Atrophic vaginitis in breast cancer survivors

Breast cancer treated with chemotherapy and other treatments that affect the endocrine (hormone) system can in effect shut of oestrogen production as a protective measure, or as an unwanted side effect.

The result of zero oestrogen production and distribution to the vaginal and urinary tissues is atrophic vaginitis and in some women, vaginal stenosis (vaginal narrowing).

Atrophic vaginitis (now part of the Genitourinary Symptoms of Menopause (GSM)) occurs in almost 70 per cent of postmenopausal breast cancer survivors (compared to 50 per cent without breast cancer), and is a huge hurdle for women and their practitioners. It is often sidelined in appointments.

Treatments responsible for this include chemotherapy itself, and aromatase inhibitors and selective oestrogen receptor modulators. Aromatase is an enzyme in fat cells that converts testosterone to oestrogen; oestrogen receptors can be switched on and off to either accept an oestrogen molecule to exert its effect, or not.

Atrophic vaginitis symptoms

Atrophic vaginitis presents as a sore, dry, irritated vagina that may burn, itch, and produce discharge. Everyday movements – going to the toilet, clothing, sex – may become uncomfortable or painful.

The emotional impact of atrophic vaginitis

The lack of vaginal comfort and function can be very distressing, and while the breast cancer may be gone, the fallout of cancer treatments can leave a person with other serious problems to contend with. Breast cancer survival involves emotional and physical elements, along with having just been through breast cancer treatment – no mean feat.

Fear of penetration can become an issue, affecting relationships, and having a detrimental impact on those who want to remain sexually active.

Treatments for breast cancer survivors with atrophic vaginitis

Because breast cancer survivors are not able to take E1 and E2 oestrogen therapy, other options must be sought. It is easier now than ever before to find different solutions to this, with E3 oestrogen hormone therapy looking promising.

Increasing vaginal moisture is the key goal, along with reducing soreness, so other therapies include lifestyle modifications, testosterone/DHEA therapy, and pH gels.

Physical signs of atrophic vaginitis

The signs you may be able to see include a sparseness of pubic hair on the vulva, reduced thickness (fat) on the pubic bone (mons pubis) and labia majora (outer labia), smaller labia minora (inner labia), a retracted clitoris and the tell-tale lack of moisture. The normally wet surfaces will look pale, dry and shiny.

The pH may have shifted, favouring the less protective microorganisms, such as yeasts and pathogenic bacteria. This shift can result in yeast infections or other microbial imbalances like bacterial vaginosis (BV) that can cause discharges, odour, itchiness, rawness and soreness.

The vagina and oestrogen

When oestrogen is high, superficial cells are dominant, but once you strip the body of oestrogen, parabasal cells become predominant, with far fewer intermediate and superficial cells. (Read about vaginal epithelial cell types here.)

The Vaginal Maturity Index (VMI) is used at this point to determine the degree of atrophy, or shrinkage and debility, the vagina is suffering due to hormonal influences.

The changes that occur once oestrogen gets taken out of the picture include physiological and structural modifications to the genital and vaginal area, particularly in the mucosa where reduced gland activity in both the vagina and the cervix result in the characteristic dryness.

The changes lead to the degeneration of tissue, decreased blood flow, a loss of elasticity, fewer rugae (the carpet-ripples of the vaginal walls), and a thinning of all tissues. An increased (less acidic) pH combined with lowered levels of glycogen (food for protective bacteria), leave the vagina susceptible to infection and microbial overgrowths. The vagina shortens and narrows.

The changes in the vagina due to a lack of oestrogen are profound.

Enter stage left oestrogen deprivation

While few would argue that dying is better than having a worse-than-useless vagina, living with the results of breast cancer treatment can pose some quality-of-life conundrums.

Chemotherapy can set off ovarian failure (CIOF – chemotherapy-induced ovarian failure) by destroying follicles, with chemotherapy during the first year after diagnosis making this more likely.

Those who are close to menopause are also at increased risk of developing CIOF compared to their breast cancer-free compadres.

Endocrine therapy is applied to three-quarters of all breast cancer patients who are considered ‘oestrogen-receptor positive’. Endocrine treatment is very successful at suppressing circulating oestrogens, which starves the oestrogen-dependent cancer of power.

There are two types of endocrine therapy: aromatase inhibitors, often prescribed post menopause, and selective oestrogen receptor modulators (SERMs), with both setting of atrophic vaginitis or making a current problem worse. Low libido is also another unwanted side effect.

Aromatase inhibitors are better at blocking oestrogen than SERMs, and are quickly becoming the standard in both pre and post-menopause (combined with other ingredients for younger survivors to induce menopause). Unfortunately the increased efficacy means more atrophic vaginitis, but problematically it also means less compliance with medication.

Tamoxifen is the usual medication given in those with oestrogen-receptor positive tumours who are premenopausal. Tamoxifen works by binding oestrogen receptors so nothing gets in or out.

The slighter benefits to the vagina in this treatment is the sort-of oestrogenic effect on the vaginal cells, which increases vaginal moisture without having to have oestrogen present. Vaginal dryness from Tamoxifen is therefore far lower, sitting at about eight per cent.

Adjusting your lifestyle

There are a handful of things that directly impact on blood vessels, blood flow, vaginal pH and stress levels, and while they aren’t going to cure the atrophic vaginitis by themselves, they will promote juiciness. Implementing all of these adjuncts to whatever treatment you are on can help.

Keep in mind this isn’t going to cure your atrophic vaginitis, or reverse it, but it can help to moisten you up a bit more than you are.

Use it or lose it

• Smoking makes capillary refill harder for your blood vessels, and good blood flow is directly linked with vaginal moistness
• Regular sex, masturbating and being physically intimate increase vaginal blood flow and regulate pH.
• Vaginal penetration with well-lubricated vaginal dilators and fingers may help to gently stretch out tight vaginal walls.
• Stress related to penetration should be managed where possible – practice, relax, try again, get help, try something else. It’s worth it.

Things to avoid if you have atrophic vaginitis

• Douches, artificial soaps and deodorisers.
• Any products that are coloured, flavoured, textured.
• Clothes or toys that are made of synthetic materials.
• Poor quality, chemically-based laundry detergent or fabric softeners
• You can’t treat your new, more delicate vagina like you used to, so be gentle – rough play will inevitably cause damage that will need to heal (and it will be slow).

Vaginal moisturisers for a dry vagina

Vaginal moisturisers are designed to be just like vaginal secretions in as many ways as possible, and used on a regular basis, can be effective. Research shows that polycarbophil-based non-hormonal moisturisers are more effective than lube, and as effective as vaginal oestrogen creams as improving moisture levels, fluid volume, pH and elasticity in the vagina. They work by reducing dryness, itching and pain on penetration.

Many vaginal moisturisers contain bioadhesive polymers that transport up to 60 times their mass in water. These polymers binds to the vaginal cells, and release water and electrolytes which dilate the blood vessels, leading to greater hydration. The polymer is also mildly acidic, which keeps the pH of the vagina stable and acidic, though this effect (according to research) is not long-lasting.

There are many vaginal moisturisers on the market, including some excellent natural products, so shop around and find one that works well for you.

Lubricants for use with a dry, irritated vagina

Lube is short-acting, and while it smooths the tissues somewhat, it doesn’t have the same qualities as a vaginal moisturiser. Lube is usually applied during sex to reduce friction and possibilities of damage, but can be used to also reduce irritation from clothing. Water-based lubricants may not offer the required levels of comfort, so using a product that contains glycerin such as Astroglide or KY Extended might help more than say KY Jelly.

Silicone lubricant may last for a longer time than either water- or glycerine-based products, for example KY Liquibeads, or a variety of others on the market.

A good combination that seems to work well for many is to insert polycarbophil gel into the vagina from between four and seven days days per week, and use quite a lot of glycerine-based lube before and during sex.

Oestrogen-based therapy for breast cancer survivors

The safety of oestrogen creams intravaginally continues to be heavily debated, since the levels of oestrogen that are absorbed vary considerably between women and products. Since most oestrogen-dependent breast cancers are treated by removing the oestrogen fuel, it is concerning to even drop a small amount of oestrogen into the blood supply.

If this is a route that is taken, it is usually done with a three-month high-dose treatment period to heal the vaginal tissues completely, and then remain on the lowest possible maintenance dose ongoing after tapering down.

Scandinavian and Stockholm breast cancer research studies both closed early after a recurrence was found in cancers after taking an E1 product orally, with twice as many women in the HRT group developing cancers again for the Scandinavian group, but not the Stockholm group. It has been determined to not be worth the risk.

Vaginal hormone products

Gynoflor, containing 0.03mg of E3 (estriol) is being studied for a variety of issues, with one in particular being atrophic vaginitis in women who are still taking preventative medication for breast cancer.

See the studies for yourself (references at the bottom of the page) and if this applies to you, speak to your healthcare provider to see if it would be beneficial for you. Research is still developing, so safety and efficacy are still being determined for E3 (oestriol)^​1​.

Vaginal oestrogen still provides the best results of any solution available, and come in a variety of forms, from rings, to creams, to gels, to pessaries, to tablets.

Tests are regularly conducted on new and novel ways of delivering oestrogen to the local vaginal tissues without it being absorbed into the bloodstream, or for activating oestrogen receptors without triggering off the cancer cascade.

Testosterone therapy

Androgen receptors exist in the vagina and vulva, and the aromatase blockers stop testosterone being converted to oestrogen, offering some hope here. Testosterone does in fact cause proliferation of the endometrium. In studies, vaginal testosterone was applied to the inner labia, the vaginal entrance and the inside of the vagina for a month. The results showed that symptoms improved, and testosterone levels increased.

DHEA, a form of testosterone, was also studied. DHEA binds to oestrogen and androgen receptors in the vaginal tissues, with the treatment resulting in stronger vaginal layers all the way through to the muscle layer, and reversed vaginal atrophy without increasing blood levels of androgens. The only concern was that offering up testosterone and DHEA to be aromatised in fat cells, and converted to oestrogen, was risky.

Omega-3 fatty acids

Omega-3 and omega-6 fatty acids have been shown to have positive impact on the vaginal mucosa. My Vagina’s pessary, Fennelope, contains sea buckthorn oil, which is a rich source of omega-3 and omega-6 fatty acids, alongside fennel oil, which has a slightly oestrogenic effect on local tissue without impact on systemic oestrogen levels.

Olive Oil, Vaginal Exercise, and Moisturiser – OVERcome Study

A study looked at how to improve quality of life, sexual function and painful sex in breast cancer survivors, with significant improvements noted. The study found that ‘this novel intervention is acceptable to patients with demonstrated efficacy in improving dyspareunia and sexual function following breast cancer.’ Read more about this study. 

What to do with atrophic vaginitis?

Your choice of solution, while limited, is varied and ever-growing. If there’s one thing pharmcos know, is that people want their genitals to work no matter what, and they’ll pay handsomely for the privilege – breast cancer treatment is always evolving, and so are treatments for the side effects.

It’s really important to understand what you’re dealing with, and while it’s confusing and overwhelming at times, knowledge really is power. Keep abreast of the latest research projects, push your doctor to also be on top of it so they can offer you their medical advice, and try lots of different things. The problem isn’t going to disappear overnight, but it can be made bearable, and at best like nothing ever happened.

References^​2–11​

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Jessica Lloyd - Vulvovaginal Specialist Naturopathic Practitioner, BHSc(N)

Jessica is a degree-qualified naturopath (BHSc) specialising in vulvovaginal health and disease, based in Melbourne, Australia.

Jessica is the owner and lead naturopath of My Vagina, and is a member of the:

• International Society for the Study of Vulvovaginal Disease (ISSVD)
• International Society for the Study of Women's Sexual Health (ISSWSH)
• National Vulvodynia Association (NVA) Australia
• New Zealand Vulvovaginal Society (ANZVS)
• Australian Traditional Medicine Society (ATMS)