MenopauseMenu guest blog post by Mary J. “Muff” Heffernan, ARNP, AOCNP, from By Your Side, LLC – Professional Breast Cancer Consulting & Advocacy
When a woman learns she has breast cancer, likely the last thing on her mind is her vagina! However, for women with estrogen/progesterone receptor-positive breast cancer, or for some women who require chemotherapy, having a plan for managing one’s vaginal health is essential. Here’s why:
What Does Breast Cancer Treatment Have to do with My Vagina?
Think back (for some of us.. WAY BACK) to Sex Ed Class where we learned the leading role estrogen played in female sexual development and the welcome news that it made breasts grow! Discussions about anything to do with the vagina, however, were limited to menstrual periods, vague pictures of intercourse, and babies emerging from the birth canal. It was simply TMI to discuss vaginal lubrication. But in fact, circulating estrogen has effects on vaginal tissues, keeping them supple and moist. So, when a woman has estrogen-driven breast cancer, blocking estrogen (a mainstay of treatment), is bound to affect vaginal health.
A lengthy discussion of breast cancer treatment is beyond the scope of this post. However, it is important to mention that key biologic features of the tumor will determine the best course of treatment.
Primary Biologic Features Important to Breast Cancer Treatment:
- Estrogen and progesterone receptor status;
- Presence of an overabundance of a protein called HER 2/neu; and
- Extent and aggressiveness of the disease at the time of diagnosis.
When estrogen and or progesterone receptors are present (approximately 80% of the time), they provide a target for effectively treating breast cancer with estrogen-blocking medication (also referred to as endocrine therapy). The goal of this form of treatment is to reduce the chance of breast cancer recurrence and improve overall survival. Chemotherapy and biologic therapies are primarily reserved for those with more aggressive disease, estrogen receptor-negative disease, or those that require targeting the HER 2/neu protein. More detailed information on breast cancer treatment can be found here.
The extent of vaginal symptoms will depend on the chosen treatment and menopausal status at the time of diagnosis. Postmenopausal women receiving endocrine therapy with aromatase inhibitor medication (anastrozole, letrozole, and others) and some premenopausal women who receive this treatment (in conjunction with other estrogen blocking treatment) are known to have more significant vaginal dryness. Premenopausal women who take a different type of endocrine therapy, namely, tamoxifen, usually have less dryness.
Chemotherapy can also induce premature ovarian failure temporarily or permanently. Thus, even in the absence of estrogen blocking medication, vaginal dryness and other symptoms can occur. Medical literature has many names for the constellation of symptoms attributed to estrogen loss. Here are some of the most popular: Genitourinary Syndrome of Menopause; vulvovaginal atrophy; and atrophic vaginitis. Whatever the term, it can be an unpleasant and uncomfortable issue and a plan is needed to manage it!
What’s Happening Down There?!
Primary symptoms include itching, irritation, more frequent urinary tract infections, and other difficult medical terms such as DYSPAREUNIA (dis-puh-roo-nee-uh), which is gynecology code for painful sexual activity. Different, not so apparent alterations include changes in the vaginal pH (more alkaline versus the ordinarily acidic environment), tissue atrophy, and narrowing of the vagina. Thankfully, not all women treated for breast cancer will experience these symptoms, but many will experience some symptoms. Consequently, let’s look at the best options for managing this problem, or as I like to think about it, Sex Ed for Breast Cancer Survivors!
First Things First: Don’t Suffer in Silence.
Just as many of us were shy about raising our hand in Sex Ed, many women are hesitant to report vaginal symptoms to their doctors. True, it is much easier to bring up subjects like hot flashes, problems with sleep, and a host of other topics. Still, your cancer care team can also help you with the right approach to vaginal health as well.
Next, Start with Ditching the Things that Make Matters Worse:
- Smoking (reduces capillary blood flow and makes vaginal dryness worse);
- Scented hygiene products (interferes with healthy vaginal flora); and
- Synthetic panties and panty liners (draws moisture).
Daily Plan: Vaginal Moisturizers and Lubricants.
Before driving to the drugstore, know intercourse itself helps to stimulate blood flow to the vagina and maintains suppleness and elasticity, as can self-stimulation or using a vibrator.
The use of vaginal moisturizers and lubricants is the primary recommendation for managing vaginal dryness from all of the following reputable medical organizations:
- National Comprehensive Cancer Care Network;
- American Society of Clinical Oncology;
- American College of Obstetricians and Gynecologists; and
- North American Menopause Society.
Vaginal moisturizers and lubricants do not contain hormones and are considered safe for women with any type of breast cancer. These products do not require a prescription; they are available at drug stores, online, or from a sex product retailer. Look for products without fragrance, preservatives, or glycerin, as these substances can be irritating or drying. Also, recall that the vaginal environment is acidic (pH between 3.5-4.5) so products with a pH more closely matching these values are best.
Moisturizers are designed for use regularly, and lubricants used as needed to reduce friction. Moisturizers can be in liquid, gel, or suppository form. Liquid or gel products are applied to the inner and outer labia (folds of skin around your vagina) and into the vagina. You don’t need to apply much at a time, but they should be used at least three times per week or more depending on the dryness you are experiencing. Hydrating products containing hayluronic acid draw moisture into the vagina and improve tissue quality. Halo GYN®, Revaree® and ReplensTM are examples. Lubricants for stimulation, intercourse, and the like, can be water, silicone, or oil-based. Water-based lubricants include such brands as Astroglide®, Aquagel®, Ah! Yes® and Sliquid®. Silicone-based products include Silicone®, Pjur® and PINKTM. Natural Oils include: Almond oil and coconut oil.
Word of caution: oil-based lubricants will damage the integrity of latex condoms, and silicone-based products can damage silicone sex toys’ integrity (bet that was not covered in your old Sex Ed Class!).
Although moisturizers and lubricants are the first steps in managing vaginal dryness, they may only provide temporary relief. They may not be enough to improve long-term vaginal moisture.
What’s Next if These Products Aren’t Working?
Again, speaking up about your symptoms is essential and will help your medical team choose the best option for you that is safe and effective. Systemic estrogen, either pills or patches, are off the list, as research has shown breast cancer recurrence or development of new breast cancers in women who take hormone replacement therapy.
Possible Options:
Based on the extent of symptoms AND after a discussion with your oncologist regarding the risks and benefits:
- Low dose vaginal estrogen;
- Testosterone cream (androgen-based treatment); and
- DHEA therapy (steroid hormone precursor).
One of the most thorough and informative articles published on this topic is in the Journal of Oncology Practice – Managing Genitourinary Syndrome of Menopause in Breast Cancer Survivors Receiving Endocrine Therapy.
What Do the Oncology Experts Say?
The most recent version of the National Comprehensive Cancer Care Guidelines (Version 2. 2020/Survivorship: Hormone-related symptoms) provides the following recommendations and serves as a primary resource for physicians caring for patients with cancer:
For women dealing with vaginal dryness and accompanying genitourinary symptoms, the panel recommends vaginal moisturizers, gels, and oils for comfort and lubricants for sexual activity. Women who do not adequately respond to these measures can receive vaginal estrogen therapy, preferably with vaginal suppositories or vaginal rings (over vaginal creams). Limited data in breast cancer survivors suggest minimal systemic absorption with rings and suppositories. The use of any topical estrogen should be individualized and discussed with the survivor’s medical oncologist. Other topical hormones (i.e., testosterone and DHEA) can be considered; however, DHEA should be used with caution in survivors with estrogen- dependant cancers, and there is a lack of safety data for the use of androgen-based therapy (testosterone) in survivors of hormone- mediated cancers. Pelvic physical therapy, over-the-counter topical anesthetics can be considered for painful sexual activity.
The NCCN panel did not recommend fractional micro ablative CO2 laser treatment (vaginal rejuvenation procedures) due to the recent (2018) safety warning of potentially serious adverse events.
I hope this post has given you the framework for dealing with a vexing problem common to many breast cancer survivors. Best advice is to start with vaginal moisturizers and lubricants and use them consistently. If this is ineffective, see your healthcare team and schedule a pelvic exam. The exam will help determine the need for further treatment and help your oncologist decide whether to recommend additional therapies for you.
Mary J. “Muff” Heffernan, ARNP, AOCNP