Low estrogen in breast cancer survivors can lead to irritation of the lining of the vagina, discomfort, leakage of urine and pain with sexual intercourse (called dyspareunia). For women without a prior history of breast cancer, doctors often prescribe creams or preparations with estrogen that allow the estrogen to benefit the lining of the vagina but allow only a small amount of estrogen into the general circulation. These topical treatments can provide good relief of general discomfort, urine symptoms and discomfort associated with intercourse. For breast cancer survivors, however, doctors generally avoid prescribing them due to the concern that even a small increase in blood estrogen levels may increase the risk of the breast cancer returning as described above. Instead, non-hormonal approaches to the relief of vaginal dryness are recommended for breast cancer survivors.
Non-hormonal approaches for the relief problems caused by vaginal dryness include lubricants that can be used before intercourse and vaginal moisturizers that can relieve the dryness over time. These are somewhat helpful but not nearly as helpful as the women and their healthcare providers would like. The February 2016 issue of the National Center for Complementary and Integrative Health (NCCIH) Clinical Digest is devoted to menopausal symptoms and complementary health practices, but it does not add much to the discussion either.
At the Center for Integrative Oncology and Survivorship (CIOS), vaginal dryness in breast cancer survivors is a frequent topic of discussion and we do recommend lubricants and moisturizers. There are, however, other strategies, including physical therapy to strengthen pelvic floor muscles (yes, it helps) and applications of lidocaine (to numb the discomfort) prior to intercourse.
Recently, the American College of Obstetrics and Gynecology (ACOG) published recommendations regarding the use of vaginal estrogen preparations for women with a history of breast cancer. First, the guidelines endorse the use of the non-hormonal methods described above. Second, the guidelines acknowledge the relative lack of medical data about the breast cancer risk for the use of vaginal estrogens by breast cancer survivors. Third, the guidelines suggest that there may be a place for the use of vaginal estrogens by breast cancer survivors, depending on the individual circumstances and consultation with the survivor’s oncologist.
I believe it is an overstatement to conclude that use of vaginal estrogens is “safe” for everyone in this setting. On the other hand, these symptoms have a huge effect on quality of life, and it is reasonable for a breast cancer survivor to confer with her oncologist and weigh whether the benefits of vaginal estrogens outweigh the uncertain but likely small risks. As one oncologist put it, “We did not treat your cancer to make you miserable!” I encourage survivors with this issue to discuss vaginal estrogen use with their doctors, including their oncologist. In some situations, use of vaginal estrogens may be a reasonable choice. It is an important topic, and I encourage breast cancer survivors to bring it up if it is an issue.
The Center for Integrative Oncology and Survivorship is committed to help people survive and thrive after a cancer diagnosis. If you have issues with vaginal dryness, or if you would like more information about other issues that affect cancer survivors, visit our website at www.ghs.org/cios or call us at (864) 455-1346.