Ovarian Cancer and Vulvovaginal Atrophy: Relationship and Management
Relationship Between Ovarian Cancer and Vulvovaginal Atrophy
Ovarian cancer itself does not directly cause vulvovaginal atrophy, but the treatments commonly used for ovarian cancer, including surgery, chemotherapy, radiation therapy, and hormone therapy, can lead to vulvovaginal atrophy. 1
- Surgical interventions for ovarian cancer, particularly bilateral oophorectomy (removal of both ovaries), cause immediate estrogen deprivation leading to vulvovaginal atrophy 1
- Radiation therapy to the pelvic area can cause long-term complications including fibrosis, stenosis, and vulvovaginal atrophy 1
- Chemotherapy agents, especially alkylating agents, can induce ovarian failure resulting in decreased estrogen production and subsequent vulvovaginal atrophy 1
- Hormone therapies that reduce estrogen levels contribute to vaginal dryness and atrophy 1
Symptoms and Diagnosis of Vulvovaginal Atrophy
- Symptoms include vaginal dryness, discomfort, pruritis (itching), dyspareunia (painful intercourse), urinary tract infections, and urinary urgency 1, 2
- Physical examination reveals pale and dry vulvovaginal mucosa, sometimes with petechiae, and disappearance of vaginal rugae 3
- A vaginal pH of 4.6 or higher supports the diagnosis of vulvovaginal atrophy 3
- Unlike vasomotor symptoms (hot flashes) which tend to resolve over time, vulvovaginal atrophy symptoms typically persist indefinitely and may worsen without treatment 1, 2
Management of Vulvovaginal Atrophy in Ovarian Cancer Survivors
First-Line: Non-Hormonal Options
- Regular use of vaginal moisturizers for daily comfort and water-based lubricants for sexual activity 1, 2
- Moisturizers may need to be applied at higher frequency (three to five times per week) in the vagina, at the vaginal opening, and on the external folds of the vulva 1
- Vaginal dilators may benefit women with vaginismus and/or vaginal stenosis, particularly important for those treated with pelvic radiation therapy 1, 2
- Pelvic floor physical therapy can help decrease anxiety, discomfort, and lower urinary tract symptoms 1
Second-Line: Hormonal Options
- For women with persistent symptoms not responding to non-hormonal measures, low-dose vaginal estrogen can be considered after a thorough discussion of risks and benefits 1, 2
- For women with hormone-positive ovarian cancer, the decision to use vaginal estrogen should involve careful consideration of risks versus benefits 1, 2
- Vaginal dehydroepiandrosterone (DHEA/prasterone) is an option for women who have not responded to previous treatments 1, 4
- Ospemifene (a selective estrogen receptor modulator) may be offered to postmenopausal women without current or history of hormone-sensitive cancer 1, 2
Special Considerations for Cancer Patients
- Postradiation use of vaginal dilators and moisturizers is strongly recommended to prevent stenosis and maintain vaginal health 1
- All patients, whether sexually active or not, should be asked about genitourinary symptoms, including vulvovaginal dryness 1
- For treatment-related menopause, hormone therapy should be considered if not contraindicated 1
- Patients should be referred to appropriate specialty providers (physical therapy, pelvic floor therapy, sexual therapy) based on symptoms and needs 1
Common Pitfalls and Caveats
- Failing to address vulvovaginal atrophy can significantly impact quality of life and may affect cancer treatment compliance 1, 5
- Assuming that all cancer survivors cannot use any form of estrogen therapy; decisions should be individualized based on cancer type, stage, and time since diagnosis 1, 2
- Not recognizing that vulvovaginal atrophy symptoms, unlike hot flashes, typically do not resolve over time without treatment 1, 2
- Overlooking the importance of regular use of vaginal moisturizers and lubricants, which can provide significant relief even before considering hormonal options 2, 6
- Not discussing sexual health concerns with cancer survivors due to discomfort with the topic 1