Safety of vaginal estrogens: a systematic review

Menopause. 2020 Mar;27(3):339-360. doi: 10.1097/GME.0000000000001468.


Objective: This systematic review included clinical trials of Food and Drug Administration-approved vaginal estrogens. The primary objective of this systematic review was to examine the comparative safety of the Food and Drug Administration-approved vaginal estrogen preparations among postmenopausal women.

Methods: We performed a PubMed search of the primary literature from January 1, 1966 to July 16, 2019 for English-language clinical trials. Manual review of retrieved citations identified additional citations.

Results: Of 882 retrieved citations, 75 clinical trials met inclusion criteria. Maximum trial duration was 52 weeks. None of the trials predesignated breast or endometrial cancer, cardiovascular events, or venous thromboembolism as primary outcomes. Studies were not designed to rule out an increase in endometrial carcinoma risk with long-term use of vaginal estrogen. There were few head-to-head comparisons. Fifty trials examined serum sex steroid and gonadotrophin levels; assay methodologies varied. Serum estradiol levels were 11 pg/mL at baseline or during placebo use and increased to a mean of 30 pg/mL after treatment. Estradiol levels were usually highest during the first 12 weeks of treatment, and were higher for estrogen creams than for inserts or rings. The 22 trials of endometrial thickness and the 15 trials of endometrial biopsy did not clearly demonstrate endometrial proliferation after vaginal estrogen treatment, but data were limited, and studies did not always perform systematic endometrial biopsy.

Conclusions: Newer low-dose estradiol rings, tablets, and inserts appear to induce the least increases in serum hormones, possibly indicating greater safety. Limited evidence in trials lasting up to 52 weeks suggest endometrial safety of vaginal estrogen use. Long-term trials are needed. : Video Summary:

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Publication types

  • Systematic Review

MeSH terms

  • Administration, Intravaginal
  • Atrophy
  • Clinical Trials as Topic
  • Endometrium / drug effects
  • Estrogen Replacement Therapy / methods*
  • Estrogens / administration & dosage*
  • Female
  • Humans
  • Middle Aged
  • Postmenopause*
  • Treatment Outcome
  • Vagina / pathology*
  • Vaginal Diseases / drug therapy*


  • Estrogens