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Vaginal Estrogen and Breast Cancer

Posted 2/29/2016

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  This is a very complicated and uncertain question. As you may know, the American College of Obstetricians and Gynecologists last week endorsed the use of vaginal estrogen, to treat urogenital problems, for breast cancer survivors. Never mind that the product package has a black box, warning of the possible risks/dangers for women who have had breast cancer. The fear is obvious: that even though very small amounts (and no one really knows how small they are) are estrogen are absorbed vaginally, even a small amount could be risky for women post breast cancer, most especially women who have had ER positive tumors.

  All women on breast cancer anti-estrogen/hormonal therapies (meaning tamoxifen and the AIs) experience a major loss of estrogen--that is the point!--that affects their sexuality and, specifically, their vaginal lubrications. There are a number of lubricants that help, but nothing is as good as the real thing. More problematically, this reduction in lubrication and the thinning of the vaginal wall that comes post menopause too often results in discomfort or pain with intercourse. And even more problematically, some women experience the dryness as painful all the time. I have known a few women who could not comfortably sit and cross their legs. That surely impacts quality of life!

  So, what is a doctor to do? At this point, there are really no good alternatives. There are a few other hormones being studied, and there may someday be other things that cane be successfully substituted for estrogen. For now, however, the choice is estrogen or nothing.

  Here is a good summary from Medscape. If this applies to you, I strongly suggest that you take a few minutes to read it.

 How Safe Is Vaginal Estrogen for Breast Cancer Survivors?
— ACOG endorsed its use, but what do experts think?

This week, the American College of Obstetricians and Gynecologists (ACOG) endorsed the
use of vaginal estrogen in breast cancer survivors to treat urogenital symptoms, if more
conservative therapies have failed. Vaginal estrogen contains a black box warning, which
tends to deter cancer survivors from its use, though the North American Menopause
Society (NAMS) is in the process of trying to get that changed.
Given this multi-faceted issue, we contacted both breast cancer experts and OB/GYNs via
email to ask:
When do you feel it is appropriate for breast cancer survivors to use vaginal
Do the risks outweigh the benefits?
Do you think the black box warning for vaginal estrogen needs to be changed --
why or why not?

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  • P said:
    2/29/2016 2:14 PM

    I have read this with great interest. I was diagnosed with an estrogen positive breast cancer 20 years ago. After a subsequent oophorectomy, I experienced great sexual difficulties. I consulted my oncologist about using the estring. She supported it, based on two things. 1) It is a medical issue for sure, but also a quality of life issue, and 2) if I had a recurrence or another primary breast cancer, no one would ever be able to determine whether the use of the estring was a factor. So, I have been using it for 18 years and am pleased to read of the OB/GYN college decision. Of course no one decision is right for everyone, but I do encourage discussing the issue with your oncologist.