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.

If you find yourself always conscious of about your vagina, there is something wrong. Even if your gynecologist tells you everything looks normal. You are likely suffering from one of the conditions tat arise form altered vaginal microflora (AVMF).  All of the following vaginal symptoms, despite how varied they my seem, have the same underlying etiology meaning they all occur secondary to AVMF. The normal vaginal secretions change from constituents that provide a lactobacilli dominant to a non-lactobacilli dominant environment that contains numerous bad bacteria which cause problems such as discharge, odor, recurrent UTI or provide a culture media that supports recurrent bacteria or yeast infections. Also the secretions may change from its normal neutral, soothing effect to eliciting an irritative effect on the vestibule at the vaginal opening. This causes burning, rawness, stinging, pain, chafing, dryness, itching and or urinary frequency and urgency. The secondary effects are pain with intercourse, tight vaginal caliber, tearing of vaginal opening with intercourse, and shortening of vagina with the cervix or top of vagina being hit during deep thrusting with intercourse.  It seems odd that similar treatment would be effective in women with such varied vulvovaginal symptoms. The reason for this is that each woman responds differently to the same stimulus depending on the innate propensity of her individual vulvovaginal tissues. Also, to say the “same treatment approach” is not to say it’s the same treatment. To get you fixed you need a protocol that is individualized based on your particular hormone profile (HP) and the results of the VFA Test which determines the type and relative quantity of vaginal constituents present. FGI uses 36 different protocols. The hormone profiling is based on factors that affect the vaginal estrogen effect.

What are the Variables of Hormone Profiling (HP)?

This includes your age, proximity to menopause, factors that influence your endogenous estrogen production such as lifestyle stress, exercise and body weight, whether there is sexual arousal wetness and a q-tip assay for vaginal moisture on physical exam. These factors are used to individualize your treatment. The mainstay of your treatment is a unique blend of hormones. The vaginal mucosa does not respond if it senses too much or too little of the hormones. It took the experts at FGI over 10 years to figure out how to get the dosing just right. Of all the commercially available hormone preparations, none of them are suitable for treatment of these conditions. Using HP indicators, FGI experts have been able to consistently achieve  excellent results.

When the “good” bacteria in the vagina, the lactobacilli, counts are low, the other 30+ “bad” bacteria that are normally in the vagina at low concentrations proliferate and become the dominant strains. They take over. If a vaginal bacterial culture is done in this setting, it will grow out something like Beta strep, Enterococcus, E. coli, Klebsiella, Gardnerella Vaginalis or some other bacteria that can be normally found in the vagina. This simply reflects what specie of bacteria has become dominate in the vagina at that time. In does not usually represent an infection. If antibiotics are prescribed, only a transient response will likely occur. Sound familiar? The treatment that is really needed is to correct the underlying reason for the shift in altered vaginal micro-flora. Find out how at FGI.

At this point you may be asking yourself, if therapy directed to underlying altered vaginal micro-

flora is so superior for the spectrum of symptoms including chronic vaginal discharge, vaginal

odor, itching, and vaginal burning, stinging or rawness then why isn’t it widely utilized in the

United States?

The primary reason is that practitioners have relied on a century old technique for the analysis

of vaginal secretions known as “wet preps” and patterns of altered vaginal micro-flora have gone

totally unrecognized. The new technique of quantitative analysis of wet preparations was

published by Dr. Fowler in a peer reviewed medical journal for worldwide viewing in October of

2012. He had been using the technique it for years; few others worldwide do so. It takes a

physicians significant time, dedication, and investment in equipment to offer this level of

expertise for very little reimbursement based on the current diagnostic codes so there is little

incentive for physicians to make the overall investment. Consequently, this test will not likely

to be routinely offered in gynecologic practices for many years to come. FGI wishes to make this

advanced diagnostic technique and treatment available to all US women.