Vaginal Estradiol vs Moisturizer to Improve Postmenopausal Vaginal Aging Symptoms and the Microbiome in Women Living With HIV

Inclusion Criteria:

* female
* at least 40 years old
* menopausal (no menses in 12 months) within 2 years of last menstrual period or perimenopausal in the late menopausal transition, defined as an interval of amenorrhea greater than or equal to 60 days
* have symptoms of the genitourinary syndrome of menopause (GSM) which developed within the prior 2 years. Symptoms of GSM include vaginal symptoms including dryness, soreness, itching, irritation and dyspareunia and/or urinary symptoms including urgency, frequency and recurrent urinary tract infections (UTIs)

Exclusion Criteria:

* Unexplained or unevaluated abnormal genital bleeding
* Current or suspected pregnancy
* Desired pregnancy
* If less than 55 years old, have had a hysterectomy and have at least one ovary (as menopause cannot be determined in this case by amenorrhea alone)
* Pelvic or vaginal surgery in the prior 60 days
* Used systemic reproductive hormones in the last 2 months
* Used antibiotics in the last 30 days
* Used immunosuppressive medications in the prior 60 days including biologics, chemotherapeutics or post transplant immunosuppressive medications
* Used any vaginal or vulvar preparations in the last month
* Current active vaginal infection diagnosed at study entry
* Any serious disease or condition that may interfere with study compliance
* Current or previous history of breast cancer or estrogen dependent cancer (e.g., ovarian, endometrial)
* Current or previous history of deep vein thrombosis or pulmonary embolism
* Current or previous history of myocardial infarction or stroke
* Known clotting disorder including Protein C, Protein S and antithrombin deficiency, Factor V Leiden or prothrombin mutations
* Known severe liver disease including cirrhosis or active Hepatitis B
* Known allergic reaction to Vagifem (estradiol vaginal tablet) or Replens