Introduction and Hypothesis <p>Vaginal estrogen therapy is widely accepted as a safe and effective treatment for symptoms of genitourinary syndrome of menopause (GSM), yet it is likely underutilized owing to various factors relating to patient perceptions, barriers to access, and health care system outreach. The aim of our study is to explore patient beliefs and opinions regarding its use.</p> Methods <p>A qualitative study was conducted with patients prescribed vaginal estrogen at an ambulatory urogynecology office between October 2022 and August 2023. Participants completed a symptom inventory followed by a 1:1 in-depth interview based on a structured guide designed to elicit candid insights and detailed responses into perceptions and experiences with vaginal estrogen. Data were analyzed using grounded theory methods in a three-phase coding process to identify key themes.</p> Results <p>Twenty-two participants were interviewed. Six major themes emerged: knowledge base, barriers to health care access, motivation for symptom relief, concerns regarding side effects, physician–patient relationship, and barriers to compliance. Although participants understood the connection between GSM and aging, they often felt unclear about which symptoms vaginal estrogen targeted, how to apply it, and how it differed from systemic hormone replacement therapy. Barriers such as cost, lack of insurance coverage, and concerns about cancer were frequently reported. Physician education helped to alleviate fears, improving patient confidence in using vaginal estrogen.</p> Conclusions <p>This study identified key beliefs and barriers affecting the use of vaginal estrogen for GSM. These findings highlight the need for improved patient education, better physician counseling, and enhanced communication to support adherence to this beneficial therapy.</p>