HRT Cream vs Pessary for Perimenopause: Which Is Right for You?
Comparing HRT cream and pessary for perimenopause symptoms. Learn how each form of local oestrogen works, who benefits most, and how to choose.
Local Oestrogen in Perimenopause
As oestrogen levels fall during perimenopause, the tissue lining the vagina and urethra can become thinner, drier, and more sensitive. This group of symptoms is known as genitourinary syndrome of menopause (GSM), and it affects a large proportion of women, though many find it difficult to raise with a doctor. Local oestrogen, applied directly to the vaginal area rather than absorbed into the bloodstream in meaningful quantities, is one of the most effective ways to manage these symptoms. Two commonly prescribed forms are oestrogen cream and oestrogen pessary. Both deliver low-dose oestrogen locally, but they differ in how they are applied, how long they last, and which situations they suit best.
How HRT Cream Works
Vaginal oestrogen cream (such as Ovestin or Premarin cream in the UK) is applied using a small applicator or fingertip directly inside or around the vaginal opening. It is typically used daily for an initial few weeks, then reduced to two or three times per week as maintenance. Cream can also be applied externally to the vulva, which makes it particularly useful if dryness or soreness extends to the outer tissue. Many women find cream offers flexibility because the dose can be adjusted easily and it can be used in multiple areas in one application.
How HRT Pessaries Work
A pessary is a small tablet or soft capsule inserted into the vagina using an applicator, where it dissolves and releases oestrogen directly into the vaginal walls. Products such as Vagifem and Imvaggis are common examples. Pessaries are generally used daily for the first two weeks, then twice weekly for ongoing management. Many women prefer pessaries because they feel less messy than cream and are straightforward to use at bedtime. The dose is fixed per pessary, which simplifies the routine for those who prefer a consistent approach.
Key Differences to Consider
The main practical difference is coverage. Cream can be applied externally as well as internally, making it more versatile if you experience vulval dryness, irritation, or discomfort during urination. Pessaries act internally and are better suited to internal vaginal dryness, discomfort during sex, and recurrent urinary tract infections linked to tissue thinning. Both forms are considered safe for long-term use and have minimal systemic absorption, so they do not typically require progesterone to be added even in women with a uterus. If you are also using systemic HRT such as patches or gel, a local pessary or cream can be added alongside without concern about doubling up on hormones.
Who Each Form Suits Best
Cream tends to suit women who have significant external dryness, those who prefer to use a single product for both internal and external discomfort, or those who want to adjust their dose over time. Pessaries work well for women whose symptoms are primarily internal, those who want a simple and less messy routine, or those who prefer a product with a fixed dose. Some women try both and settle on whichever fits their lifestyle. If initial treatment with one form does not fully relieve symptoms after six to twelve weeks, it is worth discussing switching or combining forms with a healthcare provider.
Making the Decision
Local oestrogen in any form is underused, partly because women are not always told it exists and partly because GSM symptoms are normalised rather than treated. If you experience vaginal dryness, discomfort during sex, increased urinary urgency, or recurrent UTIs, local oestrogen is worth asking about. Cream and pessaries are both effective, safe, and available on prescription in the UK and many other countries. Your prescriber can help you weigh the practicalities. Tracking your symptoms before and after starting treatment can help you see whether the chosen form is making a difference. PeriPlan lets you log symptoms over time so you can spot patterns and bring clearer information to your appointments.
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