The Cancer Journal, May/June 2022: Special edition on hormone therapy and breast cancer
Summary of ‘Individual Benefits and Risks of Intravaginal Estrogen and Systemic Testosterone in the Management of Women in the Menopause, With a Discussion of Any Associated Risks for Cancer Development’
Menopause specialist, Dr Sarah Ball summarises a recent Review Article in this month’s issue of The Cancer Journal.
The use of vaginal hormonal treatments should be less controversial – and therefore more commonplace – than systemic HRT when it comes to its use in women with a history of breast cancer. However, attitudes towards using local estrogen have also been affected by the negative perceptions after the release of the WHI study in 2002. This is why it is so important to include the topic of vaginal hormonal treatments in this special edition of The Cancer Journal.
Laing, Newson and Simon’s Review Article helps clarify the safety and effectiveness of using local estrogen treatments by detailing what the evidence shows about the different types of treatment applications and what is currently known about the level of estradiol absorption systemically.
When localised treatment is started there may be a small peak in absorption of estradiol, but this is transient and declines as the vaginal epithelium thickens approximately 2-4 weeks after treatment begins. Vaginal pessaries, cream and the estrogen ring all provide a low dose of estrogen (compared to systemic HRT) and evidence shows when ongoing vaginal estrogen is used it does not raise estradiol levels higher than a postmenopausal woman’s normal reference range. It is therefore reasonable to conclude that there are no associated risks with this form of treatment. In fact, a Women’s Health Initiative Observational Study in 2018 confirmed this (in over 45,000 women), with regard to risks of coronary heart disease, stroke, thromboembolism, colorectal cancer, endometrial cancer and invasive breast cancer. There were no increased risks for any of these conditions with the use of vaginal estrogen.
Although there is a paucity of studies for women with breast cancer and the use of vaginal estrogens, the evidence that is available does not show any increased risk of cancer recurrence when vaginal treatments are used, and they are endorsed by several organisations including the American College of Obstetricians and Gynaecologists.
For women who have had ER positive cancers of any type, the authors recommend that vaginal estrogen treatments can be considered after an informed decision-making process and non-hormonal options such as emollients, and vaginal lubricants and moisturisers have been tried.
Available evidence also suggests a positive safety profile with transdermal testosterone delivered in physiological concentrations.
This welcomed article clearly demonstrates that vaginal estrogen treatments can be confidently prescribed to women with a history of breast cancer (and other cancers) and women can be reassured that there are safe and effective treatments available for the painful and debilitating genitourinary symptoms that can arise.
Reference for this article in The Cancer Journal
Laing, Abbie J; Newson, Louise; Simon, James A. Individual Benefits and Risks of Intravaginal Estrogen and Systemic Testosterone in the Management of Women in the Menopause, With a Discussion of Any Associated Risks for Cancer Development, The Cancer Journal: 5/6 2022 – Volume 28 – Issue 3 – p 196-203 doi: 10.1097/PPO.0000000000000598