Intimacy And The Breast Cancer Survivor
Early detection and directed treatments have led to improved outcomes for women with breast cancer. Nonetheless, the gynecologic impact of these treatments is significant. In one study, 42% of breast cancer survivors experienced vaginal dryness, 38% reported that intercourse was painful, and 64% felt loss of libido. For many women, these changes affect her relationship with her partner directly, thereby increasing her risk of depression. Furthermore, medical treatment for depression can accelerate loss of sexual interest and further endanger the relationship. In one series, when 610 breast cancer survivors with normal sexual activity were given antidepressants, 57% experienced loss of libido.
For menopausal women without breast cancer, systemic or vaginal estrogens have been the treatment of choice for vaginal dryness and pain during intercourse. The dilemma facing the breast cancer survivor is that in‐vitro, animal, and human clinical studies document that long‐term estrogen exposure is linked to the development, progression, and recurrence of breast cancer. In fact, aromatase inhibitors and tamoxifen, which block estrogen, often are used prophylactically for five to ten years after immediate breast cancer treatment. Consistent with this anti‐estrogen approach, the medical community has been forced to adopt a “no hormone for you” stance for breast cancer survivors.
Efforts to evaluate the role of vaginal estrogen for breast cancer survivors have produced mixed results, but at least one small study has reported that vaginal estrogen in certain women can elevate circulating blood estrogen levels above that observed normally in menopause. Are there other approaches? Vaginal testosterone and DHEA creams have been tested clinically, and neither increases the circulating levels of estrogen above menopausal levels. The biologic benefits draw from the fact that the androgens applied to the vagina are not acting through an androgen receptor, but most likely are being converted to estrogens at the local tissue level. Nonetheless, monitoring estrogen blood levels is a critical part of this management. Neither, however, is FDA approved for this purpose currently.
Most patients using either of these androgen creams experience less vaginal dryness, a lower vaginal pH, and increased moisture. Water‐based gels are available if the vehicle used in the compounded androgen cream or gel generates local irritation. Many of these women again find intercourse less uncomfortable.
Survivors of breast cancer treatment have a very challenging journey, made more complicated by the fact that many of these treatments have an impact on the couple’s relationship. This new information about the use of androgens for treating vaginal dryness and pain on intercourse for breast cancer survivors does not address all of the symptoms of treatment‐induced menopause, but it provides some local solutions to vaginal dryness and pain.
By James Woods, M.D., and Elizabeth Warner, M.D.
Dr. Woods treats patients for menopause at the Hess/Woods Gynecology Practice.
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James Woods |