Breast Cancer Education and Support
Good sex after breast cancer treatment
Breast cancer survival is increasing. There are currently 2.5 million breast cancer survivors in the United States.
What pharmacologic interventions can improve sexual function?
Systemic and local estrogen replacement remains key in the management of female sexual dysfunction. Emerging data from the Woman’s Health Initiative study describe growing concerns about hormones and potential associated risks of cardiovascular events or breast cancer. Risks and benefit profiles should be discussed with your healthcare and sexual medicine specialist. Estrogen has many effects on the urogenital system. It promotes epithelial cell maturation and proliferation, increases vascularity and blood flow, and stimulates glandular secretions. A decrease of estrogen causes decreased blood supply to the genitals and increased atrophic vaginitis and can lead to painful intercourse and possibly a reactive lowered desire. The use of minimally absorbed local vaginal estrogen (creams, rings, and tablets) for the treatment of vaginal atrophy is widely accepted. Many products are minimally absorbed: Estring (Pfizer) and Vagifem vaginal tablets (NovoNordisk Pharmaceuticals), Premarin Vaginal Cream (Pfizer Pharmaceuticals), and Estrace Cream (Warner Chilcott) and Duramed vaginal Estradiol Cream are other hormonal products that may be used for the vagina and the vulvar tissues. The creams are especially useful for the vulvar and clitoral regions. They can be tapered and used topically in ultra small amounts. They are widely accepted, cheap, and easy to obtain with a prescription. Some sexual health providers prefer to prescribe a local 17b-estradiol tablet (Vagifem), which is minimally absorbed into the systemic circulation. Vaginally administered estrogens in small, topically applied doses can be well absorbed. Patients say that the tablets are also easy to use, less messy than cream preparations, and easier to insert than estrogen rings.
Side effects include possible blood clots, increased heart problems, an increase in breast cancer, and increased endometrial cancer if unopposed with a progestin. The long-term safety data on minimally absorbed local vaginal estrogen products used in cancer patients remain to be further studied. Talk with your clinician to analyze which one may be right for you. Women who suffer from atrophy should have an appropriate physical examination. Vaginal atrophy and dryness are relatively easy to diagnose by both a history and physical examination. Women complain of pain, irritation, and discomfort in the vulva and vagina and are fearful of pelvic and digital examinations. After detailed questioning, women often relay additional sexual complaints such as painful intercourse, lowered libido, and increased urinary tract infections. On clinical physical examination, the vagina is dry, pale, frail, and lacks the normal ridges and folds, elasticity, and pliability of a healthy vagina. There is minimal lubrication, and the tissues are easily traumatized with pelvic examination. There can be petechiae, or small hemorrhages, on the lining.
What are the common estrogen creams?
Premarin Vaginal Cream (Pfizer) and Estrace Cream (Warner Chicott) contain estrogens that may be used for the vagina and vulvar tissues. They come in a tube and often have plastic applicators. Many women find these products especially soothing to the irritated pelvic area. They can be managed individually using more or less of the product, depending on your situation. The vulvar area, which is sensitive to estrogen levels, can become irritated when hormonal levels are lowered. Women find estrogen creams especially comforting because they can be applied to the external pelvic area as well. The usual dose is 0.5 g (marked on the applicator) daily for 1 or 2 weeks, and then it is gradually reduced to one half the initial doses for a similar period. A maintenance dose can be used one to three times a week. It may be used after restoration of the vaginal lining has been achieved. You can taper the medication over 3 to 6 months. Of course, if you experience any side effects, such as vaginal bleeding, while on the cream, speak with your healthcare provider. Newer, lower doses have also been shown to be effective. New recent published data showed good safety with minimal endometrial effects and low systemic absorption with a new lower dose of 0.5 gram two times a week. The FDA has granted approval of Premarin Vaginal Cream for the treatment of moderate to severe vaginal dyspareunia! An interesting new and exciting use for vaginal estrogen creams is in the field of sexual arousal and orgasms. Recently, the Journal of Sexual Medicine published a small case series of women who used estrogen cream applied to the clitoral tissue. These women experienced increased arousal and increased orgasmic intensity. Use cream in the clitoral region if you are suffering from clitoral atrophy or have changes in arousal or orgasm. The use of hormonal creams remains controversial in breast cancer patients and cancer patients are advised to discuss their medical condition with their managing oncological team. Some oncology health care providers have agreed that quality of life concerns and the impact of vaginal dryness can be devastating and have begun to cautiously prescribe local estrogen products to selected patients. Discuss your personal and individual situation with your provider today.
What are vaginal estradiol tablets and vaginal rings?
Intravaginal estrogens are applied to the vaginal tissues, and many products are minimally absorbed. Some sexual health providers prefer to prescribe minimally absorbed local 17Beta estradiol tablets (NovoNordisk Pharmaceuticals). Vaginally administered estrogens in small, topically applied doses can be well absorbed. Patients say that the tablets are also easy to use, sometimes less messy than cream preparations, and technically easier to insert than estrogen rings. Ultralow doses of vaginal tablets are expected on the market shortly-they allow for vaginal health with minimal systemic effects. Sometimes vaginal estradiol rings are prescribed for older women who complain of vaginal dryness and painful penetration. Not all vaginal estrogen rings are the same; they vary with respect to absorption into systemic circulation. Many women find them convenient because the rings are placed within the vaginal vault and are not changed for several months. The lower dose vaginal rings release 7.5 micrograms per day of estradiol;
this dose produces a steady state of serum (blood) levels of 6–8 pg/mL. This dose can treat local complaints of vaginal dryness but is not sufficient to treat hot flashes or other menopausal symptoms. According to the North American Menopause Society’s recent position statement concerning local vaginal estrogens, rings may change position during bowel movements, douching, and intercourse; however, there is no need to remove the ring during intercourse. In clinical experience, some women and men find rings uncomfortable. No data report on possible allergy to the silasitic plastic ring. Thickening of the endometrium or endometrial hyperplasia usually does not occur until levels surpass 19 pg/mL. The routine addition of a progestational agent is often not used or recommended. All estrogen products carry a black-box warning and may mention some of the risks or complications. Some of the rare side effects include possible blood clots, increased heart problems, an increase in breast cancer, and increased endometrial cancer if unopposed with a progestin.
Terms:
Epithelial cell – Any one of several cells arranged in one or more layers that form part of a covering or lining of a body surface.
Progestin – A synthetic form of progesterone often used in birth control pills and hormone therapy.
Petechiae – Small hemorrhages.
