Vaginal atrophy, a manifestation of estrogen deprivation after the menopause, could affect up to 60% of women, with a significant impact on their quality of life. It is often under-diagnosed and inadequately treated. Symptoms are more common and severe in breast cancer survivors. Systemic estrogen replacement therapy may be unacceptable for many women because of the concerns over possible risks and may not cure vaginal symptoms in up to 45% of users. Non-medicated vaginal lubricants or moisturizers have been found to be no better than placebo and less effective than estrogen. Topical vaginal estrogen preparations reverse atrophic changes and relieve associated symptoms, while avoiding systemic effects. This article provides an up-to-date overview of the role, safety and effectiveness of topical vaginal estrogen therapy.