Estrogen levels plummet after menopause, due to declining ovarian function, causing atrophic urogenital symptoms in 1/3 rd of women to the tune of almost as high as 50-60%.The most commonly perceived symptoms are dryness, itching, burning , irritation of vagina, dyspareuniaie pain during intercourse, dysuria, urgency, frequency and recurrent urinary tract infections. They are together called as the Genitourinary syndrome of menopause.(1) Most of the women report them as moderate to severe in severity. In 2014 , this  new terminology was introduced by the International society of women’s sexual health and the North American Menpause Society in replacement of the older term(VVA)ie Vulvar-vaginal atrophy(2) .Vulva, vagina, urethra, bladder and pelvic musculature  conspicuously show changes  with connective tissue thinning,due to estrogen deficiency  due to the presence of estrogen receptors in these tissues.The urinary tract is also affected alongside these vaginal and vulval changes, due to their common embryological origin, causing recurrent urinary tract infections without a positive urine culture due to atrophic urethritis.(1)

The effectiveness of  local application of vaginal estrogen cream for treating urogenital atrophy has been well established  beyond doubt in literature(3). Intravaginal estrogen use is assosciated with relief of  genitourinary symptoms of menopause and improved quality of life with lesser incidence of recurrent urinary tract infections, and incontinence observed with a maximal effect over a period of 12 weeks treatment.(1)

Nice guidelines 2015 recommends intravaginal estrogen therapy for  urogenital atrophy  for as long as needed , including in women on  systemic HRT. It’s efficacy and tolerability is to be reviewed every 3 months.It is also recommended to increase the dose of intravaginal estrogen, if the current dose fails to provide adequate relief to the patient. Adverse effects due to local estrogen use are very rare and hence, no routine monitoring of endometrial thickness during treatment has been recommended till date for unopposed low dose estrogen usage.(3,(4)) In the past, systemic HRT use was stressed on upon, for the genitourinary symptoms of menopause, but recently , the interest has shifted upon the local estrogen use due to increased and better efficacy with  delivery of locally applied drug to the target areas with no side effects.(5). Relief of incontinence symptoms  of both Sui and Overactive bladder in menopausal women have been attributed to local estrogen use with statistical supremacy in various studies in literature. Intravaginal estrogen increases urethral coaptation by increasing MUCP, in lieu of increased blood supply due to local estrogen use , reducing Sui symptomatology over 3 months usage(6)Also, frequency of uninhibited uterine contractions and their amplitude are dampened with local estrogen use as estrogen deficiency is an etiological factor in irritated bladder with increased frequency, urgency and nocturia , as its manifestations -according to a Cochrane review, published in 2003, and updated in 200(7). The sensory threshold of bladder is also increased promoting relaxation of the bladder –proving to be very useful in  relieving urge incontinence symptomatology of menopausal  women(8).The use of local vaginal estrogen therapy is assosciated with significant improvement in women’s self-reported prior bothersomeness and improvement in quality of life post treatment.(9)