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Vaginal estrogen may be used in women who have been treated for ER-positive breast cancer


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After breast cancer treatment, some women experience vaginal dryness, urinary tract problems and other survivorship issues. Vaginal estrogen creams, rings and tablets effectively address these symptoms in menopausal women; however, there is concern that vaginal estrogen may not be safe for women with a history of estrogen-dependent (ER+) breast cancer. A recent opinion from the American College of Obstetricians and Gynecologists Committee on Gynecologic Practice states that, based on available data, vaginal estrogen should be safe to use for women if nonhormonal approaches do not alleviate their symptoms. (3/29/16)


STUDY AT A GLANCE

This study is about:

Whether vaginal estrogen is safe to use for women who have a history of estrogen-dependent breast cancer.

Why is this study important?  

After cancer treatments, some women experience survivorship issues such as vaginal dryness or soreness, painful sex, and urinary tract problems. Products containing estrogen are sometimes used to treat these symptoms in menopausal women. However, there is some concern that estrogen products might be unsafe for women with a history of certain breast cancers that are sensitive to estrogen (ER-positive breast cancers). Vaginal estrogen has been shown to relieve symptoms while delivering a lower dose of estrogen.

Study findings: 

The American College of Obstetricians and Gynecologists recommends the following:

  • The first options for women with ER-positive breast cancer who are experiencing vaginal issues and urinary tract problems should be nonhormonal approaches such as lubricants, moisturizers, or oils.
  • If symptoms are not relieved by nonhormonal approaches, then low dose vaginal estrogen (i.e. estrogen applied directly to the vagina) can be used.
  • The decision to use vaginal estrogen “should be preceded by an informed decision-making and consent process in which the woman has the information and resources to consider the benefits and potential risks of low-dose vaginal estrogen.”

What does this mean for me?

Women with ER-positive breast cancer who are experiencing vaginal issues and urinary tract problems should first try nonhormonal remedies. If those remedies do not work, the Committee advises that vaginal estrogen may then be used. According to the authors of the opinion piece, “When the decision is made to use vaginal estrogen, it should be prescribed at the lowest dose to affect vaginal symptoms and for a limited period until symptoms are improved.”

Questions to ask your health care provider:

  • I have vaginal issues and urinary tract problems after breast cancer treatment. What treatments can I try?
  • I stopped using vaginal estrogen when my symptoms subsided, but they have now returned. Is it safe to resume using vaginal estrogen?
  • I am taking tamoxifen after having ER-positive breast cancer.  Can I use vaginal estrogen to treat some of my symptoms?
  • I am taking an aromatase inhibitor (Arimidex, Aromasin, or Femara) after being diagnosed with ER-positive breast cancer.  Can I use vaginal estrogen to treat some of my symptoms?

IN DEPTH REVIEW OF RESEARCH

Study background:

Breast cancers are often characterized by the presence of estrogen receptors (ER) and/or progesterone receptors (PR).  Breast cancers that are ER-positive and/or PR-positive are often called hormone sensitive because one or both hormones stimulate tumor growth. There are concerns that women with these types of hormone-sensitive breast cancers should not use products containing estrogen to manage menopausal symptoms and/or other sexual side effects of breast cancer treatment. However, some women find that moisturizers, lubricants, topical anesthetics, and other nonhormonal approaches do not alleviate their vaginal issues, urinary tract problems and other sexual side effects.

One option is treating the area directly with vaginal creams, rings, and tablets that are inserted into the vagina. These products deliver low doses of estrogen directly to the vaginal tissue; studies show that they do not increase levels of estrogen in the bloodstream. These are “local” products; they work only where they are placed, unlike pills, patches and other systemic therapies that deliver estrogen to the bloodstream, and therefore can impact the entire body.

The American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice drafted a Committee Opinion in March of 2016 regarding the use of vaginal estrogen in women with a history of ER-positive breast cancer. This opinion was based on a number of research studies that looked at the use of vaginal estrogen by breast cancer survivors.   

Researchers of this study wanted to know:

Whether vaginal estrogen is safe for women with a history of estrogen-dependent breast cancer. 

Population(s) looked at in the study:

The committee based their opinion on the results of multiple studies that looked at women with breast cancer who did or did not use vaginal estrogen, as well as women who used vaginal estrogen while taking hormonal therapies, including aromatase inhibitors (name some here) or tamoxifen.

Study findings: 

  1. The first options for women with estrogen-dependent breast cancer who are experiencing vaginal issues and urinary tract problems should be nonhormonal approaches, including moisturizers, lubricants and oils.
  2. Women who still have symptoms after trying nonhormonal approaches may then use low-dose vaginal estrogen.
  3. The decision to use vaginal estrogen “should be preceded by an informed decision-making and consent process in which the woman has the information and resources to consider the benefits and potential risks of low-dose vaginal estrogen.”
  4. The current data do not indicate that there is an increased risk of cancer recurrence for women who use vaginal estrogen while currently undergoing breast cancer treatment or who have a personal history of breast cancer.
    • Concern still remains about the risk of recurrence for women who use vaginal estrogen  while taking aromatase inhibitors such as Arimidex, Aromasin, or Femara, and some studies caution against vaginal estrogen for these women.
    • The committee writes that using low-dose vaginal estrogen may be appropriate for women who are currently using tamoxifen. 

Limitations:

This is an expert opinion paper, but it is not a research paper.  This means that the conclusions are only as good as the available evidence cited in the opinion. Additionally, research in this area is still limited, and each study involved women in different situations, including age of diagnosis, whether or not the woman had gone through menopause prior to treatment, young women with chemo-related issues, progesterone (PR) and Her2-receptor status, and use of hormonal therapies, including tamoxifen or aromatase inhibitors. More work should be done to confirm the findings across the array of breast cancer survivors. Breast cancer survivors considering use of vaginal estrogen should recognize that such use is considered “off-label” (used for treatment other than the specific conditions for which the medication has received FDA approval). In practice, off-label use of medications is common, and it is appropriate if based on available evidence and the patient is aware of the off-label status.

Conclusions:

This committee opinion states that low-dose vaginal estrogen is appropriate for women who have/had ER-positive breast cancer and are experiencing vaginal or urinary tract issues that cannot be treated by nonhormonal approaches. However, more research is needed to firmly establish the safety for women who are currently using aromatase inhibitors. The decision to use low-dose vaginal estrogen should be made with a healthcare provider, and women should stop using vaginal estrogen as soon as their symptoms are no longer present.  

References

Committee on Gynecologic Practice, “The Use of Vaginal Estrogen in Women With a History of Estrogen-Dependent Breast Cancer.” Number 659, March 2016.   

Posted 3/29/16

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