New AUA Guidelines on Vaginal Estrogen.
What You Need to Know About the 40% Reduction in Morbidity and 70% Reduction in Mortality
As a WHNP passionate about hormone therapy, I’m thrilled to see growing recognition of the life-changing — and potentially life-saving — impact of vaginal estrogen therapy. The American Urological Association (AUA) recently released updated guidelines that underscore just how significant this treatment can be for postmenopausal women, not only improving quality of life, but also decreasing risk of mortality at 10 years compared to control (3.0% vs 4.3%, RR 0.70, 95% CI 0.51-0.96). A recent study by Wells BA published in 2025 by the "Journal of Urology" confirms in women over the age of 55 with recurrent UTIs, with use of vaginal estrogen a 40% reduction in urosepsis and hospitalization and a 70% reduction in death.
A Shift in Perspective: Vaginal Estrogen and Urogenital Health
The AUA’s new guidelines are a response to mounting evidence that genitourinary syndrome of menopause (GSM) — which includes vaginal dryness, irritation, urinary urgency, urinary frequency and recurrent urinary tract infections — is not just a quality-of-life issue. When left untreated, GSM can significantly contribute to increased healthcare utilization, repeated infections, urosepsis, falls (often linked to nocturia), and even fractures in older adults.
Vaginal estrogen, when used locally (via creams, tablets, or rings), delivers targeted, low-dose hormone therapy directly to affected tissues. This avoids the systemic risks traditionally associated with oral or systemic estrogen. This therapy is affordable and should be made available to all women by not only OBGYN/WHNP providers, but all primary care providers. A pelvic exam should be completed prior to beginning therapy and again after a woman has been on therapy to assess effectiveness. If symptoms remain unresolved she should then be seen by a specialist in Women's Health to assess for other disorders that may be contributing to symptoms.
Safety First — And Reaffirmed
One of the most important takeaways from the updated AUA guidelines is the strong reaffirmation of the safety profile of vaginal estrogen. Studies have consistently shown no increased risk of breast cancer, cardiovascular disease, or stroke with local vaginal estrogen use, even in women with a history of these conditions or those that are BRCA positive. This makes it a safe and effective treatment for the majority of postmenopausal women, including those previously considered “high risk.”
What This Means for Patients
As a provider, I often see women suffer silently — either because they believe their symptoms are a “normal part of aging,” or because they’ve been told hormone therapy is too risky. These new guidelines help shift that narrative. Vaginal estrogen is not only safe, it’s potentially life-extending.
If you're experiencing symptoms of GSM, I recommend consulting your healthcare provider. The benefits go far beyond comfort — they can significantly reduce your risk of infection, hospitalization, and other serious complications. Search and print out the 2025 American Urology Association GSM Guidelines and bring them to your healthcare provider to begin the discussion.
Final Thoughts
The AUA’s updated stance on vaginal estrogen is a major win for patients and providers alike. As we continue to prioritize evidence-based care in hormone therapy, let’s not underestimate the power of restoring quality of life — and even saving lives — with one of the safest and most effective tools we have.
— Written by Jean Walker, WHNP-BC | Arctic Rose Wellness Clinic
References:
1. Wells BA, De EJB, Visingardi J, Feustel PJ. IP15-36 Impact of Vaginal Estrogen on Serious Adverse OUtcomes in Postmenopausal Women with Recurrent Urinary tract Infections: A Retrospective Study. Journal of Urology [Internet]. 2025 May 1 [cited 2025 Jun 4]; 213(55):e778. Available From: https://doi.org/10.1097/01.JU.0001109984.67114.74.36
2. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 0(0). doi:10.1097/JU.0000000000004589. https://www.auajournals.org/doi/10/1097/JU.0000000000004589
