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The Use of Vaginal Estrogen in Women with a History of Estrogen-Dependent Breast Cancer

acog The Use of Vaginal Estrogen in Women With a History of Estrogen-Dependent Breast CancerIn a new Committee Opinion, "The Use of Vaginal Estrogen in Women with a History of Estrogen-Dependent Breast Cancer," the American College of Obstetricians and Gynecologists (ACOG) outlines the options and treatments for female-specific survivorship issues. One particular challenge for providers to understand and address is vaginal symptoms of menopause, whether naturally occurring or treatment-induced.

Many therapies that treat estrogen-dependent breast cancer cause vaginal atrophy and increase symptoms of vaginal dryness, bleeding, bacterial infections and painful sex. These symptoms may worsen over time and, as women live longer, may pose significant challenges. It is estimated that up to 20% of all patients terminate or consider terminating therapies due to the severe detrimental effect that vaginal atrophy poses on their quality of life.

According to the new Committee Opinion, for women with estrogen-dependent breast cancer or a history of estrogen-dependent breast cancer, non-hormonal options for vaginal atrophy should be the first choice. However, health practitioners may now consider topical estrogen therapy for patients with a history of estrogen-dependent breast cancer who are unresponsive to non-hormonal remedies. Although there is controversy related to the risk of topical estrogen therapy and breast cancer recurrence, the Committee Opinion notes that data show there is no increased risk of cancer recurrence with the use of topical vaginal estrogen.

Diana Nancy Contreras, MD, Chair of ACOG's Subcommittee on Gynecologic Oncology, stated, "These new recommendations are especially important and helpful because they provide the patient with the information needed to make an informed decision with the input of her health care provider."

See PDF version at 
https://www.acog.org/-/media/Committee-Opinions/Committee-on-Gynecologic-Practice/co659.pdf?dmc=1&ts=20160222T2107434698

Abstract

Cancer treatment should address female-specific survivorship issues, including the hypoestrogenic-related adverse effects of cancer therapies or of natural menopause in survivors. Systemic and vaginal estrogen are widely used for symptomatic relief of vasomotor symptoms, sexual dysfunction, and lower urinary tract infections in the general population. However, given that some types of cancer are hormone sensitive, there are safety concerns about the use of local hormone therapy in women who currently have breast cancer or have a history of breast cancer. Nonhormonal approaches are the first-line choices for managing urogenital symptoms or atrophy-related urinary symptoms experienced by women during or after treatment for breast cancer. Among women with a history of estrogen-dependent breast cancer who are experiencing urogenital symptoms, vaginal estrogen should be reserved for those patients who are unresponsive to nonhormonal remedies. The decision to use vaginal estrogen may be made in coordination with a woman’s oncologist. Additionally, it 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. Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.

Recommendations and Conclusions

The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:

  • Nonhormonal approaches are the first-line choices for managing urogenital symptoms or atrophy-related urinary symptoms experienced by women during or after treatment for breast cancer.
  • Among women with a history of estrogen-dependent breast cancer who are experiencing urogenital symptoms, vaginal estrogen should be reserved for those patients who are unresponsive to nonhormonal remedies.
  • The decision to use vaginal estrogen may be made in coordination with a woman’s oncologist. Additionally, it 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.
  • Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.

Reference

Committee Opinion No. 659: The Use of Vaginal Estrogen in Women With a History of Estrogen-Dependent Breast Cancer. Obstet Gynecol. 2016 Mar;127(3):e93-6. doi: 10.1097/AOG.0000000000001351. 

Content updated 29 March 2016

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