Vaginal Estrogen for Women with Breast Cancer?

 by Lauren Streicher, MD

For the woman who is newly contending with a diagnosis of breast cancer and dealing with the overwhelming stress of surgery, chemotherapy and radiation, sex is usually the last thing on her mind. The emphasis is, and should be, on treating the cancer. But after the physical scars have healed and hair has grown back, the consequences on a woman’s sexuality are often minimized. Sadly, many cancer survivors feel reluctant to complain about something as “trivial” as the loss of their sex life. It’s not unusual for a breast cancer survivor to attempt intercourse, only to find what was once satisfying and enjoyable is intolerable and upsetting, If she is brave enough to bring it up to her doctor, it’s typical to not get a lot of advice beyond “buy a lubricant” When that doesn’t work most women give up, assuming that vaginal estrogen, the most successful way to reverse vaginal dryness and intercourse, are just not an option.

Even if a doctor does give the go ahead, many women take one look at the package insert that practically has a skull and cross bones on it and decide it just isn’t worth the risk.

I published a study in 2013 in The Journal of Sexual Medicine showing a majority of gynecologists would themselves use vaginal estrogen even if they had breast cancer. It’s not that gynecologists are more willing than the general population to risk their lives in the name of having good sex, it’s that gynecologists know that the Black Box Warning that lists the dangers of using estrogen is not based on data that has anything to do with vaginal estrogen, much less women with breast cancer who use vaginal estrogen.

Today, the American College  of Obstetricians  and Gynecologists (ACOG) released a position statement very clearly stating that the use of estrogen in women with a history of an estrogen dependent breast cancer is safe and appropriate . ACOG  states, " 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. "

Since there is   essentially no evidence that using a tiny amount of estrogen directly on vaginal tissues to increase lubrication and elasticity of tissue that has become thin and dry causes an increased risk of breast cancer recurrence, it is time for the  FDA to   remove the scary, inappropriate black box warnings. Clearly the miniscule amount of estrogen absorbed from the vaginal use of estrogen doesn’t even increase blood estrogen levels above the normal menopausal range andis not  risky.  And in fact, what little data there is regarding the use of vaginal estrogen in women with breast cancer is very reassuring. One study which was published in a medical journal (Climacteric 2003; 6:45-52) followed 1,472 breast cancer patients who routinely used vaginal estrogen and were found to have a LOWER recurrence rate than women who did not use vaginal estrogen.

Most  breast surgeons and oncologists are  now comfortable allowing women with breast cancer to use vaginal estrogen. Ultimately, you need to do what you are comfortable with, but if you do decide to use vaginal estrogen, it should ease your anxiety a lot knowing not only most gynecologists, but alsoACOG is now firmly on board. 


Busting 5 Hormone Replacement Therapy Myths

By Lauren Streicher, MD

Published May 9, 2014, Everyday Health

Between the “expert” at Whole Foods, your hairdresser, and your most savvy friend, it’s hard to know who or what to believe when it comes to hormone replacement therapy (HRT). Even your gynecologist and internist may give conflicting recommendations! My new book, Love Sex Again, is your go-to guide for comprehensive, medically accurate information on hormone therapy risks and benefits. Here’s the scoop on some common hormone replacement therapy myths.

Myth No. 1:  Local vaginal estrogen carries the same risks as oral estrogen.

The facts: FDA class labeling requires all products with the same ingredient to have the same warning, even if the problem indicated by the warning has never been demonstrated in that product. That’s why risks associated with oral estrogens are listed on vaginal estrogen rings, tablets and creams even though not one single complication, warning or risk listed on the package insert (dementia, blood clots, breast cancer, oh my!) has ever been shown to result from using a local vaginal estrogen product. There is a movement among scientists to get these dire warnings off the label, since there is no evidence of truth, and many women who would benefit are too frightened to use vaginal estrogen products.

Myth No. 2: Bioidentical hormones are ‘natural.’

The facts: The only way to really get a natural bioidentical hormone is to drink the horse urineor eat the soy plant. All plant-derived hormone preparations, whether they come from a compounding pharmacy or a commercial pharmacy, require a chemical process to synthesize the final product, which can then be put into a cream, a spray, a patch, or a pill.

Promoters of compounded, plant-derived hormones use the terms “natural” and “bioidentical ” because they are appealing to consumers and imply an advantage over manufactured pharmaceutical products. FDA approved plant-derived products from your corner drugstore are just as “natural” as the products you get from a compounding pharmacy.

Myth No. 3: Saliva levels are a useful way to determine hormone therapy dosage.

The facts: No one argues that estrogen and progesterone levels are detectable in saliva, and it would be great if a drop of spit could actually unravel the mysteries of menopause. Unfortunately, salivary hormone levels, which are used to create the illusion of individualized therapy, are not biologically meaningful; do not correlate with blood levels; vary depending on diet, time of day, and other variables; and have not been proven useful in any scientific studies in determining the appropriate dosage for hormone replacement.

Likewise, blood tests, while more accurate, are not routinely used to determine the appropriate dosage of hormone therapy since there is a wide range of “normal” blood levels. What matters is not a target number, but how someone feels.

Myth No. 4: Estrogen therapy is a leading cause of breast cancer.

The facts: This is the one that will have a lot of you shaking your heads and thinking, “Is she kidding?” But the facts speak for themselves. Over 80 percent of women who have breast cancer have never taken hormones. In addition, the risk of developing breast cancer from hormone therapy is lower than the risk associated with daily alcohol use or obesity. According to the 2002 WHI study (the one that made women across the nation flush their estrogen down the toilet) only the women who took estrogen and progestin together had a slight increase in breast cancer.

The news flash that didn’t make it to the news is that in the estrogen only group there was an 18 percent decrease in breast cancer. It is now clear that the modest increase in breast cancer in women who take hormone therapy is due to the progestin, not the estrogen.

Myth No. 5: Orgasms require estrogen.

Rejoice! Even if your estrogen tank is on empty most women can still experience the big O. Appropriate local or systemic estrogen therapy goes a long way to make intercourse more comfortable if pain or dryness is an issue, but it does not appear that addition of hormone therapy is necessary for most women to have an orgasm. Having said that, there is data that suggests that supplemental estrogen alone or with testosterone in some post-menopausal woman will facilitate orgasm by increasing blood flow and sensitivity to the clitoris.