How Doctors Decide Between Hormonal and Nonhormonal Options

When vaginal dryness, burning, irritation, painful sex, or urinary symptoms develop during perimenopause or after menopause, there is rarely a single treatment that is right for everyone. Doctors may discuss hormonal and nonhormonal options, depending on the symptoms, their underlying cause, medical history, preferences, and treatment goals.

This is particularly relevant for genitourinary syndrome of menopause (GSM), a collection of genital, sexual, and urinary symptoms associated with declining sex hormones. GSM can affect the vulva, vaginal opening, vagina, clitoris, urethra, and bladder. Symptoms can include dryness, irritation, burning, painful penetration, urinary urgency, frequency, and other urinary concerns.

The decision between hormonal and nonhormonal treatment is not necessarily an either-or choice. Some women use nonhormonal products alone, while others use them alongside prescription treatment. The goal is to identify the underlying problem and select an approach that fits the individual’s needs.

What Are Nonhormonal Options?

Nonhormonal treatments do not contain estrogen or another hormone intended to replace declining ovarian hormones.

For GSM, common nonhormonal options include:

• Vaginal moisturizers
• Vaginal lubricants
• Pelvic floor physical therapy
• Vaginal dilators in selected situations
• Behavioral or sexual-health approaches
• Treatment of another underlying condition when one is identified

Vaginal moisturizers are generally used regularly to help maintain vaginal moisture, while lubricants are typically used during sexual activity to reduce friction and discomfort. Water-, silicone-, and oil-based lubricants are available, although oil-based products may not be compatible with certain condoms.

These options can be especially useful when symptoms are mild, when a person prefers to avoid hormones, or when a nonhormonal approach is appropriate alongside another treatment.

What Are Hormonal Options?

Hormonal treatments are designed to influence tissues or symptoms affected by declining sex hormones.

For GSM, one important option is low-dose vaginal estrogen. It is applied directly to vaginal or vulvar tissue and is available in forms such as creams, tablets or inserts, and vaginal rings. The Menopause Society describes low-dose vaginal estrogen as an effective treatment for vaginal dryness, irritation, discomfort, and painful sex associated with GSM.

Other prescription options can include vaginal dehydroepiandrosterone (DHEA) and oral ospemifene, depending on the symptoms and individual circumstances.

It is important to distinguish local vaginal hormone therapy from systemic hormone therapy. Systemic hormone therapy is absorbed throughout the body and may be used for symptoms such as hot flashes and night sweats, while low-dose vaginal estrogen is primarily directed at local genitourinary symptoms.

The First Question: What Symptoms Are You Trying to Treat?

Before deciding between hormonal and nonhormonal treatment, a doctor will generally want to understand exactly what is happening.

For example, someone who experiences occasional discomfort during intercourse because of friction may benefit from a lubricant.

Someone experiencing daily vaginal dryness, burning, and tissue changes may need a different approach.

Another person may have painful penetration primarily because the pelvic floor muscles are excessively tense.

And urinary urgency or burning may have more than one possible cause.

The symptoms themselves provide clues, but they do not always identify the underlying condition. A thorough history and, when appropriate, an examination can help distinguish GSM from infections, vulvar skin conditions, pelvic floor dysfunction, medication effects, and other gynecologic or urinary conditions.

How Severe Are the Symptoms?

Symptom severity can also influence the discussion.

For mild dryness that occurs mainly during sexual activity, a lubricant may provide enough relief. For ongoing dryness or irritation outside sexual activity, a vaginal moisturizer may be more useful.

When symptoms are persistent or significantly affecting quality of life, a doctor may discuss prescription options.

A systematic review presented by The Menopause Society found that vaginal estrogen may improve vulvovaginal dryness and painful intercourse, while vaginal moisturizers may also improve dryness; however, the evidence varied and many studies were relatively short.

The decision therefore involves more than simply asking which treatment is “stronger.” It involves asking which treatment addresses the particular symptoms and goals.

Medical History Matters

A person’s medical history can substantially influence treatment choices.

Doctors may consider:

• Age and stage of menopause
• Whether symptoms began during perimenopause or after menopause
• Previous gynecologic conditions
• Medications
• History of blood clots or cardiovascular disease
• Liver disease
• History of hormone-sensitive cancer
• Previous cancer treatments
• Surgical menopause
• Current or previous hormone therapy
• Other urinary or pelvic conditions

The Menopause Society notes that the benefits and risks of systemic hormone therapy vary according to factors such as age, health history, time since menopause, and individual risk factors.

Local low-dose vaginal estrogen is a different treatment category, with substantially lower systemic exposure than systemic hormone therapy. Nevertheless, people with complex medical histories should discuss treatment decisions with their healthcare professional.

What If Someone Prefers Nonhormonal Treatment?

A preference to avoid hormones is an important part of shared decision-making.

Some women may prefer to start with vaginal moisturizers and lubricants. Others may choose nonhormonal treatment because of personal preferences, previous experiences, or specific medical considerations.

Nonhormonal treatment can also be used alongside prescription therapy.

For example, someone using vaginal estrogen may still use a lubricant during sexual activity to reduce friction. A vaginal moisturizer can also be used regularly for additional comfort. The Menopause Society specifically notes that nonhormonal lubricants and moisturizers can be combined with prescription therapies when appropriate.

What If Hormonal Treatment Is Preferred?

For women whose symptoms are related to estrogen deficiency, hormonal therapy may directly address some of the tissue changes associated with GSM.

Low-dose vaginal estrogen can improve the vaginal environment and help relieve dryness, irritation, and painful sex. Improvements generally occur with consistent use and may take weeks or longer depending on the individual and treatment.

This does not mean that hormones are automatically the best choice for every woman.

A doctor still needs to consider the person’s symptoms, medical history, preferences, and whether another condition may be causing the problem.

Can Hormonal and Nonhormonal Treatments Be Combined?

Yes. In many cases, these approaches can complement one another.

For example, a treatment plan might include:

Regular vaginal moisturizer + lubricant during sex

This combination can provide ongoing moisture while reducing friction during sexual activity.

Another person might use:

Low-dose vaginal estrogen + lubricant

The estrogen addresses menopause-related tissue changes, while the lubricant provides additional friction reduction during sex.

Someone experiencing pelvic floor dysfunction might have:

GSM treatment + pelvic floor physical therapy

This can be relevant when both vaginal tissue changes and pelvic muscle dysfunction contribute to discomfort.

The right combination depends on the underlying causes rather than a predetermined formula.

What About Pelvic Floor Dysfunction?

Not every symptom involving vaginal discomfort is caused by vaginal tissue.

The pelvic floor muscles can become weak, overly tense, painful, or poorly coordinated. Muscle dysfunction can contribute to painful penetration, pelvic pressure, urinary symptoms, and sexual difficulties.

If pelvic floor dysfunction is identified, pelvic floor physical therapy may become part of the treatment plan.

This is one reason doctors may evaluate muscle function before assuming that vaginal dryness or pain should be treated with hormones alone.

A person can have both GSM and pelvic floor dysfunction, meaning both may need attention.

When Nonhormonal Treatment May Not Be Enough

Some women experience persistent symptoms despite using lubricants or moisturizers.

That does not necessarily mean they need a procedure. Instead, it may be a reason to reassess the diagnosis and consider whether another treatment is appropriate.

For example, persistent dryness may reflect GSM that is not adequately controlled. Persistent pain may involve pelvic floor tension. Burning or itching could also be related to infection, inflammation, or a vulvar skin disorder.

The Menopause Society notes that GSM often becomes more persistent over time without treatment, while multiple effective prescription and nonprescription options are available.

How Personal Preferences Fit Into the Decision

Medical treatment is not only about clinical findings.

A person’s preferences matter.

Some women prioritize avoiding hormones. Others prioritize addressing persistent symptoms as directly as possible. Some may prefer a nonprescription option before considering prescription therapy, while others may want to discuss prescription treatment early.

Cost, convenience, frequency of treatment, comfort with a particular method, and concerns about side effects can also influence the decision.

The Menopause Society specifically identifies symptoms, severity, age, underlying health, preferences, available treatments, and cost as factors that may influence hormone therapy decisions.

When Should Symptoms Be Evaluated?

Vaginal symptoms should not automatically be assumed to be caused by menopause.

An evaluation is particularly important when symptoms are persistent, worsening, or accompanied by:

• Bleeding after menopause
• Significant or unexplained pelvic pain
• Unusual discharge or odor
• Severe burning or itching
• Pain that continues despite lubrication
• Burning with urination
• Recurrent urinary tract infections
• New or unusual vulvar or vaginal changes

These symptoms can have causes other than GSM and may require different treatment.

The Bottom Line

Doctors decide between hormonal and nonhormonal options by looking at the underlying cause, symptoms, severity, medical history, treatment goals, and personal preferences.

Nonhormonal options such as vaginal moisturizers and lubricants can be useful for managing dryness and friction, while pelvic floor physical therapy can address muscle-related problems.

For GSM-related tissue changes, low-dose vaginal estrogen and other prescription therapies may provide additional treatment options.

Importantly, these approaches do not always have to be used separately. A personalized treatment plan may combine hormonal and nonhormonal therapies when appropriate.

The most useful question is not simply “Should I use hormones or not?” It is “What is causing my symptoms, and which treatment or combination of treatments best addresses that cause while fitting my health history and preferences?”

That conversation with a qualified healthcare professional can help turn a confusing list of treatment choices into a more individualized plan for vaginal, sexual, and urinary health.