A 59-year-old woman, G2P2, presents to a family medicine clinic with 2 years of vaginal dryness, burning, and pain with intercourse. She also reports urinary urgency and 2 urinary tract infections in the past 12 months. Her last menstrual period was at age 51, and she has no hot flashes. She has used a water-based lubricant with intercourse and a vaginal moisturizer 3 times weekly for the past 3 months with minimal relief. She has an intact uterus and no history of breast cancer, venous thromboembolism, or unexplained vaginal bleeding. On examination, the vaginal mucosa is pale and thin with loss of rugae, there is no discharge, the vulvar skin appears normal without white plaques, and vaginal pH is 6.0. Urinalysis is negative.
| Heart rate | 74/min |
| Respiratory rate | 14/min |
| Temperature | 36.8 °C |
| O2 saturation | 98%, room air |
| Blood pressure | 128/78 mm Hg |
Question 1 of 12
Which one of the following is the most appropriate pharmacologic therapy at this time?
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