Sex Matters: What About Vaginal Hormones?

By on November 6th, 2014 Categories: Sex Matters

We’ve discussed vaginal and vulvar dryness and some conservative measures that can be used to help treat symptoms, including nonhormonal vaginal moisturizers that help hydrate the tissues and vaginal lubricants that can make intercourse and sex more comfortable. The question that many women diagnosed with breast cancer often ask is, “What about vaginal hormones? Are they safe? Can we use them?” In this month’s column, we will talk about locally applied vaginal hormones that are placed in the vagina or on the vulvar skin. They come in a variety of different application methods. Locally applied vaginal hormones are different than systemic and oral hormones; this column will focus on local hormones.

Since many breast cancers contain estrogen receptors (ER) and progesterone receptors (PR), caution should be used with the use of any type of hormonal product, even if it’s locally placed in the vagina. All local estrogen products have a black box warning because they may be harmful to women who’ve had breast cancer. To make issues more confusing, there is emerging and limited data that may suggest that the local hormones that are minimally absorbed may be used in small quantities. When it comes to local hormonal products, there are NO long-term safety data or any significant safety studies in the breast cancer population, and it is important to discuss your specific cancer and condition with your healthcare professional or your oncological team to see if you may be a candidate for the use of any type of local estrogen.

Most of these local products cause some absorption into the circulation, so again, it’s important to discuss your specific situation with your doctor. We certainly know that oncologists, breast specialists, sexual medicine professionals, and women diagnosed with breast cancer may all disagree about the risks and benefits of these products. It is important to know the cancer’s hormone receptor status and stage and understand your personal risk. Some women may in fact choose to use certain products when others may decline all interventions. It’s important to have an open and honest dialogue concerning these issues with your healthcare team!

For the treatment of vaginal dryness and painful sex, there are many products available, and they may be in the form of creams, gels, rings, and tablets. There is also a newly approved oral medication, Osphena (chemical name: ospemifene), that treats painful intercourse. Many of these minimally absorbed vaginal estrogen products provide very small doses of estrogen directly in the vagina, vulva, and surrounding tissues.

Some women with extreme vulvar atrophy and shrinkage may benefit from topical cream application. Creams are helpful when considering treatment for vulvar dryness, clitoral shrinkage, and atrophic changes. Vaginal and vulvar creams such as Premarin (conjugated estrogens) or Estrace (estradiol vaginal cream) are typically applied to both the interior of the vagina and exterior of the vaginal opening. Premarin cream contains a mixture of estrogens and is readily available; new lowered doses demonstrate excellent safety on the endometrial lining, but this medication has not been studied for efficacy or safety in the breast cancer population. Estrace vaginal cream contains estradiol, which is a bio-identical type of estrogen and may also be helpful for treatment of vulvovaginal atrophy, a genital syndrome of menopause and sexual pain. Some women find these creams especially soothing. And some women may experience pain when a man’s penis enters her vagina; placing a small amount of local estrogen cream only at the vaginal entrance (an area called the introitus) may also be helpful in this situation.

The “ring,” or Estring (estradiol vaginal ring) is placed deep within the vagina for 3 months and then is replaced. Some women find this helpful because they don’t have to remember to use a product on a daily basis and it is minimally absorbed, but others find it uncomfortable and some partners complain of feeling the ring during intercourse. An important note: Estring does not work as a pessary (medical device used for pelvic floor defects) and does not help with urinary incontinence (involuntary loss of urine).

Minimally absorbed estradiol vaginal tablets, or Vagifem, are another type of vaginal hormone replacement. Vagifem tablets are contained in a plastic disposable applicator. The tablets are inserted into your vagina every night for 14 days and then twice a week.  This medication comes in convenient prefilled applicators that are biodegradable, and many women prefer Vagifem since there is no mess or leakage and it is easy to use. A small study in the United Kingdom, which followed only seven breast cancer patients on both an aromatase inhibitor and Vagifem, reported increased estradiol levels in the women using Vagifem. The study was too small to be valid, and there were several serious flaws with the study, making the results controversial.

An oral tablet, Osphena, is an estrogen agonist (turns estrogen receptors on in certain cells) as well as an antagonist (turns estrogen receptors off in certain cells) that is approved for the treatment of moderate to severe dyspareunia (or painful) sex due to menopause. It has not been adequately studied in the breast cancer patient, but preclinical studies in animals demonstrate that it may be antagonist (turns estrogen receptors off) in breast tissue. At present, there is a warning for women who’ve had breast cancer to avoid using Osphena.

The long-term safety for ALL minimal absorbed vaginal estrogen products needs to be further studied, especially in special populations including women who’ve had breast cancer.

Although many women who’ve had breast cancer use minimally absorbed local estrogen products, their safety in this population has not been proven scientifically. Whether you actually need a progesterone agent if you are only on a minimally absorbed vaginal product is controversial. Some healthcare professionals advocate using progesterone in women who still have a uterus (have not had a hysterectomy) to prevent precancerous conditions of the endometrial lining.

It’s important to know that if you’ve had breast cancer, any abnormal vaginal bleeding should always be reported to your healthcare professional as soon as possible so that you can get a work-up and evaluation. This evaluation may include a pelvic ultrasound and/or an endometrial biopsy.

When you are suffering from severe dryness and painful intercourse, it can significantly impact your quality of life and your relationship with your partner. Don’t ignore these symptoms — discuss them with your oncology team members and your nurse practitioner or other sexual medicine specialists. Your team can help create a personalized treatment plan for your vaginal and vulvar dryness.

Stay tuned for next month’s blog on the recent FDA meeting on female sexual dysfunction, and we’ll also start to talk about loss of sexual libido and what can be done about it.

As always, we welcome your comments, suggestions, and questions!

Michael L. Krychman, M.D.C.M., is the executive director of the Southern California Center for Sexual Health and Survivorship Medicine in Newport Beach, California. He is the former co-director of the Sexual Medicine and Rehabilitation Program at Memorial Sloan-Kettering Cancer. Dr. Krychman is also an American Association of Sexuality Educators, Counselors and Therapists (AASECT) certified sexual counselor. He is an associate clinical professor at the University of California, Irvine, Division of Gynecological Oncology, and the medical director of Ann’s Clinic, a high-risk program for breast and ovarian cancer survivors. His special interests include menopausal health, hormone therapy, sexual pain disorders, loss of libido, and chronic medical illness and its impact on female sexual function as well as breast cancer sexuality. Dr. Krychman is also a member of the Breastcancer.org Professional Advisory Board.

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  1. Michael Krychman, M.D.

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