When it comes to menopause, most women worry about hot flashes. But doctors say an increasing number of women are discovering another unpleasant, and unexpected, symptom.

The decision of many women to abandon traditional menopause hormones in recent years has led to an increase in vaginal complications associated with a loss of estrogen, including dryness, itching and pain.

Estrogen helps prevent vaginal aging, but use of menopause hormones dropped by half after a major government study in 2002 linked hormone use among older women with heart attacks and other health problems. Doctors say many women who stopped hormone treatments are now surprised to find they are suffering from symptoms. It's a "neglected" area of women's health, says Lila Nachtigall, professor of obstetrics and gynecology at New York University School of Medicine.

For some, the solution has been to return to hormones, but in a different form. Sales of vaginal hormone products have surged 9% in the past year even as the overall hormone market continues to drop, according to IMS Health, which provides data on prescription-drug use. Currently women can use estrogen creams, tablets or hormone-dispensing rings that are inserted into the vagina.

Even so, many doctors and women aren't aware that these estrogen products are an option. Dr. Nachtigall said she just saw a patient who was suffering from recurrent urinary-tract infections. The woman had gone to a urologist who gave her antibiotics. The real problem, says Dr. Nachtigall, was that the woman had recently stopped hormone therapy. She was experiencing aging of the genital tissues, which was causing dryness and repeated infections. Dr. Nachtigall prescribed a vaginal estrogen that she believes will solve the woman's problem.

Another reason such concerns are on the rise is the popularity of Viagra and other drugs for erectile dysfunction. Some older couples are engaging in intercourse after having gone long stretches without it. But as women age and natural estrogen drops, the vagina starts to atrophy and becomes less elastic, making sex painful or impossible.

"It's very frequently an issue," says Alan Altman, menopause expert and assistant clinical professor at Harvard Medical School. "It's very important if somebody is going to go on Viagra that either the clinician or the patient should know enough to ask" about the man's partner.

Part of the problem is awareness. Women know that hot flashes are an obvious symptom of menopause, but for most women, hot flashes eventually go away as a woman's estrogen levels stabilize. But few realize that every woman will experience some degree of vaginal atrophy as she ages.

Estrogen treatments are surprisingly effective at restoring the health of aging tissue. After regular use, women may be able to get by with occasional "maintenance" doses, but symptoms could return once a woman stops using the treatment. A recent study suggests women get more benefit if they start treatments relatively close to menopause, when estrogen levels are just beginning to drop.

Researchers looked at vaginal cells from women before and after menopause and showed that the cells respond differently to estrogen. Estrogen treatment on the cells of the postmenopausal women only partially restored cell function, while the premenopausal cells were fully restored, according to the report last year in the medical journal Menopause.

One question about the estrogen creams and rings is whether they pose the same or different health risks compared with estrogens taken by pill or patch. Warnings about health risks required by the Food and Drug Administration are the same for all estrogen products. But most experts say vaginal estrogens are delivered in a low enough dose that they likely have a minimal effect on the rest of the body. Vaginal estrogens typically won't relieve hot flashes, and most doctors believe the treatments don't carry the same risks of blood clots and other problems linked with oral and patch estrogen therapy, but little research has been done on the issue.

Women who still have a uterus may need extra monitoring in the early days of treatment. Estrogen use by itself is linked with a higher risk of uterine cancer. But most studies show that the majority of women who use a low-dose vaginal estrogen won't experience a worrisome buildup of the uterine lining; if left untreated, such buildup can increase the risk of cancer. Even so, some doctors may use ultrasound monitoring to be sure. Others may advise women to alert them to spotting or bleeding problems that could signal early changes in the uterine lining.

While estrogen clearly makes a difference after menopause, it isn't the only option for women. Regular use of nonhormonal lubricants and moisturizers have been shown in some studies to be just as effective as hormonal creams for reducing dryness and painful sex.

And it's important to note that simply having sex fairly often also appears to help. Women who are more sexually active are less likely to experience vaginal atrophy as they age. Doctors call it the "use it or lose it" effect.