Vaginal estrogen in breast cancer survivors

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With over 3 million breast cancer survivors now living in the US, there is growing recognition among health care providers that quality of life issues for those women should be assessed and treated.

One particular challenge for providers to understand and address are vaginal symptoms of menopause in this population. Many breast cancer survivors struggle with vaginal dryness and painful intercourse, a common menopausal symptom that can also be a side effect of anti-estrogen therapies used to treat hormone-sensitive tumors.

Systemic and vaginal estrogen are widely used for symptomatic relief of vasomotor symptoms, sexual dysfunction and lower urinary tract infections in the general population. Given that a large number of breast cancers are estrogen sensitive, there are safety concerns about the use of local hormone therapy in women who currently have breast cancer or have a history of breast cancer.

According to the Committe Opinion published in March 2016 by ACOG, non hormonal therapies (moisturizers, lubricants, topical anesthetics) should be the first choice for managing urogenital symptoms or atrophy-related urinary symptoms experienced by women during or after treatment of breast cancer. However, health practitioners may now consider vaginal estrogen therapy for breast cancer survivors who are unresponsive or failed non-hormonal therapies.

There are three main commercially available preparations of vaginal estrogen in the US: cream, ring and tablet. Vaginal estrogen delivers a low dose of hormone to the local vaginal tissue with minimal systemic absorption. Studies show that the use of low-dose vaginal estrogen does not result in sustained serum estrogen levels exceeding the normal menopausal range; the lowest rates of systemic absorption are found in the ring and the tablet. When used at the appropriate dose, estradiol creams also deliver a low dose of hormone.

Data do not show an increase risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.

The decision to use vaginal estrogen may be made in coordination with the patient’s oncologist. Additionally, it should be preceded by an informed decision-making and consent process in which the patient has the information and resources to consider benefits and potential risk of the therapy.

As health care providers our role is to provide some guidance, ultimately each breast cancer survivor will need to decide what is right for her.

For more information about this topic contact Dr. Evelyn Zeda at 939-261-2222.

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