Vaginal Estrogen Therapy in Patients With a History of Breast Cancer

Introduction:

In women, after the treatment of breast cancer, many changes occur in their body. They are not only breast-related changes but also menstrual cycles, hair loss, or sexual changes. As age increases, vaginal atrophy is common in women. But it can also be associated with women who have had breast cancer and received treatment with endocrine hormones like Tamoxifen or any aromatase inhibitors.

Why Is Vaginal Estrogen Therapy Needed in Patients With a History of Breast Cancer?

Women with a history of breast cancer have many genitourinary syndromes due to decreased estrogen levels. They include itching, burning sensation, vaginal dryness, and overactive bladder. Vaginal estrogen therapy helps reduce these genitourinary symptoms caused by reduced estrogen levels in women. So vaginal estrogen therapy is usually indicated in women with a history of breast cancer.

What Is Vaginal Atrophy?

Drying and inflammation of the vagina due to less estrogen is called vaginal atrophy or atrophic vaginitis. It is usually seen in women after menopause. Vaginal atrophy can cause pain during sexual intercourse as well as urinary symptoms. Symptoms of vaginal atrophy are called genitourinary syndrome of menopause or GSM. Women with breast cancer who received antiestrogen therapy like aromatase inhibitors usually have vaginal atrophy.

What Are the Causes of Vaginal Atrophy?

Vaginal atrophy is caused due to a decrease in the level of estrogen. Reduced estrogen levels can be seen in cases like:

• In women after or before menopause.

• After the removal of ovaries.

• During the period of breastfeeding.

• While taking birth control pills.

• After cancer radiation therapy.

• After cancer chemotherapy.

• A side effect of hormonal treatment for breast cancer.

What Are the Symptoms of Vaginal Atrophy?

The symptoms of vaginal atrophy or genitourinary syndrome of menopause are:

• Dryness in the vagina.

• Burning sensation in the vaginal region.

• Discharge from the vagina.

• Itching in the genital region.

• Burning sensation during urination.

• Increased frequency of urination.

• Urinary tract infections.

• After intercourse, there will be light bleeding.

• Discomfort or pain during intercourse.

• Less vaginal lubrication during intercourse.

• Thinning of the vaginal canal.

How Is Vaginal Atrophy Diagnosed?

Vaginal atrophy is diagnosed by assessing signs and symptoms and gynecological examination.

• Physical Examination - Pelvic organs, cervix, vagina, and external genitalia are examined.

• Urine Test - A urine sample is collected to assess urinary tract infections.

• Acid Balance Test Acid Balance Test - Vaginal fluids are taken to assess the acid balance. Vaginal pH of more than five can be considered a vaginal infection.

What Is the Treatment for Vaginal Atrophy in Patients With a History of Breast Cancer?

Vaginal moisturizers or water-based lubrication can be used to restore moisture in the vaginal area and treat vaginal atrophy or genitourinary syndrome of menopause, which are, or. If the symptoms do not improve with vaginal moisturizers, then vaginal estrogen therapy is the next resort. In patients with a history of breast cancer, estrogen therapy is used. Topical estrogen therapy is an effective treatment method for people with lower estrogen levels. Systemic estrogen therapy uses a higher dosage of estrogen, so it is contraindicated in patients having vaginal atrophy with a history of breast cancer since there is a chance of recurrence.

What Is Topical Vaginal Estrogen Therapy?

Topical vaginal estrogen therapy can reduce the signs and symptoms like dryness and burning of the vagina than oral or systemic intake of estrogen doses. They are even effective at lower doses. The lower dosage of topical vaginal therapy is as effective as a higher dose of systemic estrogen therapy. Vaginal estrogen therapy is available in different forms. They are:

• Vaginal estrogen cream is inserted directly into the vagina during bedtime with the help of an applicator brush. It is used once daily for three weeks and, after that, only three times weekly. Examples of vaginal estrogen rings are 17-beta estradiol vaginal cream and conjugated estrogen vaginal cream.

• Vaginal estrogen suppositories (dosage form that delivers medications through an opening in the body) are inserted into the vaginal canal for about two inches daily for a few weeks. An example of vaginal estrogen suppositories is estradiol vaginal inserts.

• A vaginal estrogen ring is inserted into the vagina. It is a soft and flexible ring that releases a certain amount of estrogen into the vagina. It is convenient for women because it is replaced once every three months. It releases only a small amount of hormone and is called topical therapy. If it releases higher amounts of estrogen, then it is called systemic estrogen therapy. An example of a vaginal estrogen ring is the 17-beta estradiol vaginal ring.

• A vaginal estrogen tablet is placed using a disposable applicator. It is used once daily for two weeks and, after that, twice weekly. An example of a vaginal estrogen tablet is estradiol hemihydrate vaginal tablet.

What Is the Disadvantage of Estrogen Therapy in Patients With a History of Breast Cancer?

Treating breast cancer with chemotherapy and hormonal therapy with Tamoxifen and aromatase inhibitors seems to reduce the Estrogen level. Decreased estrogen level causes vaginal atrophy or dryness and urinary tract infections. Vaginal atrophy is treated with topical vaginal estrogens.

The production of estrogen can cause a recurrence of breast cancer after some time. Thus, an increased estrogen level due to vaginal estrogen therapy can increase the risk of breast cancer recurrence. So to prevent breast cancer recurrence, topical vaginal estrogen therapy is advised in women who experience severe discomfort or pain, which affects the quality of their life. In the initial days of topical vaginal estrogen therapy, only a low-dosage formulation should be used for the first few weeks. The chance of breast cancer recurrence is less with low doses of vaginal estrogen levels.

If vaginal estrogen cannot be used as a treatment option, then vaginal dehydroepiandrosterone (DHEA), like Prasterone or testosterone, can be used. Other treatment options that are nonhormonal in approach, like vaginal moisturizers, poly acrylic acid, water-based lubricants, hyaluronic acid, and vitamin E and vitamin D suppositories can also be used for vaginal atrophy. Non-hormonal treatment is considered the first line of treatment for vaginal atrophy in women with a history of breast cancer which was estrogen dependent.

Conclusion:

Women with a history of breast cancer have a higher risk of developing vaginal atrophy due to treatments like chemotherapy, hormonal therapy with Tamoxifen and aromatase inhibitors, due to menopause, etc. So the first line of treatment for these patients with vaginal atrophy is non-hormonal therapy. If the non-hormonal therapy does not reduce the signs and symptoms of genitourinary syndrome of menopause, the patients are then advised to go for hormonal therapy like vaginal estrogen therapy.