Is topical estrogen appropriate for treating atrophic vaginitis in breast cancer survivors?

From the Guidelines

Topical estrogen is a suitable treatment option for atrophic vaginitis in breast cancer survivors, particularly when non-hormonal approaches have failed, as it has been shown to be effective in treating vaginal dryness, itching, discomfort, and painful intercourse in postmenopausal women, with minimal systemic absorption and no increased risk of breast cancer recurrence, as supported by a large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years 1. When considering topical estrogen for breast cancer survivors, it is essential to weigh the benefits against the potential risks, taking into account individual factors such as cancer type, stage, recency of diagnosis, and current cancer treatments. Key considerations include:

• The use of low-dose vaginal estrogen preparations, which result in minimal systemic absorption, making them safer than oral estrogen therapy
• The recommendation to try non-hormonal options first, including vaginal moisturizers and lubricants during intercourse
• The importance of discussing the decision to use vaginal estrogen with the patient's oncologist, considering individual risk factors and balancing quality of life improvements against theoretical risks of cancer recurrence
• The availability of various formulations, including estradiol vaginal tablets, estradiol vaginal rings, and estradiol vaginal creams, which have been shown to be effective in treating vaginal atrophy and sexual function in postmenopausal breast cancer survivors 1. It is also crucial to note that vaginal androgens, such as DHEA, can be considered for vaginal dryness or pain with sexual activity, although safety data for their use in survivors of hormonally mediated cancers are limited 1. Ultimately, the decision to use topical estrogen or other treatments should be guided by the specific type of problem and individual patient needs, with a focus on improving quality of life while minimizing potential risks.

From the FDA Drug Label

There is an increased risk of endometrial cancer in a woman with a uterus who uses unopposed estrogens Known, suspected, or history of breast cancer

• Topical estrogen is not mentioned in the provided drug labels.
• The labels discuss oral ospemifene, an estrogen agonist/antagonist, which has contraindications for women with known or suspected estrogen-dependent neoplasia, including breast cancer.
• Given the information, topical estrogen may not be directly addressed, but the concern about estrogen-dependent neoplasia, such as breast cancer, suggests caution with any form of estrogen therapy in breast cancer survivors.
• Therefore, it is not possible to conclude that topical estrogen is appropriate for treating atrophic vaginitis in breast cancer survivors based on the provided information 2, 2, 2.

From the Research

Treatment Options for Atrophic Vaginitis in Breast Cancer Survivors

• Topical estrogen therapy is a potential treatment option for atrophic vaginitis in breast cancer survivors, but its use is controversial due to concerns about systemic absorption and potential impact on breast cancer recurrence 3, 4.
• Non-hormonal treatments, such as vaginal moisturizers and lubricants, are often recommended as first-line treatment for genitourinary syndrome of menopause (GSM) in breast cancer survivors, but may not be as effective as topical estrogen therapy 5, 6.
• Low-dose vaginal estrogen treatments have been shown to be effective in relieving urogenital atrophy in breast cancer survivors, with minimal increase in serum estrogen levels 6.
• Topical estrogen therapy has been found to reverse atrophic changes and relieve associated symptoms in postmenopausal women, including breast cancer survivors, while avoiding systemic effects 7.

Safety and Efficacy of Topical Estrogen Therapy

• The safety of topical estrogen therapy in breast cancer survivors is a major concern, with unknown levels of systemic absorption of estradiol and potential impact on breast cancer recurrence 3, 4.
• Studies have shown that low-dose vaginal estrogen treatments do not significantly increase serum estrogen levels, but long-term safety data are limited 6.
• Non-hormonal treatments, such as vaginal moisturizers and lubricants, are considered safe for use in breast cancer survivors, but may not be as effective as topical estrogen therapy 5, 6.

Clinical Recommendations

• Breast cancer survivors with atrophic vaginitis should be evaluated and treated by a healthcare professional, taking into account their individual risk factors and medical history 3, 4.
• Non-hormonal treatments, such as vaginal moisturizers and lubricants, may be recommended as first-line treatment, but topical estrogen therapy may be considered for women who do not respond to these treatments or have severe symptoms 3, 5, 6.
• Healthcare professionals should carefully weigh the potential benefits and risks of topical estrogen therapy in breast cancer survivors and monitor them closely for any adverse effects 3, 4.