Vaginal health after breast cancer: A guide for patients

Key points Women who have had breast cancer treatment before menopause may develop a range of symptoms related to low oestrogen levels, while post-menopausal women may have a worsening of their symptoms. These symptoms relate to both the genital and urinary tracts. A range of both non-prescription/lifestyle and prescription treatments is available. Discuss your symptoms with your specialist or general practitioner as they will be able to advise you, based on your individual situation.

AMS Vaginal health after breast cancer - patient guide366.94 KB

• Women who have had breast cancer treatment before menopause might find they develop symptoms such as hot flushes, night sweats, joint aches and vaginal dryness.
• These are symptoms of low oestrogen, which occur naturally with age, but may also occur in younger women undergoing treatment for breast cancer. These changes are called the genito-urinary syndrome of menopause (GSM), which was previously known as atrophic vaginitis.
• Unlike some menopausal symptoms, such as hot flushes, which may go away as time passes, vaginal dryness, discomfort with intercourse and changes in sexual function often persist and may get worse with time.
• The increased use of adjuvant treatments (medications that are used after surgery/chemotherapy/radiotherapy), which evidence shows reduce the risk of the cancer recurring, unfortunately leads to more side-effects.
• Your health and comfort are important, so don't be embarrassed about raising these issues with your doctor.
• This Information Sheet offers some advice for what you can do to maintain the health of your vagina, your vulva (the external genitals) and your urethra (outlet from the bladder), with special attention to the needs of women who have had breast cancer treatment.

Why is oestrogen important for vaginal health?

• The vaginal area needs adequate levels of oestrogen to maintain healthy tissue.
• The vagina's lining responds to oestrogen which keeps the walls thick and elastic.
• When the amount of oestrogen in the body decreases this is commonly associated with dryness of the vulva and vagina.
• Before menopause the vagina is acidic but after menopause the acidity (pH) changes and this may affect the resistance of the vagina and bladder to infection.
• The vulval area also changes with ageing, as fatty tissue reduces and the labia majora (outer lips of the vagina) and the hood of skin covering the clitoris may contract. If sensitive areas become more exposed, chafing can occur.
• Pelvic floor muscles become weaker and urination may become more frequent and difficult to control.

What symptoms occur with changes in vaginal health?

• Irritation, burning, itching, chafing, or other discomfort.
• Dryness due to decreased vaginal secretions, which may also mean sexual intercourse becomes uncomfortable or painful.
• Light bleeding, because the vagina may injure more easily. Any vaginal bleeding needs to be investigated by your medical practitioner.
• Inflammation, known as atrophic vaginitis, which can lead to pain on urination and infection.
• Persistent, smelly discharge caused by increased vaginal alkalinity (higher pH) which is sometimes mistaken for thrush. Any vaginal discharge needs to be investigated by your medical practitioner.

How are these symptoms related to my breast cancer treatment?

• Chemotherapy: women can develop vulvar and vaginal burning due to inflammation. These are similar to the changes that occur in the lining of the mouth and gastrointestinal tract.
• Tamoxifen: the effects of this medication are variable; some pre-menopausal women note dryness due to the effect of tamoxifen blocking oestrogen in the lining of the vagina while others experience more vaginal discharge. In post-menopausal women, who already have lower levels of oestrogen, the change may be less marked.
• Aromatase inhibitors (post-menopausal women with oestrogen receptor-positive breast cancer are often treated with these drugs – anastrozole (Arimidex®), letrozole (Femara®), or exemestane (Aromasin®)): studies have shown more vaginal symptoms with aromatase inhibitor-only treatment than with tamoxifen-only treatment.
• Raloxifene: this drug (Evista®) originally approved for treatment of osteoporosis, has been approved for breast cancer risk reduction since 2007. In post-menopausal women it has not been associated with adverse vaginal symptoms and does not affect sexual function. There is no good evidence about raloxifene's effects in pre-menopausal women.

How can I minimise irritation to the vagina?

• Wear underwear made of natural fibres such as cotton and change underwear daily. Consider going without underwear when possible e.g. going to bed.
• Avoid, or at least limit, time spent wearing tight-fitting underwear, pantyhose/tights, jeans or trousers as this may lead to sweating. Also limit time in a damp or wet swimming costume or exercise clothing.
• Wash clothing with non-perfumed or low-allergenic washing products. Avoid use of fabric softeners. Consider second-rinsing if symptoms persist.
• Avoid use of feminine hygiene sprays and douching. Avoid pads, tampons and toilet paper which are scented.
• Avoid shaving or waxing the genital area, particularly if irritation is present.
• Gently wash skin of the genital area only with plain water. Or, use soap alternatives such as Cetaphil®, QV wash®, or Dermaveen® and avoid soap, liquid soap, bubble bath and shower gels. Always pat dry (don't rub).
• You can continue to be sexually active and in fact it may improve your symptoms. Sexual activities, whether with a partner or masturbation, improve blood flow and help maintain healthy tissue. Consider using a vaginal lubricant or moisturiser (see What treatments are available? below).
• Practice safe sex in new relationships, in order to reduce sexually transmitted infections (STIs).
• Quit smoking. Smoking increases atrophy by decreasing blood flow to the genital area and directly affecting vaginal cells, as well as threatening your overall health.

What treatments are available?

• Cool washes or compresses may help itching and mild discomfort. Dissolve half a teaspoon of bicarbonate of soda in 1 litre of water and apply gently with a cloth a few times a day. Softly pat dry. Avoid scratching and keep the genital area cool and dry. See your doctor if symptoms persist or if they get worse with this treatment.
• Vaginal moisturisers can temporarily increase the water content of the vaginal cells. Ask your doctor or pharmacist about available products.
• Water or silicone based vaginal lubricants may reduce friction and make intercourse more comfortable. Some products containing alcohol/preservatives may cause irritation. Water-based or silicone-based lubricants can be used safely with latex condoms. However oil-based lubricants should never be used with latex condoms.
• Natural oils (such as sweet almond or avocado oil) may help, but some oils and creams (such as tea-tree oil and paw-paw ointment) can cause contact dermatitis, increasing itchiness and discomfort.
• Vitamin E, either taken orally or applied topically (as ointment) can reduce symptoms.
• Phyto-oestrogens are used by some women but there is a lack of evidence for their effectiveness and safety, and they are not recommended for women who have had breast cancer.
• Pelvic floor relaxation exercises may help and seeing a pelvic floor physiotherapist who may offer advice on the exercises and techniques to make penetration during intercourse easier.

Sexual issues after breast cancer treatment

Sexual problems occur in many women who have had treatment for breast cancer, and you may feel the need to obtain professional help for these difficulties.

Here are some things that might assist:

• Many women benefit from the advice of a physiotherapist who specialises in treatment of the pelvic floor.
• A physiotherapist can recommend techniques for overcoming sexual problems. Using several techniques together (such as relaxation, massage, pelvic exercises and lubricants) can be helpful.
• Tiredness is often a consequence of therapy and a 'turn off' when it comes to sex. Ensure that you have adequate rest, including some mid-day rest if necessary, and try to enlist relatives or friends to help with housework and child-minding.
• Ask your GP about counsellors who specialise in helping people who are experiencing problems in their sexual relationship.

Prescription treatments for vaginal health

• Oral or patch oestrogen or progestogen therapy is not recommended for breast cancer survivors because these hormones may increase the risk of a new breast cancer or cancer recurrence. Tibolone (Livial®) is also not recommended because it has been shown to increase the risk of breast cancer recurrence.
• Vaginal oestrogen, which comes in the form of pessaries or creams inserted with an applicator, may sometimes be recommended because it mainly acts locally, but some oestrogens are also absorbed into the circulation. This decision needs careful consideration.
• Some treatments for breast cancer, such as aromatase inhibitors, are designed to reduce the amount of oestrogen in the body as much as possible. Using vaginal oestrogens may increase the oestrogen in the body, and potentially reduce the benefits of using the aromatase inhibitor. Although no studies have shown that using vaginal oestrogen is more likely to lead to breast cancer recurrence, many oncologists are reluctant to advise women to use vaginal oestrogen after breast cancer. Tamoxifen works differently from aromatase inhibitors and acts like oestrogen in some tissues and blocks it in others. For this reason, oncologists may be more willing to consider vaginal oestrogen use in tamoxifen users compared to aromatase inhibitor users.
• For women with problematic vaginal dryness, it is essential to discuss management options with your oncologist or breast cancer specialist as quality of life issues are considered as part of your overall treatment.

Further reading

1. Portman, D. J., & Gass, M. L. (2014). Genitourinary Syndrome of Menopause: New Terminology for Vulvovaginal Atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society. Journal of The Sexual Medicine.
2. Wills, S., Ravipati, A., Venuturumilli, P., Kresge, C., Folkerd, E., Dowsett, M., Hayes, D.F., Decker, D. A. (2012). Effects of vaginal estrogens on serum estradiol levels in postmenopausal breast cancer survivors and women at risk of breast cancer taking an aromatase inhibitor or a selective estrogen receptor modulator. Journal of Oncology Practice, 8(3), 14144-14148.
3. THE INTERNATIONAL SOCIETY FOR THE STUDY OF VULVOVAGINAL DISEASE for patient education

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Content updated October 2018