The Journal of Obstetrics and Gynecology published a study in September 2023 that investigated whether treating with vaginal estrogen for vulvovaginal symptoms of menopause posed a safety risk to breast cancer survivors, particularly the risk of breast cancer recurrence. The conclusion, that they found NO increase in risk and therefore the use of vaginal estrogen appears to be safe in breast cancer survivors, regardless of whether they had estrogen receptor positive (ER+) versus estrogen receptor negative (ER-) breast cancer.1

In the United States, breast cancer is the #2 cancer affecting women and will likely affect 1 in 8 women within their lifetime.2 Of women diagnosed and treated systemically for breast cancer, an estimated 70% of them will develop vulvovaginal symptoms of menopause which presents with symptoms such as genital dryness/burning/irritation, lack of vaginal lubrication, pain with intercourse, urinary urgency, pain with urination, and recurrent urinary tract infections.3 The root cause of these symptoms is the lack of estrogen. Up until present day, the use of Vaginal Estrogen for treatment of vulvovaginal symptoms has been contraindicated in women with a history of breast cancer. Many physicians believe it to be a major contraindication, and so this treatment has been uncommon in this patient population. Only an estimated 5 in 100 women with a history of breast cancer were treated with vaginal estrogen for vulvovaginal symptoms of menopause, and 4 in 100 women who had a history of ER+ breast cancer were treated.

The findings of this recent study is good news for patients with a history of breast cancer. Both women and their healthcare providers can feel more confident when deciding whether the benefits of treatment with vaginal estrogen outweigh the overall risks. The quality of the study is more good news for healthcare providers, because 1) the study looked at a substantial patient group of more than 42,000 breast cancer survivors and 2) the study followed these women for up to 5 years.

While this study is robust and encouraging, there was likely variability in what was considered treatment with vaginal estrogen and dosages/formulations varied. At Fowler Gyn International, treatment for chronic vulvovaginal conditions associated with altered vaginal microflora may use doses of vaginal estrogen that are higher than the doses commonly prescribed by gynecologists. If you are one of the many proud breast cancer survivors and still fear the use of any estrogen supplementation, the FGI Approach also offers effective non-estrogen treatment for vulvovaginal conditions. Inquire here thru Talk-to-Doc!

References:
1. Agrawal P, Singh SM, Able C, Dumas K, Kohn J, Kohn TP, Clifton M. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023 Sep 1;142(3):660-668. doi: 10.1097/AOG.0000000000005294. Epub 2023 Aug 3. PMID: 37535961.
2. American Cancer Society: information posted on their website.
3. Kim HK, Kang SY, Chung YJ, Kim JH, Kim MR. The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 2015 Aug;21(2):65-71. doi: 10.6118/jmm.2015.21.2.65. Epub 2015 Aug 28. PMID: 26357643; PMCID: PMC4561742.

Rate of Squamous Cell Turnover: The vaginal epithelium is in a constant state of turn-over or shedding. The full layer turns over in about 30 days from the basal layer to the top layer. The fully maturated cells on top are being exfoliated into the vagina where they provide nutrition for the microflora. This is how the vaginal ecosystem works. The cells and fluids in the vagina provide the nutrients for the lactobacilli. Then lactobacilli secrete substances that suppress the 30+ bad bacteria in the vagina to a degree where they cause no harm. With the lack of sufficient nutrients, the concentration of fully maturated squamous cells will be too low. Also, certain inflammatory conditions in the vagina will cause the epithelium to turn over faster resulting in a higher proportion of Basal, Parabasal and Intermediate Cells. Once this process has been going on for some time, then there are fewer cells that are fully maturated and being exfoliated into vaginal secretions. These are patterns of vaginal constituents that are detected as part of the Vaginal Fluid Analysis (VFA Test).

Tissue Response to AVMF: In women who have developed AVMF patterns, the vaginal secretions can be irritative rather than neutral to surrounding tissues. These secretions do not tend to bother the upper two-thirds of the vagina on account of the relative low innervation or concentration of nerve endings found there. It’s the lower third of the vagina and particularly the vestibule where the epithelium often gets sensitized resulting in variable degrees of burning and itching depending on the woman’s innate tissue propensities. In other women, the AVMF also can cause discharge and or odor without genitalia symptoms.

The Vestibule: Is an area approximately 1-1.5cm wide encircling the opening of the vagina beginning just inside the labia minora or inner lips and extending up to to the level of the hymenal ring. The vestibule is made of endodermal embryologic origin which is wedged in between ectodermal epithelium. It is the vestibule that has the propensity of getting adversely stimulated by aberrant vaginal secretions. On the inside of the labia minora or small lip there is an invisible line to the human eye, known as the vestibular line of Hart, which demarcates the beginning of the vestibule being derived of endodermal or urogenital sinus origin.  (Kurman RJ, Ronnett BM, Sherman ME, Wilkinson EJ. Anatomy of the lower genital tract. Vol 4 Silver Springs: Armed Forces Institute of Pathology; 2010. This line can be demarcated by applying an iodine based Monsel’s solution. It stains the endoderm but not the ectoderm. Symptoms of burning and itching arise from the endoderm. Odor and discharge arise from the direct effect of the AVMF itself.

Hart’s line is visible over a portion of lower left vestibule.

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