Vaginal Estrogen Found Safe After Stroke

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Stroke survivors often face tough choices about managing menopause symptoms.

A new study from Copenhagen University Hospital–Herlev and Gentofte found that vaginal estrogen tablets were not linked to an increased risk of recurrent ischemic stroke in postmenopausal women.

The results suggest these drugs may be a safe option for symptom relief in women with a prior stroke.

Estrogen therapy and its stroke risks

Stroke is a serious concern for postmenopausal women. Many of these women turn to hormone therapy to relieve menopause symptoms that affect daily life, such as hot flashes, vaginal dryness or pain during sex. For some, these drugs can make the difference between ongoing discomfort and a return to normal activities.

Systemic hormone therapy, such as oral estrogen pills or patches, is linked to a higher risk of ischemic stroke. Large trials such as the Women’s Health Initiative found that estrogen (with or without progestin) raises stroke risk by ~30–40% in generally healthy postmenopausal women. Because of that, these systemic hormone drugs are usually off-limits for women with a history of stroke.

Vaginal estrogen tablets may offer an alternative. They are prescribed to ease vaginal dryness, uncomfortable sex or urinary symptoms. These tablets act locally and cause only a small amount of estrogen to enter the bloodstream.

“While other studies have not detected an increased risk of stroke associated with the use of vaginal estrogen in healthy postmenopausal women, there is no data on whether vaginal estrogen tablets pose an increased risk for women who have already had a stroke,” said lead author Dr. Kimia Ghias Haddadan, from the Department of Cardiology at Copenhagen University Hospital-Herlev and Gentofte.

This is the first large study to test the safety of vaginal estrogen in women with a history of stroke.

Vaginal estrogen and recurrent stroke in postmenopausal women

Haddadan and colleagues identified 56,642 women who had a first ischemic stroke between 2008 and 2017 using nationwide health records from Denmark. Women under 45, those who had used vaginal estrogen before their stroke and those who had taken systemic hormone therapy were excluded – leaving 34,276 women in the final analysis.

The team then identified 3,353 women who went on to have another stroke. Each of these cases was matched by birth year with a control who had not had a second stroke.

There was no link between vaginal estrogen use and recurrent ischemic stroke. The risk of another stroke was the same whether women had recently used vaginal estrogen, had used it months or years earlier or had taken higher doses. No pattern suggested that the drug raised stroke risk.

Use of vaginal estrogen was slightly less common in women who had another stroke than in those who did not.

“It is important to note that these findings suggest that vaginal estrogen is likely safe for this high-risk group of women who have already had a stroke; however, they do not imply that vaginal estrogen prevents strokes,” said Haddadan.

Postmenopausal women and future research

The results offer reassurance to doctors and patients: the drug can help ease menopausal symptoms without adding to stroke risk. It also extends earlier safety findings from healthy women to a higher-risk group.

“As an epidemiologist, I see this study as a valuable contribution because it focuses on a population often excluded from hormone therapy research, midlife women with a prior stroke, and examines an increasingly used route of administration: vaginal tablets,” said Dr. Samar R. El Khoudary, a professor in the department of epidemiology at the University of Pittsburgh School of Public Health who was not involved in the study.

“While the study did not find a statistically significant association with stroke recurrence, the findings should be interpreted with caution. Real-world data can’t account for all clinical and behavioral factors, and prescription fill records don’t confirm whether the medication was actually used,” she added.

Future research should test different vaginal estrogen formulations and include more clinical data to refine risk estimates.

“We hope our findings reassure health professionals caring for postmenopausal women with a history of stroke. For these women, especially those with troubling menopause symptoms, the study shows that this type of therapy may be a safe choice. It could improve their quality of life without raising the risk of another stroke,” said Haddadan.

Reference: Haddadan KG, Eckert-Lind C, Meaidi A, et al. Recurrent ischemic stroke and vaginal estradiol in women with prior ischemic stroke: a nationwide nested case-control study. Stroke. 2025. doi: 10.1161/STROKEAHA.125.050986

This article is a rework of a press release issued by the American Heart Association. Material has been edited for length and content.