[CG] Managing vulvovaginal atrophy after breast cancer

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Abstract

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Cancer treatment may result in loss of ovarian function through surgical removal of the ovaries, chemotherapy, or radiation. While menopausal symptoms, such as hot flashes, night sweats, sleep disturbance, memory concerns, and mood issues can be extremely bothersome to some women going through menopause naturally, women who undergo an induced menopause usually experience more sudden and severe symptoms.

Pain and vaginal dryness can occur whether a woman has a sexual partner or not.  In women with breast cancer, the aetiology of impaired sexual functioning, and lowered sexual desire, is often multifactorial, and may be related to physical and/or psychological reasons.  

It is important to discuss sexual difficulties and/or discomfort so that appropriate treatment can be offered.  

Pain and vaginal dryness in women without a history of breast cancer can usually be safely treated with vaginal estrogens, in the form of a cream, pessary or ring, and simple lubricants or vaginal moisturizers.  Safe usage of vaginal oestrogen replacement therapy (ERT) in breast cancer patients has not been studied within RCTs of long duration; the guidelines below reflect a clinical consensus.

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Last reviewed: 05 June 2018

Next review: 31 December 2022

Author(s): Dr. Jenifer Sassarini (Consultant Gynaecologist)

Approved By: Dr. R. Jamieson, Clinical Director

References
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  2. Notelovitz M, Funk S, Nanavati N, Mazzeo M. Estradiol absorption from vaginal tablets in postmenopausal women. Obstet Gynecol. 2002 Apr;99(4):556-62. 
  3. Santen RJ, Pinkerton JV, Conaway M, et al. Treatment of urogenital atrophy with low-dose estradiol: preliminary results. Menopause. 2002 May-Jun;9(3):179-87. 
  4. Eugster-Hausmann M, Waitzinger J, Lehnick D. Minimized estradiol absorption with ultralow-dose 10 μg 17β-estradiol vaginal tablets. Climacteric. 2010 2010/06/01;13(3):219-27.
  5. Ponzone R, Biglia N, Jacomuzzi ME, et al. Vaginal oestrogen therapy after breast cancer: is it safe? Eur J Cancer. 2005 Nov;41(17):2673-81. 
  6. Le Ray I, Dell’Aniello S, Bonnetain F, Azoulay L, Suissa S. Local estrogen therapy and risk of breast cancer recurrence among hormone-treated patients: a nested case–control study. Breast cancer research and treatment. 2012;135(2):603-9.
  7. Kendall A, Dowsett M, Folkerd E, Smith I. Caution: Vaginal estradiol appears to be contraindicated in postmenopausal women on adjuvant aromatase inhibitors. Ann Oncol. 2006;17(4):584-7.
  8. Wills S, Ravipati A, Venuturumilli P, et al. Effects of vaginal estrogens on serum estradiol levels in postmenopausal breast cancer survivors and women at risk of breast cancer taking an aromatase inhibitor or a selective estrogen receptor modulator. Journal of oncology practice / American Society of Clinical Oncology. 2012 May;8(3):144-8.