Before we begin, I just want to reiterate our long-held position here at MiddlesexMD: Natural is always better. By that I mean, if you can ease vaginal pain and enjoy sex comfortably using non-hormonal products like moisturizers and lubricants, that is always the first and best option.
That is also the position taken in a new report issued two weeks ago by the American College of Obstetricians and Gynecologists (ACOG). But when the non-hormonal route just doesn’t cut it, when the pain of vaginal dryness and atrophy is unpleasant enough to interfere with life and good things like sex, then the ACOG committee says that topical estrogen treatment is a good option even for breast cancer survivors. (Check out this link on our website for tons more information.)
Let’s dig into this.
For a long time, doctors focused on simply helping women with breast cancer to survive. Now, the good news is that women who have had breast cancer are indeed surviving for years longer. So the focus has shifted to quality of life—like making sure that sex is comfortable, for example.
This can be tricky, because we all know that estrogen is a bad thing for breast cancer survivors. In fact, a type of breast cancer, called “estrogen-receptor positive,” which unhappily is more common in postmenopausal women, has special receptors that are sensitive to estrogen. With this type of cancer, estrogen acts like fuel, making the cells grow more quickly. That’s why ongoing treatment for women who have had this type of cancer includes Tamoxifen or “aromatase inhibitors” that block estrogen activity.
Problem is, of course, estrogen is a good thing for our vagina, among other parts, and a lack of estrogen wreaks havoc on that sensitive system. Thus, drugs that block estrogen activity also cause urinary tract infections and painful vaginal dryness and atrophy. These side-effects can be so severe that 20 percent of women simply stop taking the drugs.
We know that oral estrogen replacement therapy—taking estrogen pills—increases systemic estrogen levels, but what about localized estrogen that’s used externally to treat vaginal dryness and atrophy? Does that increase estrogen levels in the body? Does it increase the risk of relapse?
While there hasn’t been a lot of research on the subject, ACOG released its committee report early in February stating: “Data do not show an increased 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 ACOG guidelines recommend using the lowest effective dose for as little time as possible. And while the hormone comes in three forms: cream, ring, and a vaginal tablet, the lowest rates of absorption and the most accurate dosages occur with the ring and tablet.
For women whose symptoms are severe and who aren’t sufficiently relieved just by vaginal moisturizers and lubricants, it’s nice to know that there are other options. If you’re a breast cancer survivor who is suffering from vaginal dryness and painful sex, it’s time for a sit-down with your doctor to discuss treatment options. It’s time to start living well again.
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.