ACOG Supports Vaginal Estrogen in Breast Cancer Survivors

Veronica Hackethal, MD

February 23, 2016

The Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists (ACOG) has issued an opinion in support of vaginal estrogen in breast cancer survivors, published online February 22 and in the March issue of Obstetrics & Gynecology.

Although nonhormonal treatments remain first-line therapy for managing symptoms of low estrogen and vaginal atrophy during and after breast cancer treatment, the committee concluded that vaginal estrogen may be used in women with a past history of estrogen-sensitive breast cancer who do not respond to nonhormonal therapies.

The committee, which included Diana Nancy Contreras, MD, chair of ACOG's Subcommittee on Gynecologic Oncology, notes that current evidence does not show increased risk for cancer recurrence with the use of vaginal estrogen in women who are currently receiving treatment for breast cancer, or who have a past history of breast cancer.

As more women in the United States are surviving breast cancer, their treatment needs and quality-of-life issues have become a focus of interest. Systemic and vaginal estrogen can be used to relieve the symptoms of low estrogen and vaginal atrophy related to natural menopause and cancer therapies. Common symptoms include hot flashes, sexual dysfunction, and lower urinary tract infections. Safety concerns arise, however, about the use of vaginal estrogen in women who have had breast cancer, particularly hormone-sensitive breast cancer.

Vaginal estrogen usually has minimal systemic absorption and delivers lower doses of estrogen closer to normal menopausal levels, the committee found. Options include moisturizers, lubricants, and topical anesthetics. The ring and the tablet have the lowest rates of systemic absorption, whereas the cream delivers more variable doses of estrogen.

While acknowledging controversy about recurrence risk with the use of vaginal estrogen in women with breast cancer who are receiving aromatase inhibitors, the committee concludes that such women "may benefit" from short-term topical estrogen combined with tamoxifen, followed by a return to aromatase inhibitors. Current data indicate no increased risk for recurrence among women receiving tamoxifen, they write.

The committee also emphasizes an individualized approach and informed decision making, in which women can thoroughly weigh the risks and benefits of vaginal estrogen in coordination with an oncologist.

"When the decision is made to use vaginal estrogen, it should be prescribed at the lowest dose to affect vaginal symptoms and for a limited period until symptoms are improved," the committee concludes.

Obstet Gynecol. 2016;127:e93-e96. Full text


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