Vulvovaginal Atrophy and Sexual Dysfunction in Postmenopause

Treatment of Vulvovaginal Atrophy-Related Sexual Dysfunction in Breast Cancer Patients

Sexual dysfunction after breast cancer diagnosis and treatment is common,^[76] with some reports suggesting that nearly all women have some sexual dysfunction after treatment of cancer.^{[76,77,78,79]} Surgical treatment of breast cancer in the form of oophorectomy, premature ovarian failure as a consequence of chemotherapy, or endocrine therapy results in estrogen deprivation and the onset of menopausal symptoms, which can impair well-being and negatively affect sexual function.^[80]

Breast cancer survivors have a high prevalence of severe symptoms because of the induction of a premature menopause with chemotherapy^[80] and the increased use of aromatase inhibitors (AIs) over tamoxifene in recent years, leading to profound estrogen deprivation.^[81,82] AIs have previously been shown to disrupt sexual function.^[76] Increasing use of AIs means that the number of women complaining of symptomatic atrophic vaginitis after breast cancer treatment is likely to increase.^[83] In the Arimidex, Tamoxifen, Alone or in Combination Trial, anastrozole (AI) users experienced significantly more vaginal dryness, diminished libido, and dyspareunia compared with tamoxifen users.^[84] With the greater incidence of vaginal atrophy in women taking AIs, a safe and effective nonestrogen therapy is necessary. A 2011 study investigated whether vaginal testosterone cream could safely treat vaginal atrophy in women with history of breast cancer on AIs. Twenty postmenopausal women with breast cancer treated with an AI with symptoms of vaginal atrophy were treated with testosterone cream applied to the vaginal epithelium daily for 28 days. Ten women received a dose of 300 μg and 10 received 150 μg. Estradiol levels, testosterone levels, symptoms of vaginal atrophy, and gynecologic examinations with vaginal pH and cytology were compared before and after therapy. A 4-week course of vaginal testosterone was associated with improvement of dyspareunia, vaginal dryness, and vaginal maturation index without increasing estradiol or testosterone levels.^[85] However, current data on testosterone use are limited, and future trials are warranted to confirm these findings.

Although systemic estrogens are avoided after estrogen receptor–positive breast cancer, vaginal estrogens are commonly used via an estradiol-releasing vaginal ring, estrogen-based vaginal creams, pessaries containing estriol, and a slow-release 17β-estradiol tablet. However, there are few data on either safety or efficacy.^[86,87] Small retrospective studies on women with breast cancer suggest that vaginal estrogens do not adversely affect the outcome.^[86] However, in a survey of 250 survivors of breast cancer, 78% of the participants would not consider estrogen therapy for the relief of menopausal symptoms because of the negative opinion of clinicians and the participant's reluctance to consider estrogen therapy.^[88] In a study involving 69 women with a history of breast cancer, participants were given either Vagifem (estradiol) tablet (n = 33) or Ovestin Cream (estriol; n = 36) for vaginal atrophy. Tamoxifen therapy was used in 48% of the participants alongside the topical vaginal estrogen. Topical estrogen use was not associated with an increased risk of recurrence.^[86] However, the number of participants was small in that study. A 2010 study aimed to evaluate the efficacy and safety of two low-dose vaginal estrogen treatments and of a nonhormonal vaginal moisturizer in postmenopausal breast cancer survivors with urogenital atrophy. Eighteen women receiving estriol cream 0.25 mg (n = 10) or estradiol tablets 12.5 μg (n = 8) twice a week for 12 weeks were evaluated and compared with eight women treated using polycarbophil-based moisturizer 2.5 g twice a week. Low-dose vaginal estrogen therapies at given doses were effective for relieving urogenital atrophy in survivors of breast cancer, whereas nonhormonal moisturizer only provided transient benefit.^[89] If the patient with a history of breast cancer does not want to use vaginal estrogen preparations, less effective vaginal moisturizers or lubricants may be preferred.^[28,89]

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