Fighting breast cancer was hard. It was also unfair. Linda was only 53, she ran marathons, ate lean meats, enjoyed her vegetables and took a walk every night with her husband. So it was profoundly unfair when a spot was found on her annual screening mammogram. She had a core needle biopsy, which demonstrated a breast cancer. Although the tumor was small, it was high grade. Linda chose to remove her breast and have a mastectomy. And then she took chemotherapy.
Chemotherapy was hard. Linda was “bone” tired, she lost her hair, she had short bouts of nausea, and she lost the feeling in the tips of her fingers and toes. At times, Linda no longer felt like the woman she once was. Although her hair grew back, it was different. She couldn’t take as long a walk with her husband anymore because of the loss of sensation in her toes (“Chemotherapy Induced Peripheral Neuropathy” or CIPN). And it burned when she had to urinate. She did not have a bladder infection. Linda had vaginal dryness, known as vaginal atrophy.
Vaginal dryness or atrophy can be a normal condition after menopause and is not uncommon in women who have had chemotherapy and are taking an anti-estrogen pill to fight their breast cancer. Vaginal atrophy can lead to symptoms of urinary incontinence (a leaking bladder); it can lead to painful urination as the urine irritates that vaginal wall; it can lead to painful sex (dyspareunia) as the vagina does not become well lubricated; and it can lead to a feeling of just being dry between the legs.
The best therapy for vaginal dryness is estrogen as the vagina has many estrogen receptors. However, breast cancer survivors cannot take estrogen without increasing the risk of recurrence. Initial therapies for vaginal dryness for breast cancer survivors should include moisturizers, lubricants, and topical anesthetics. However, these methods may work only temporarily and eventually most breast cancer survivors with vaginal dryness will have recurrent symptoms.
The answer then is not oral estrogen but local estrogen delivered directly to the vagina. ESTRING® (17-ß Estradiol silastic ring) and Vagifem® (estradiol hemihydrate tablet) are probably the safest vaginal estrogens as they most likely have the lowest systemic absorption of estrogen. No formal studies have been completed to prove the safety of these topical estrogens in breast cancer survivors, but we do know that the levels of estrogen in the blood remain very low with these two methods of vaginal estrogen delivery. And yes, women can remain on their anti-estrogen pills while using these topical estrogens. While the vaginal creams are also local delivery options, the creams probably have more systemic estrogen absorption and are therefore not recommended for breast cancer survivors.
In short, for the woman with breast cancer who has vaginal atrophy, ESTRING® or Vagifem® are the two best options for local delivery of estrogen to treat the symptoms of vaginal dryness: overactive bladder, urinary tract infections, painful sex and just feeling dry between the legs. Moisturizers, lubricants, and topical anesthetics should also be tried or used in addition to the topical estrogens.
Linda talked with both her medical oncologist and her gynecologist about her symptoms. Linda was prescribed Vagifem® and feels much better today. It does not burn when she urinates; she still has some incontinence (she has four kids); intimacy with her husband is no longer painful, although she does use lubricants at times; and she can take walks with her husband every night without feeling dry. Surviving breast cancer can sometimes be just as hard as fighting breast cancer and you don’t have to suffer. Talk with your doctors because there are many treatments for the conditions women experience after beating breast cancer.