Individual Benefits and Risks of Intravaginal Estrogen and Systemic Testosterone in the Management of Women in the Menopause, With a Discussion of Any Associated Risks for Cancer Development

Abstract

Several formulations of intravaginal oestrogen are available for the treatment of genitourinary syndrome of menopause (GSM). These are safe and effective treatments for the symptoms of GSM. Licensed doses of intravaginal oestrogen do not elevate systemic estradiol levels above the normal postmenopausal range with long term use and there is no evidence of an increased risk of coronary heart disease, stroke, thromboembolism, colorectal cancer, endometrial cancer, breast cancer or breast cancer recurrence with their use. This should reassure both women and their healthcare professionals and should lead to more women receiving these localised, vaginally administered hormonal treatments. Available evidence also suggests a positive safety profile for transdermal testosterone treatment when delivered at physiological concentrations.

Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer

“…1 Lack of circulating estrogen can lead to genitourinary syndrome of menopause, which encompasses symptoms associated with decreased sex steroids related to the urinary and genital systems and can include sexual dysfunction. [2][3][4] More than 70% of postmenopausal women who survive breast cancer and are treated with systemic therapies subsequently experience genitourinary syndrome of menopause. 1 Although there are many treatments for genitourinary syndrome of menopause, one of the most effective options for vulvovaginal atrophy is vaginal estrogen therapy.…”

“…Recent reviews have described the controversy surrounding the use of vaginal estrogen in women with a history of breast cancer because of concerns about systemic estrogen absorption and possible increased cancer recurrence risk. 4,5 Currently, few survivors of breast cancer with genitourinary syndrome of menopause are prescribed vaginal estrogen because of concerns about cancer recurrence, leading to undertreatment of genitourinary syndrome of menopause in this population. 5 A recent expert consensus statement cited a paucity of safety data as a primary contributor to clinicians' reluctance to use vaginal estrogen in women at a high risk for breast cancer.…”

“…17 However, vaginal estrogen has not been shown to elevate systemic levels of estrogen above the normal postmenopausal range. 4 A recent meta-analysis of 11 studies of local hormonal treatment, including nine studies on vaginal estrogen therapy, demonstrated a lack of systemic absorption of sex hormones, supporting the low risk of breast cancer recurrence associated with this therapy. 18…”

“…17 However, vaginal estrogen has not been shown to elevate systemic levels of estrogen above the normal postmenopausal range. 4 A recent metaanalysis of 11 studies of local hormonal treatment, including nine studies on vaginal estrogen therapy, demonstrated a lack of systemic absorption of sex hormones, supporting the low risk of breast cancer recurrence associated with this therapy. 18 Despite the evidence of minimal systemic absorption, few studies have examined the association between cancer recurrence risk and vaginal estrogen therapy, including a lack of data from randomized clinical trials.…”

“…Recent reviews have described the controversy surrounding the use of vaginal estrogen in women with a history of breast cancer because of concerns about systemic estrogen absorption and possible increased cancer recurrence risk. 4,5…”