If this sounds familiar, know this: you’re not alone, and you’re not without options. Today, two clinically proven therapies—vaginal estrogen and vulvar or vaginal DHEA—offer powerful tools for relief. Let’s explore the science behind each, how they differ, and which might fit your unique body and goals.
Vaginal Estrogen: Direct Hormonal Replacement
Vaginal estrogen comes in creams, tablets, or rings, all designed to deliver estradiol or estriol directly to vaginal tissue. Estrogen binds to estrogen receptors (ERs) in the tissue and starts working quickly. The result?
- A thicker, more elastic vaginal lining
- Increased lubrication
- Healthier pH levels (goodbye infections)
- Decreased pain with intimacy
Most women feel relief within 2–6 weeks, with full benefits typically by 8–12 weeks. The prescription version is usually 17β-estradiol, which has a high affinity for estrogen receptor alpha (ERα). That’s important—this receptor is highly active to resolve symptoms, but also proliferative, which explains why even low-dose vaginal estrogen still carries an FDA-mandated boxed warning.
Though estrogen therapy is considered very safe when used vaginally, especially at low doses, women with estrogen-sensitive cancers are often advised to steer clear unless cleared by an oncologist.
And here’s the rub: while vaginal estrogen tackles dryness and pH beautifully, it doesn’t help very much with libido. That’s because it doesn’t touch your androgen pathways, which are crucial for arousal, desire, and sexual sensation.
DHEA: The Intracrine Powerhouse
Enter DHEA (dehydroepiandrosterone), a precursor hormone (pro-hormone) produced naturally by your adrenal gland and ovaries. It’s not estrogen. It’s not testosterone. But it becomes both—in the tissues that need it, thanks to a process called intracrine conversion.
Note that DHEA sulfate (DHEA S) is the storage form of DHEA that circulates in the blood, this can be converted to active DHEA when needed by the body.
When applied to vaginal or vulvar tissues, DHEA is absorbed and converted on-site into testosterone and estrogen in the exact amounts needed by each cell. This “on-demand” synthesis makes DHEA especially smart, targeted, and biologically elegant.
What is DHEA?
DHEA, or dehydroepiandrosterone, is a hormone produced by the adrenal glands, which sit atop the kidneys. This hormone is also available as a dietary supplement, often marketed for its potential to boost energy, improve mood, and enhance physical and sexual health. Natural DHEA levels peak in your 20s and gradually decline with age, which may contribute to age-related health issues such as cognitive decline, menopausal symptoms, and decreased sexual function. DHEA plays a crucial role in producing sex hormones, including testosterone and estrogen, which are essential for maintaining hormonal balance and overall well-being.
Here’s what the research shows DHEA can do:
– Restore vulvovaginal moisture and elasticity
– Improve sexual sensation and clitoral/vestibular sensitivity
– Relieve pain and dryness with intimacy
– Boost libido by activating androgen receptors (which estrogen ignores)
In clinical trials, vaginal DHEA matched estrogen in restoring vaginal tissue and pH. One 12-week study found a 46% drop in atrophic cells and a 7% increase in healthy superficial cells. But unlike estrogen, DHEA also improved sexual function across all six domains—desire, arousal, lubrication, orgasm, satisfaction, and pain.
That’s because DHEA activates androgen receptors more powerfully, which are especially concentrated in the vulva and vestibule. These structures are vital for arousal and comfort, and they’re not well-supported by estrogen alone.
In fact, one of the key metabolites of DHEA—5-Androstene-3β,17β-diol—binds to both androgen and estrogen receptors, but preferentially to estrogen receptor beta (ERβ). That matters because ERβ has anti-inflammatory and anti-proliferative effects and may even be protective against certain cancers.
When DHEA is used intravaginally the absorption is rapid and nearly complete, and because the enzyme for conversion of testosterone (aromatase) to estrogen is highly expressed, more estrogen is created.
When DHEA is used topically such as on the vulva, absorption is more difficult (through the outer vulva), and when applied to skin DHEA turns primarily into testosterone – because the enzyme required for conversion to estrogen is less active in the skin.
Safety Comparison and Cognitive Function
| Treatment | Systemic Absorption | FDA Warning | Best Use Case |
| Vaginal Estrogen | Low | Yes | Dryness, pH issues, fast relief |
| Vulvovaginal DHEA | Minimal | None | Dryness + low libido, sexual function|
In breast cancer survivors using aromatase inhibitors (substances to block testosterone conversion to estrogen), DHEA significantly improved GSM symptoms without raising blood estrogen levels—a key safety feature that makes it uniquely suitable for hormone-sensitive patients (with medical oversight).
Unique Benefits of Each for Menopausal Symptoms
Estrogen Pros:
– Fast symptom relief
– Long clinical track record
– Available in various formats (cream, ring, tablet)
DHEA Pros for Postmenopausal Women:
– Also improves libido and orgasmic function
– Activates both estrogen and androgen receptors
– Safer for some women avoiding estrogen
– More comprehensive vulvovaginal tissue support
What the Experts Say About DHEA
Dr. Susan Kellogg-Spadt (vulvovaginal specialist):
“DHEA represents an exciting non-estrogen alternative. It improves the vaginal microenvironment and has a favorable safety profile, even in women with complex histories.”
Dr. James Simon (OB/GYN, hormone specialist):
“Androgen levels fall with age just like estrogen. DHEA supports both hormone pathways and may be the best first-line option for women with libido concerns.”
Dr. Lauren Streicher (Clinical Professor, OB/GYN):
“There’s no one-size-fits-all. But the era of ignoring vaginal health after menopause is over. We have effective, evidence-based options.”
Your Decision-Making Framework
Ask yourself:
1. Do I have a history of breast or uterine cancer?
– Yes: DHEA may be safer (ask your doctor)
2. Are my main symptoms dryness and irritation?
– Either therapy can help
3. Do I also struggle with libido or sexual sensation?
– DHEA offers more support
4. Am I concerned about systemic hormones?
– DHEA is locally converted and minimally absorbed
5. Do I have urinary symptoms or mild leakage?
– DHEA may be slightly more effective based on early data
6. Do I want something easy to use?
– Estrogen offers more delivery formats
– DHEA is now available in creams and inserts, too
Final Thoughts: You Deserve Options
Here’s the truth: Menopause is not a disease, but suffering through it isn’t a badge of honor either. We live longer than ever, often spending 30+ years in the postmenopausal phase. That’s too long to be uncomfortable, and too long to live without intimacy if that’s something you want.
Vaginal estrogen and vulvovaginal DHEA are both safe, science-backed tools. Estrogen brings fast, targeted relief. DHEA offers a holistic, wider approach that can boost arousal, comfort, and confidence.
You deserve agency and accuracy in your care. That means understanding your choices, knowing what each molecule does, and matching your treatment to your biology, your values, your goals, and your health history. The good news? There’s no one right answer—just the right answer for you.
Talk with your provider about which path aligns with your health profile and your vision for a vibrant, empowered life beyond menopause.
Dr. Laura Kelly, DAOM, L.Ac, Dipl. OM is a double board-certified Doctor of Oriental Medicine and nationally licensed primary care provider based in Topanga, California. She earned her clinical doctorate in Oriental Medicine and integrates traditional Eastern healing practices with modern Western diagnostics, including genetics and advanced clinical testing, to deliver personalized, natural medicine solutions. With a deep commitment to Assisted Self-Healing, Dr. Kelly creates personalized, natural medicine programs that support the body’s innate ability to heal. She is the author of multiple internationally published books, including The Healthy Bones Nutrition Plan and Cookbook series, which emphasizes nutrition-based treatments for bone health.
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