By Michele Promaulayko
Until mere moments ago, menopause was treated as an ending—the point at which women were expected to quietly retreat from relevance. But that rude framing has collapsed under the weight of a generation of women proving that midlife looks a lot different than it used to.
Hormone replacement therapy (HRT) has shed its bad rap and is finally getting credit for performing a long list of health heroics, empowering women in their 40s, 50s and beyond to amplify their vibrancy.
Also amazing: Prescription estrogen creams originally intended to rejuvenate vaginal tissue have traveled north in new formulations specifically meant for the face. That’s right—menopause, long cast as beauty’s nemesis, is seeking the ultimate revenge by inspiring advancements in skin care.
HRT: The Case for Your Face
Estrogen plays a key role in collagen production, skin thickness and moisture retention, all of which decline when estrogen levels dip in perimenopause and menopause. This isn’t controversial—it’s been known for over 20 years, noted OB-GYN Jennifer Ashton, M.D., in an Instagram post. Ashton also revealed that roughly half of dermal collagen can vanish in the first five years of menopause. Skin becomes thinner, less elastic and drier, and that depletion often shows up first on the face and neck.
The fix seems logical: Put the estrogen back where it’s needed—locally, on the skin. But since estrogen is a regulated pharmaceutical, the research and development pathway is more complex and expensive than it is for cosmetic active ingredients. In fact, the foundational research for how topical estrogen impacts the complexion comes from two German studies dating back to the mid-’90s. Those found that topical estriol (a naturally occurring estrogen hormone) applied to the faces of pre- and perimenopausal women produced significant improvements in skin firmness, reduced wrinkles, increased skin moisture and elevated levels of type III (aka structural) collagen, with no systemic effect on hormone levels. “The fact that we’re still anchoring to that work 30 years later says everything about how under-resourced this area has been,” says Michelle Montville, M.D., a board-certified OB-GYN, Menopause Society-certified practitioner and clinical director of Alloy Health.
To move the needle forward, Alloy commissioned its own randomized, double-blind, placebo-controlled trial, led by dermatologist Zoe Diana Draelos, M.D. The trial compared a 0.3 percent estriol cream, a 0.01 percent estradiol cream and a placebo over 12 weeks in 90 participants. The results of the trial, which were published in 2024, showed a 68 percent improvement in overall skin health versus placebo for the estriol arm, along with a 29 percent improvement in radiance, 31 percent improvement in skin roughness and 15 percent improvement in firmness. The estradiol produced similar results.
Estriol vs. Estradiol: What’s the Difference?
There are two main forms of estrogen to consider here: estradiol (E2), the stronger version your body mainly produces during reproductive years and the one used in most systemic HRT and vaginal cream prescriptions, and estriol (E3), its gentler counterpart, which is the type your body makes in higher doses when pregnant. Think of estradiol as the one that grabs onto estrogen receptors and holds on, which is exactly what you want when you’re trying to shift hormone levels throughout the body. Estriol, by contrast, binds more transiently and clears more quickly. Because of their potency differences, they are usually given in different dosages—typically, estradiol at 0.01 percent and estriol at 0.3 percent.
Dermatologic investigators have found that the two forms conduct themselves almost identically, but which does your skin actually prefer? Again, the science is still thin and the skin care category is nascent, but Alloy is pioneering the charge with its M4 line, a trio of prescription products (face cream, face serum and eye cream) built around topical estriol in conjunction with ingredients such as glycerin, oleic acid and vitamin E to support barrier function and hydration. “For facial use, that lower systemic potency is actually an asset,” says Montville, hinting at the question everyone wants answered: Does it get into your bloodstream?
Alloy’s 2024 trial measured hormone levels in participants’ blood at the start of the study and again at week 12. Systemic levels didn’t budge. It’s the same principle behind vaginal estrogen, long prescribed to address the localized dryness and tissue thinning of genitourinary syndrome of menopause, and widely considered safe because it acts locally on the mucosal tissue without meaningfully raising systemic estrogen levels. Which brings us to…
The Vaginal Cream Work-Around
Scroll any menopause-focused account on social media and you’ll land on this hack: using prescription vaginal estradiol cream on the face. Plenty of dermatologists and other doctors are out there demoing this off-label use, including Ashton, Amy Killen, M.D., and Corinne Erickson, M.D.
Despite that, Montville explains why formula intention may matter: “The vehicles, pH and concentrations of vaginal estrogen products are optimized for mucosal tissue with very different absorption characteristics than facial skin,” she says. “Applied to the face, absorption dynamics are unpredictable, and the vehicle itself may cause irritation or other issues unrelated to the estrogen.” Erickson has explained it this way: The specially compounded estriol creams are “a more elegant vehicle.” Meaning, they resemble a luxury face lotion—emollient and silky.
The options and formulations are widening as prescription face creams become increasingly accessible through telehealth platforms such as Alloy (currently the only company with its own clinical study), HerMD, Winona, Musely, Midi, Wisp and others. Most formulations rely on estriol and many layer in other beneficial skin care ingredients, like hyaluronic acid, vitamin C and tretinoin.
For those still interested in exploring the off-label vaginal estradiol route, one approach is to dot a very small amount to targeted areas like crow’s-feet or the “11 lines” that show up between the eyebrows. Or dot a scant amount around the entire face before gently rubbing it in.
When to Start—and What to Expect
Earlier is better. “As estrogen declines, receptor density and responsiveness follow,” explains Montville. So it’s ideal to start before irreversible structural changes, significant collagen loss and deep dermal thinning have fully set in: roughly between ages 45 and 52, during perimenopause or early menopause. That said, later is not too late. “Collagen synthesis and barrier remodeling don’t happen overnight,” cautions Montville. “I tell patients to expect improved skin feel and hydration within four to six weeks, with more visible changes emerging at three months with consistent use.”
A few caveats: If you’re adequately making estrogen, you do not need an estrogen face cream. Anyone with sensitive skin or a history of melasma should patch-test before committing to full facial use; estrogen’s association with melanocyte activity means individual pigmentation responses can vary.
As for women with a history of breast cancer who are still nervous about using anything containing hormones: A large Johns Hopkins cohort study published in Obstetrics & Gynecology in 2023 found no increased risk of breast cancer recurrence within five years in women using vaginal estrogen vaginally, including those with estrogen receptor-positive disease. The same is thought to be true for face creams. “I assess these cases individually,” Montville says, “and always recommend the patient discuss with their own medical team before starting.”
A Devotional Practice
In the end, here’s what the science makes clear: Skin is an estrogen-responsive organ. Declining hormone levels leave visible, measurable, addressable changes, and the most effective way to adequately address these changes is with ongoing attention. “Estrogen deficiency doesn’t resolve, and neither does the skin’s ongoing need for support,” says Montville. “What we can do is meaningfully slow the process and sustain improvements.” For a growing number of women, those alone are worthwhile skin goals.