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Symptoms include vaginal dryness, dyspareunia, urinary urgency, dysuria, and recurrent urinary tract infections. Despite strong evidence supporting the safety and efficacy of local vaginal estrogen (VE) therapy, treatment remains underutilized due to clinician uncertainty, misconceptions regarding systemic risk, and regulatory warnings. Recent clinical guidelines emphasize vaginal hormones as first-line therapy for GSM. This review summarizes the pathophysiology of GSM, evidence supporting local hormone therapy, safety considerations, and practical prescribing strategies for clinicians. Pearls for clinical practice are discussed, including dosing regimens, formulation selection, patient counseling, and strategies to overcome barriers to treatment adherence.<\/jats:p>","DOI":"10.1177\/15409996261465193","type":"journal-article","created":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T05:07:59Z","timestamp":1782882479000},"page":"900-907","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Vaginal Estrogen: Pearls for the Practitioner\n                    <i>A Practical Review of Evidence, Guidelines, and Prescribing Strategies for Genitourinary Syndrome of Menopause<\/i>"],"prefix":"10.1177","volume":"35","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6011-9228","authenticated-orcid":false,"given":"Sara","family":"Perelmuter","sequence":"first","affiliation":[{"name":"Weill Cornell Medicine, New York, New York, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3413-5555","authenticated-orcid":false,"given":"Meha","family":"Srivastava","sequence":"additional","affiliation":[{"name":"Case Western Reserve University, Cleveland, Ohio, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kayla P.","family":"Freedman","sequence":"additional","affiliation":[{"name":"Tulane University School of Medicine, New Orleans, Louisiana, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarina","family":"Hanfling","sequence":"additional","affiliation":[{"name":"University of Maryland School of Medicine, Baltimore, Maryland, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel S.","family":"Rubin","sequence":"additional","affiliation":[{"name":"Department of Urology, Georgetown University, Washington, District of Columbia, USA."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,6,30]]},"reference":[{"key":"e_1_3_3_2_1","doi-asserted-by":"publisher","DOI":"10.3109\/13697137.2014.946279"},{"key":"e_1_3_3_3_1","volume-title":"Genitourinary Syndrome of Menopause","author":"Carlson K","year":"2026","unstructured":"2.Carlson K, , Nguyen H. 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