Low oestrogen symptoms: why your vulva and vagina get dry

The Big O

Or, if you're in the US, the big E. I love a confusing spelling variation in my medical papers. Oestrogen (estrogen in the US) is a family of hormones that play an important role across the body from puberty onwards.

There are three main forms. Oestradiol (estradiol) dominates puberty and the reproductive years. Oestrone takes over at menopause. Oestriol (estriol) is the main version produced in pregnancy. You'll often see the US spellings estradiol and estriol on UK prescriptions, because those are the names the medicines now use.

You've got oestrogen receptors all over your body: brain, liver, colon, skin, reproductive tract and even your salivary glands. All types of oestrogen can bind to these receptors, but oestradiol binds more tightly and prompts a bigger response in whatever that cell is making. How much oestrogen you have, and which type is dominant, affects how moist your vulva and vagina stay.

Symptoms of low oestrogen in the vulva and vagina

Oestrogen helps keep vulval and vaginal tissue healthy. When levels drop, or a weaker form of oestrogen takes over, blood flow to the vulva and vagina decreases, bringing less oxygen and fewer nutrients. Collagen and hyaluronic acid production declines, so the tissue loses its bounce, and the moisture-producing glands in the vulva become less active. Vaginal cells also become thinner and store less glycogen. Lactobacillus bacteria feed on glycogen, so their numbers fall, the vagina becomes less acidic, and other microbes find it easier to grow.

Together these changes can cause dryness, soreness, itching and irritation. They usually come on gradually, and it can take years before you notice the difference. For other causes of dryness and itching, see Why is my vulva dry, itchy or sore?

What changes the level or type of oestrogen

Menstrual cycle

Before and during your period, oestradiol levels fall briefly. Most people won't notice, but for some it brings a few days of dryness or soreness. This usually settles once oestradiol rises again.

Contraception

The combined pill contains a synthetic oestrogen and a progestogen. It works by stopping ovulation, which keeps your own oestradiol low and steady, and some people notice dryness or less natural lubrication while taking it.

Progestogen-only contraceptives use a synthetic hormone related to progesterone. Depending on the method, they may stop ovulation, thicken cervical mucus or thin the lining of the womb. The implant (Nexplanon) and the injection (Depo-Provera) usually stop ovulation. So do the desogestrel and drospirenone progestogen-only pills, while people taking the older types of pill still ovulate in around 4 in 10 cycles. Stopping ovulation can lead to dryness or reduced natural lubrication.

Hormonal coils like Mirena and Kyleena release a lower dose of progestogen that is mostly used up in the womb. Most users keep their normal ovulation cycle and oestradiol levels, even though their periods often become lighter or stop.

Birth and breastfeeding

After giving birth, oestrogen (mainly oestriol) and progesterone drop sharply and prolactin, the milk-making hormone, rises. Prolactin then holds oestradiol and progesterone down until breastfeeding is over, which can leave the vulva and vagina feeling dry, tight or sore.

Perimenopause and menopause

For most women, perimenopause starts somewhere in their late thirties to late forties. This is the zigzag part, when oestradiol rises and falls unpredictably and oestrone begins to take over. Dryness can start here, coming and going as levels swing.

After menopause, oestrone becomes the main form of oestrogen. It's weaker than oestradiol and is made in your body fat, using an enzyme found in fat tissue, rather than in your ovaries.

Over time, the switch from oestradiol to oestrone can lead to genitourinary syndrome of menopause (GSM), the modern term for what used to be called vaginal atrophy. These changes often take several years to become noticeable. Exact figures vary, but GSM becomes more common with time after menopause and eventually affects most women to some degree.

Local vaginal oestrogen (estradiol or estriol) is an effective treatment for GSM. It can help stop it developing or getting worse by giving the vaginal and vulval tissue a local dose of oestrogen. In the UK, creams are commonly prescribed, but pessaries, tablets and rings are also available. Since 2022, a low-dose estradiol vaginal tablet has also been available from pharmacies without a prescription, for women aged 50 or over who haven't had a period for at least a year.

Vaginal oestrogen can be used whether or not you take hormone replacement therapy (HRT). Some women with a history of breast or gynaecological cancer may also be able to use it, but this should always be discussed with their specialist.

Premature ovarian insufficiency (POI)

Premature ovarian insufficiency (POI), previously called premature ovarian failure, is when the ovaries stop working normally before the age of 40. Recent estimates suggest it affects around 4 in 100 women and girls, including me, far more than the 1 in 100 older figures gave. It has a lot in common with menopause because oestrogen levels are low, although the ovaries can sometimes start working again for a while. 

Sometimes these conditions are linked to genetics, autoimmune conditions, or medical treatments like surgery, chemotherapy or radiotherapy. In many cases there's no clear reason. As the Daisy Network and ESHRE both point out, POI and early menopause can bring extra challenges: fertility loss, delayed diagnosis, and the emotional impact of hormonal change at a younger age.

Because our oestrogen levels are so low for our age, we usually need higher doses of oestrogen than those prescribed for menopause at the usual age, to support bone strength, heart health and sexual wellbeing. Guidance for clinicians on safe and effective treatment is available from the British Menopause Society and ESHRE. Vaginal oestrogen can be added if dryness continues.

Despite being diagnosed with POI in my thirties and given HRT, I ended up developing GSM. When I started treatment, over a decade ago, I was told the vaginal oestrogen cream was optional if my systemic dose was doing its job. I found HRT enough of a faff as it was. Remembering a cream twice a week too, on top of everything else, didn't last. Eventually I just stopped. Years later, I found out two things: I'd been prescribed the standard menopause dose, not the higher one recommended for POI, and I hadn't been absorbing it well either. Between the two, I was nowhere near covered, and I wish I'd used the bloody cream.

References

Faculty of Sexual & Reproductive Healthcare (FSRH), "Progestogen-only Pills," Clinical Guideline (August 2022, amended April 2026) https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-ceu-clinical-guideline-progestogen-only-pills-aug22-amended-11july-2023-.pdf

GP Infant Feeding Network (UK), "Reproductive Health: Postpartum Vaginal Dryness and Atrophic Vulvovaginitis," (2019) https://gpifn.org.uk/reproductive-health/

British Menopause Society, "Genitourinary Syndrome of Menopause (GSM)," Consensus Statement (November 2025) https://thebms.org.uk/publications/consensus-statements/genitourinary-syndrome-of-menopause-gsm/

British Menopause Society, "Premature ovarian insufficiency," Consensus Statement (reviewed March 2024) https://thebms.org.uk/wp-content/uploads/2024/04/05-BMS-ConsensusStatement-Premature-ovarian-insufficiency-POI-APRIL2024-C.pdf

ESHRE, "Guideline on premature ovarian insufficiency," (December 2024), with patient version https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Premature-ovarian-insufficiency

MHRA, "Easier access to locally-applied HRT to treat postmenopausal vaginal symptoms in landmark MHRA reclassification," (July 2022) https://www.gov.uk/government/news/easier-access-to-locally-applied-hrt-to-treat-postmenopausal-vaginal-symptoms-in-landmark-mhra-reclassification

Daisy Network, "Premature Ovarian Insufficiency," https://daisynetwork.org/