A NATUROPATHIC APPROACH TO
VAGINAL ESTROGEN FOR GENITOURINARY SYNDROME OF MENOPAUSE
Vaginal dryness and pain? Local estrogen may help.
Effective Treatment for Genitourinary Syndrome of Menopause
Vaginal dryness, pain with intercourse, recurrent UTIs, and more.
We know many perimenopausal and menopausal patients present with pelvic pain, dyspareunia, or urinary symptoms that are being driven — at least in part — by low estrogen levels in the vaginal and vulvar tissue (genitourinary syndrome of menopause, or GSM). And even pre-menopausal women using hormonal contraception may experience GSM-like symptoms secondary to altered hormone levels. Pelvic floor physiotherapy is foundational treatment for these patients, but the evidence is clear that outcomes are often best when physiotherapy is combined with local vaginal estrogen — a treatment your patients often can’t easily access through their family doctor, especially given how stretched primary care capacity is right now.
Our naturopathic doctors have completed extensive continuing education in menopausal hormone therapy (including with ISSWSH, the International Society for the Study of Women’s Sexual Health) and see local vaginal estradiol prescribing as a natural extension of the work being done by pelvic physiotherapists, as well as for patients not yet seeing a pelvic physiotherapist. This page explains the evidence, our process, and how to refer.
Why local vaginal estrogen alongside pelvic floor physiotherapy
Low-dose vaginal estrogen is recommended as first-line hormonal therapy for GSM by the AUA/SUFU/AUGS 2025 guideline and the Menopause Society, with a favourable safety profile — it acts locally with minimal systemic absorption, and a progestogen is not required alongside it.
The International Urogynecological Association’s committee opinion on hormones and pelvic floor dysfunction found that vaginal estrogen improves vaginal atrophy symptoms, dyspareunia, and urinary symptoms compared with placebo, and several trials show a greater benefit when local estrogen is combined with pelvic floor rehabilitation than with either treatment alone.
For patients where atrophic, thinned, or inflamed tissue is a barrier to progressing manual pelvic floor work, restoring the tissue with local estrogen can make your physiotherapy more effective and more comfortable for the patient.
What other conditions do we treat? Check out our hormonal health hub for educational content about various women’s health concerns.
A note on access
We know many patients are on long waitlists to discuss this with their family doctor or gynecologist, or their provider isn’t comfortable prescribing it. Naturopathic doctors in Ontario can prescribe local vaginal estrogen, and our NDs have specific training and an established clinical protocol for GSM management — so we can usually see a referred patient and prescribe within a week.
Minimal Systemic Absorption
Local vaginal estradiol has minimal systemic absorption, which is part of why it’s considered appropriate first-line therapy for GSM even in many patients who wouldn’t be candidates for systemic hormone therapy. The options available to us in Ontario, and their typical drug plan coverage, are below.
How the referral pathway works
If a patient is a referral from a pelvic physiotherapist, she books a Pelvic Physio Hormone Therapy — 30 Minute appointment with one of our NDs — $150 (usually covered by her health care insurance at 80%, leaving her to pay $30).
At this visit, we take a focused history, confirm there are no contraindications to local vaginal estrogen, discuss options, and prescribe if appropriate.
Follow-up visits every 6 months (30 minutes, $125 – with her paying $25) to renew the prescription and check in on symptoms.
We’ll communicate back to the referring clinic (with the patient’s consent) so treatment stays coordinated.
Most extended health care benefit plans in Ontario include naturopathic doctor coverage, commonly up to about $500/year — many patients can offset almost ALL of the visit cost through their insurance plan.
Regional limitations for access to guideline supported medications
Evidence-support products not all available in Ontario/Canada.
Guideline bodies (AUA/SUFU/AUGS, the Menopause Society) list estradiol cream as one of the standard first-line formulations for GSM, in part because it can be applied externally and dosed flexibly — an important option for patients with significant vestibular pain or vaginismus where any insertable product is intolerable.
In Ontario, however, we do not have commercial access to an estradiol vaginal cream — only the insertable tablet (Vagifem) and capsule (Imvexxy). There are two other cream options, neither of which contain the estradiol that the guidelines support; Estragyn which is estrone (a hormone that does not drop significantly in menopause), and Premarin vaginal cream which is a conjugated equine estrogen containing various forms of non-human estrogen.
For patients where insertion itself is the barrier, a compounded estradiol cream through a compounding pharmacy is our only option, and it usually is not covered by insurance. We’ll always start with a covered option where clinically appropriate, and reserve compounded cream for patients who genuinely need it, or who request it.
Note! Vaginal estrogen rings are not included in this list as we find patients not keen on this option, as the inconvenience of replacement every 3 months is an obstacle to consistency.
VAGIFEM
Dosing
Vagifem (estradiol 10mcg vaginal tablet with applicator)
Form
Insertable tablet, daily for 2 weeks, then twice weekly
Drug Plan Coverage
Generally covered — listed on the Ontario Drug Benefit formulary and typically covered by private plans
Best Fit
Patient with mild GSM who can tolerate vaginal insertion
IMVEXXY
Dosing
Estradiol 4 mcg or 10 mcg vaginal insert
Form
Softgel insert, no applicator needed, same dosing schedule
Drug Plan Coverage
Generally covered by most private plans; as a newer brand-only product, occasional prior authorization may apply
Best Fit
Patients who prefer finger-insertion over an applicator (less plastic waste), or want the lowest available dose (4 mcg)
COMPOUNDED ESTRADIOL CREAM
Dosing
Various. Lots of flexibility with dosing
Form
Custom-compounded vaginal/vulvar cream (only availble via compounding pharmacies)
Drug Plan Coverage
Not covered — compounded preparations are typically an out-of-pocket cost ~$30/month
Best Fit
Severe GSM where any insertion (tablet or insert) causes too much pain — cream can be applied externally to the vulvar vestibule
Our Prescribing NDs
Dr. Janna Fung and Dr. Sarah Goulding are our licensed naturopathic doctors who are passionate about treating genitourinary syndrome of menopause. It’s an easy fix, so why not give more women easy access?
Questions about a specific patient, or want to discuss a case before referring?
Reach out any time — we’re glad to be a resource.
FAQ
What's wrong with the Premarin cream I was prescribed by my doctor?
At Sequence Wellness our NDs have extensive training in women’s health and use the evidence-based guidelines to direct our treatment choices. The evidence shows that an estradiol cream or insert is the best therapy for GSM, so we abide by those recommendations. Estragyn contains estrone, which is a hormone that does not plummet in menopause like estradiol does. It is an estrogen made via out fat cells, not our ovaries. Premarin is derived from pregnant horse/mare urine, and contains other estrogenic compounds that are not native to human bodies.
Can my doctor prescribe estradiol creams and inserts?
Absolutely! And if you ask for it specifically, they should have no issues with giving you this prescription. Just watch out that they are not prescribing your Estragyn or Premarin. And if you are not able to tolerate the insertion, you can ask them for a compounded estradiol cream (though many MDs are not comfortable with compounding as there is less standardization than with factory prepared options.
Will it be expensive for me to get a vaginal estrogen prescription via a naturopathic doctor?
If you have health insurance (which usually covers 80% of naturopathic visits up to $500 per year) you only have to pay $80 out of pocket in the first year (1st appointment at $150, 2nd and 3rd appointments at $125). After the first year, appointments are only needed every 6 months, so your out of pocket costs goes down to $50 for the year, plus the cost of the prescription at the pharmacy.
Is vaginal estrogen expensive?
Vagifem and Imvexxy (vaginal estrogen inserts) cost between $20-40 per month, but are almost always covered by your drug plan, so usually less than $10 per month. Compounded estrogen cream is about the same price to start, but is less often covered by insurance.
Do I need a referral to book an appointment?
With a referral you can access the condensed initial visit (vaginal estrogen initial appointment which is $150), as it allows us to piggy-back on your physiotherapist’s existing diagnosis before we prescribe. We still will perform a shortened directed intake to be sure nothing is missed, but it is not as extensive as our typical 90 minute naturopathic intake appointment. Without a referral please book the regular naturopathic initial appointment.
Is this the same as menopausal hormone therapy?
No. Menopausal Hormone Therapy (MHT) is a high dose prescription of systemic hormone therapy. We must do a more extensive assessment to be sure this would be an appropriate intervention for you. Please book a regular naturopathic initial appointment for this.
What if I want systemic menopausal hormone therapy?
Great! We see a lot of women for systemic menopausal hormone therapy. Please book a regular initial naturopathic appointment so that we can be a thorough assessment and education session before prescribing.
Do I need a physical exam for vaginal estrogen to be prescribed?
The current guidelines have determined that a physical exam, though ideal, is not required to prescribe vaginal estrogen for genitourinary syndrome of menopause.
References:
American Urological Association / SUFU / AUGS. Genitourinary Syndrome of Menopause Guideline (2025).
The Menopause Society. Position statement on genitourinary syndrome of menopause (2020).
International Urogynecological Association Research and Development Committee. Effectiveness of hormones in postmenopausal pelvic floor dysfunction — committee opinion.
Canadian Menopause Society. Estrogen and progestogen products available in Canada — reference table (2024).
We Welcome All Humans
At Sequence Wellness, we are committed to providing inclusive, respectful, and compassionate care. We welcome people of all races, ethnicities, ages, abilities, religions, sexual orientations, gender identities, and gender expressions. Your health, dignity, and lived experience matter here.
Land Acknowledgement
We respectfully acknowledge that our clinic operates on the traditional, unceded territory of the Algonquin Anishnaabeg People. We are deeply grateful for the opportunity to live and work on this land.
