Managing the vaginal and urinary symptoms of menopause in breast cancer survivors

Chemotherapy and hormonal therapy can reduce estrogen levels, which often results in early menopause in breast cancer patients. As a result, this population is at special risk of developing the vaginal and urinary symptoms associated with menopause. Unfortunately, treating these symptoms in breast cancer patients poses unique challenges.

Estrogen helps regulate the female genital and urinary systems. When estrogen levels decline, as they do naturally during menopause, vaginal and urinary symptoms commonly arise. Sometimes called vaginal atrophy (or vulvovaginal atrophy), this collection of vaginal and urinary changes may more accurately be referred to as Genitourinary Syndrome of Menopause (GSM).

Breast cancer survivors are particularly susceptible to GSM thanks to their cancer treatments. In fact, women with cancer who are being treated with aromatase inhibitors (which severely deplete estrogen), have twice the risk of developing GSM compared to the general population (ref1).

The menopausal symptoms attributable to estrogen loss can significantly decrease quality of life. Unlike for post-menopausal women without cancer, best practices for treating menopause symptoms in breast cancer survivors have not yet been established, and unfortunately, managing the symptoms of cancer therapy-induced estrogen decline is an often overlooked area of cancer rehabilitation.

Vaginal and urinary symptoms arising from estrogen decline:

• Vaginal dryness, irritation
• Painful intercourse (dyspareunia)
• Urinary frequency, urgency and/or urge incontinence
• Recurring urinary tract infections
• Vulvar tissues may appear pale in colour

Why does estrogen decline create vaginal and urinary problems?

Decreased estrogen can lead to vaginal atrophy, the thinning, drying and inflammation of the vaginal wall, which can cause vaginal soreness, itching and painful intercourse. Pain in the vulva (the external genitalia) can in turn increase tension in the pelvic floor muscles which can further exacerbate pain. Hypertonicity (excess muscle tone) in these muscles combined with increased sensitivity in nerve endings can also trigger the urge to urinate, and can lead to incontinence.

Among its many functions, estrogen also supports immune system integrity in the bladder and urinary tract. It appears to be important in maintaining protective linings in these areas and help generate a robust immune response to infection.

Treatment for vaginal and urinary symptoms of menopause in breast cancer survivors:

1. Vaginal moisturizers and lubricants (non-hormonal). Lubricants and vaginal moisturizers can provide short-term benefit to reduce pain and discomfort, and should be considered a first-line treatment. As tissues can be sensitive, it is best to look for water based lubricants with no perfumes, colouring, spermicides, or flavours. Coconut oil is a natural form of lubricant that tends to be less irritating to sensitive, fragile tissues, however it may decrease the integrity of latex condoms.
2. Pelvic Floor Physiotherapy. Pelvic Floor Physiotherapy can be used to treat vulva/vaginal pain, painful intercourse, and urinary incontinence. This therapy typically involves: manual treatment for tender points in the first layer of the pelvic floor and related connective tissue, reverse kegels to release tension in pelvic floor muscles, methods to decrease central sensitization, and education on vulvar skin care to decrease irritation. Vaginal dilators may be beneficial for some individuals as part of a home program. 
3. Regular sexual activity. Sexual activity increases blood flow to the vagina and decreases vaginal dryness.
4. Local estrogen therapy: Vaginal estrogen supplements in the form of gels, creams, tablets, or an inserted ring. While local estrogen therapy appears effective for safely treating the vaginal and urinary symptoms of estrogen depletion post-menopause, hormonal therapy is contraindicated in breast cancer survivors. Insufficient clinical studies exist to adequately assess the safety of local estrogen therapy in this population, even at low doses. As such, it should be considered only for patients who do not benefit from non-hormonal approaches. For a detailed discussion of the risk posed by this treatment, see our post “Is local estrogen therapy safe for breast cancer survivors?” The risks and benefits of local estrogen therapy should be discussed in detail with your physician.  If you do choose to use local estrogen therapy, it should be noted that all FDA estrodiol creams contain PEG or PGs that may cause a burning sensation to sensitive tissues, and often contain dyes that may be irritating. Compounding pharmacies can make topical creams without PEG and PGs.
5. Other tools: couple counseling, topical lidocaine, and vaginal dilators may be beneficial in certain circumstances.

References:

1. Chollet JA. Update on alternative therapies for vulvovaginal atrophy. Patient Prefer Adherence. 2011; 5:533-6.