Current Overview of the Management of Urogenital Atrophy in Women with Breast Cancer

Abstract

Systemic treatments for women with breast cancer frequently induce urogenital symptoms that can negatively impact a women's quality of life. Urogenital atrophy is frequently undiagnosed and untreated, particularly in breast cancer survivors. Symptoms of urogenital atrophy can usually be relieved with vaginal estrogen preparations, but risk of recurrence and safety is undefined in women with a history of breast cancer. Treatment with nonhormonal modalities including vaginal moisturizers or lubricants and lifestyle modification are the first lines of management. Low-dose vaginal 17 β-estradiol (vaginal estradiol tablets 10 μg or vaginal estradiol ring) can be considered for the treatment of symptomatic urogenital atrophy in women with a history of breast cancer after appropriate disclosure to the patient. While effective in treating the urogenital symptoms, the safety of such therapy remains uncertain. The decision to offer vaginal estrogen therapy needs to be individualized and should be made jointly with the oncologist.

Clinical Pearls in Breast Disease

“…A review of various vaginal and oral estrogen agents demonstrated that when they were administered vaginally either as a tablet or ring, the serum estradiol concentration was substantially less than with oral or transdermal estrogen medications. 16 Compared with oral estrogen therapy, consideration of local low-dose vaginal estrogen (eg, vaginal tablet once a week) is reasonable for treatment of severe symptoms, given the potential for much lower serum estradiol concentrations. A clinical trial evaluating the safety of vaginal estrogen preparations is under way (http://clinicaltrials.gov/ ct2/show/NCT00984399).…”

Caring for the breast cancer survivor’s health and well-being

“…Newer evidence has demonstrated that serum pharmacokinetics can be used to determine the maximum annual dose delivered and serum estradiol levels of various LVETs. Vaginal estrogen tablets (10 mg) prescribed twice a week demonstrated the lowest annual delivered systemic dose as compared to other LVET [44] . Providers should be aware of barriers to breast cancer treatment adherence and take into account individual patient's symptom severity, preference, and potential cancer recurrence risk when considering LVET.…”

“…In women with VVA, meticulous vulvar care is important, and products with perfumes or dyes should be avoided (toilet tissue, soaps, fabric softeners, stimulating lubricants, vaginal hygiene products) [44] . Vaginal moisturizers can be used on a regular basis to replace vaginal moisture, whereas lubricants are needed with sexual activity to reduce friction [45] .…”

Endocrine Therapy in Older Women with Early-Stage Hormone Sensitive Breast Cancer

“…However, it is absorbed systemically to some extent and has been shown to increase serum estradiol levels to variable degrees [86,87]. This raises some concerns about the safety of vaginal estrogens in patients with breast cancer, particularly in patients on AI though the clinical implications of this increase in estrogen on breast cancer outcomes is unclear [82,86].…”

“…Some suggest that vaginal estrogen therapy can be considered after a discussion of risks and benefits with the patient, particularly as vaginal symptoms that are not well controlled can potentially result in non-compliance or early discontinuation [59]. If utilized, consideration of vaginal estrogens with lower levels of systemic estrogen uptake should be considered [87]. Tamoxifen is associated with less vulvovaginal atrophy and dryness due to its weak pro-agonistic effect on the vagina and changing from an AI to tamoxifen is also a reasonable alternative strategy.…”