Dr. Lisa Jervis, MD, is part of The After Cancer's Care Team. She's board-certified in both Obstetrics/Gynecology and Integrative Medicine.
Vaginal Dryness (Genitourinary syndrome of menopause)
Vaginal dryness and discomfort are very common symptoms/concerns among many women of all ages. These symptoms are frequently due to hormonal changes that lead to lower estrogen levels—whether from natural menopause or cancer treatment-induced menopause. Decreased estrogen levels affect the cells and tissues in the genital tract in a way that thins out these linings making them drier, thinner, and more fragile which may cause bleeding and/or discomfort. Sometimes this process causes soreness and irritation which is not necessarily related to sexual activity. It can also cause an annoying vaginal discharge. Even if other symptoms of menopause go away at some point, the vaginal symptoms may persist throughout life. Although not everyone is affected by these symptoms, genitourinary syndrome of menopause remains the leading cause of problems related to sexual health among female cancer survivors.
Non-hormonal options
There are many options available for this which are available over the counter or online
Lubricants are recommended and used for sexual activity. They can range from natural oils (vegetable, coconut, or olive oil) to a wide variety of commercially produced options. Some of these contain additional ingredients to enhance sexual pleasure.
Vaginal moisturizing products are used on a more regular basis, usually 2 or more times per week depending on the product. These products work by providing a protective film or attracting more water into the vaginal tissue. This process can potentially help with lubrication and elasticity of the vaginal tissue, and it can lead to improvement of the pH of the environment. Examples of these products are things that are polycarbophil based (like "Replens") or contain hyaluronic acid (like Revaree/Hyalogyn) They are available over the counter but may be costly over time. Both types have been tested in scientific studies and have been proven to be effective for some people. There does not seem to be a strong advantage of one type over another.
Compounding pharmacies may be able to make non-hormonal vaginal suppositories containing ingredients such as Cocoa Butter, Vitamin E and Vitamin A. Ask your Oncologist or GYN about help with prescribing these if interested.
Hormonal options
Many patients with a history of cancer may be candidates for topically placed vaginal estrogens, even patients with breast cancer! This is something that would need to be discussed with your oncologist. The estrogen can be in the form of a vaginally placed ring, creams or tablets. Vaginal estrogen has NOT been shown to raise estrogen levels above the normal postmenopausal range*. Further, a meta-analysis published in 2019 demonstrated a lack of systemic absorption of estrogen during vaginal estrogen therapy**. In patients with Triple Negative breast cancers—this is very likely to be an effective and safe option. It may (or may not) be more complicated if there are Estrogen/Progesterone receptors positive in the cancer. A very large cohort study just published in Obstetrics & Gynecology in 2023 showed that vaginal estrogen therapy did not increase recurrence rates of breast cancer in survivors even with a history of estrogen receptor-positive cancer***. The exception in the study was a slight increased recurrence when patients were also on Aromatase Inhibitors (Femara, Arimidex).
Overall—the evidence is showing more and more that vaginal estrogens may be a safe and proven effective option for breast cancer survivors. Always have this discussion with your Oncologist and your Gynecologist.
There is also a vaginally inserted treatment called Intrarosa, which is actually DHEA (dehydroepiandrosterone). This gets converted into testosterone and estrogen within the vaginal cells. IntraRosa has been studied in patients with a history of breast cancer, and it has been very promising with regards to safety and effectiveness****.
LASER technology
Another option that has been available for the past decade, is more invasive and utilizes use of office based LASER technology. One of these is the “Mona Lisa Touch”. Some patients have great success with these procedures, although some do not. The procedure can be fairly costly and may not be covered by insurance. The procedure also usually needs to be repeated over time.
Remember all of this is highly individualized—but there is a lot of room for help and hope with regards to managing your symptoms.
Want some more personalized support?
Book a visit with a member of our Care Team
1* Laing AJ, Newson L, Simon JA. “Individual Benefits and Risks of Intravaginal Estrogen and Systemic Testosterone in the Management of Women in the Menopause, with a Discussion of any Associated Risks for Cancer Development” Cancer J 2022;28:196-203
2**Pavlovic’ RT, Jankovic’ SM, Milovanovic’ JR, Stefanovic’ S, Folic’ M, Milovanovic’ O. “The Safety of Local Hormonal Treatment for Vulvovaginal Atrophy in Women with Estrogen Receptor-Positive Breast Cancer who are on Adjuvant Aromatase Inhibitor Therapy, meta analysis” Clin Breast Cancer 2019; 19:e731-40
3***Agrawal P, Singh S, Able C, Dumas K, Kohn J, Kohn T, Clifton M. “Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer” Obstet Gynecol 2023; 142:660-8
4****Casiano Evans E, Hobson D, Aschkenazi S, et al “Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause” Obstet Gynecol 2023; 142:555-70