Treating Bothersome Genitourinary Symptoms in Menopausal Women After Breast Cancer

Andrew M. Kaunitz, MD


December 29, 2021

This transcript has been edited for clarity.

With some 3.8 million US breast cancer survivors, we often see women who have been treated for this common type of cancer and are dealing with vaginal dryness and sexual discomfort caused by genitourinary syndrome of menopause (GSM). Clinicians will find the December 2021 ACOG Clinical Consensus Recommendations to be useful.

Over-the-counter vaginal lubricants, which are used for sexual activity, and moisturizers, which can be used on a regular basis (such as several times weekly), represent first-line treatment for women with symptomatic GSM. Although traditionally, lubricants have been water-based, more recently silicone-based lubricants, which may be more slippery and less irritating, have become widely available. With respect to moisturizers, I have received positive patient feedback regarding Hyalo Gyn, which is applied with an applicator, as well as K-Y Liquibeads, which are applied digitally. These moisturizers may be easier to find online than in pharmacies. I have no disclosures to report regarding these products.

Although the US Food and Drug Administration (FDA) considers use of vaginal estrogen to be contraindicated in women with a personal history of breast cancer, available data have not found an increased recurrence risk among survivors using vaginal estrogen. ACOG's guidance states that if lubricants and moisturizers prove inadequate in addressing GSM symptoms, off-label low-dose vaginal estrogen, available as creams, tablets, inserts and a ring, may be used.

Many women who have been treated for hormone receptor–positive breast cancer take long-term tamoxifen or aromatase inhibitors (AIs) to reduce recurrence risk. Tamoxifen blocks the impact of estrogen on breast tissue. Accordingly, use of vaginal estrogen is likely to be safe in women using tamoxifen. In contrast, AIs do not block the action of estrogen. Therefore, if use of vaginal estrogen elevates serum estradiol levels in women using an AI, this in theory could increase recurrence risk.

Fortunately, use of available vaginal estrogen formulations as recommended in package labeling does not appear to elevate serum estradiol levels.

Two other options to treat GSM in survivors are DHEA (also known as prasterone) vaginal tablets and oral ospemifene, a selective estrogen receptor modulator. Because these are newer formulations, we have little data on their use in breast cancer survivors.

In summary, this welcome ACOG guidance should make clinicians more knowledgeable when caring for women with a history of breast cancer and bothersome GSM, and more comfortable when prescribing vaginal estradiol off-label. In this latter setting, clinicians should engage in shared decision-making as well as communication with the patient's oncology team.

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