Breast Cancer: Topical Estrogen Risky
Study Highlights Concerns for Some Breast Cancer Patients Who Use Topical Estrogen Products
Jan. 25, 2006 — Breast cancer patients taking drugs that block estrogen production should not use estrogen-based topical products to treat vaginal dryness and related problems, according to new research from the U.K.
Estrogen-based topical drugs were found to raise levels of the estrogen-hormone estradiol in patients taking aromatase inhibitors.
The findings were published today in the online issue of the journal Annals of Oncology.
Diagnosis Of Vaginal Atrophy
When serum estradiol level decreases below 73pmol/l postmenopausal patients candevelop a clinically relevant vaginal atrophy. An exact knowledge of the symptoms ofvaginal atrophy is necessary in order to make a rapid and targeted diagnosis. Thediagnosis of vaginal atrophy is generally made in the course of a gynaecologicalexamination. Here, attention should be paid first of all to dry vaginal mucousmembranes and possible petechial haemorrhages or, respectively, bleeding on contact.Patients often report on accompanying dyspareunia, itching and burning sensations.Furthermore, breakage of collagenous reinforcement fibres in the vaginal epitheliumcan lead to a loss of vaginal membranous folds, the so-called rugae of thevagina.
An increase of the vaginal pH value to a basic value > 5 can be an indication fora vaginal infection caused by reduced colonisation of the vagina by lactobacilli. Asummary of the clinical symptoms of vaginal atrophy is given in .
Table 1Symptoms of a vaginal atrophy .
|Symptoms of vaginal atrophy|
Due to the close embryological relationship of the female urinary bladder and urethrawith the vaginal system, they all have a high density of estrogen receptors. Thiscan lead to recurrent cystitis and prolapse complaints due to a postmenopausal ortherapy-induced decline of the serum estradiol level.
An algorithm for the clinical diagnosis of vaginal atrophy is presented in .
Table 2Algorithm for clinical diagnosis of vaginal atrophy.
Treatment Options For Vaginal And Urinary Menopause Symptoms In Breast Cancer Survivors
The vaginal and urinary symptoms of menopause can be addressed using a variety of approaches, albeit with varying degrees of success. These include vaginal moisturizers and lubricants, pelvic floor physiotherapy , and local estrogen therapy which may take the form of estriol, estradiol, promestriene, or conjugated equine estrogens. For a more comprehensive discussion of treatment options please see our post Managing the vaginal and urinary symptoms of menopause in breast cancer survivors.
Current health recommendations advise against local estrogen therapy for breast cancer survivors. So while breast cancer patients are at greater risk of developing vaginal and urinary symptoms of menopause, their recommended options for treatment are more limited.
Is this recommendation warranted?
A conservative approach to treating vaginal and urinary symptoms in menopausal women without breast cancer would begin with lower-risk therapies such as vaginal lubricants and pelvic floor physiotherapy, before graduating to local estrogen therapy. Could the same conservative approach be considered for breast cancer survivors?
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How Much Does Local Estrogen Therapy Reduce The Risk Of Breast Cancer Recurrence Compared To Systemic Hormone Therapy
Local estrogen therapy likely reduces the risk of breast cancer recurrence in breast cancer survivors considerably. But by how much is a difficult question to answer, for three reasons:
Topical Treatment Of Vaginal Dryness With A Non
Roles Conceptualization, Supervision, Writing review & editing
Affiliation Gynaecologicum, Kreuzlingen, Switzerland
Roles Conceptualization, Project administration, Validation, Visualization, Writing review & editing
Affiliation DR. AUGUST WOLFF GmbH & CO. KGARZNEIMITTEL, Bielefeld, Germany
Roles Conceptualization, Funding acquisition, Project administration, Validation, Writing review & editing
Affiliation DR. AUGUST WOLFF GmbH & CO. KGARZNEIMITTEL, Bielefeld, Germany
Roles Conceptualization, Funding acquisition, Supervision, Validation, Writing review & editing
Affiliation DR. AUGUST WOLFF GmbH & CO. KGARZNEIMITTEL, Bielefeld, Germany
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Womens Wellness: Vaginal Atrophy After Breast Cancer
Breast cancer and its treatments can cause many changes in your body. In addition to breast-related changes, you might also experience menstrual changes, hair loss or skin changes. In some cases, these changes can cause sexual challenges.
Vaginal atrophy, a thinning, drying and sometimes irritation of the lining of the vaginal walls, can be one of these challenges.
Vaginal atrophy is common as women age, but it can be worsened in women who’ve had breast cancer and are receiving endocrine treatments like tamoxifen or aromatase inhibitors.
Other situations that can result in vaginal atrophy include surgically induced menopause, and certain radiation therapies and chemotherapies.
Vaginal atrophy can make intercourse painful due to vaginal dryness or irritation and decreased lubrication. It can also lead to urinary symptoms like burning with urination, urinary urgency, incontinence and urinary tract infections.
Hot Flashes And Night Sweats
Women who go through early menopause or have temporary ovarian suppression due to breast cancer treatment may have hot flashes and night sweats. They may have worse symptoms than women who go through menopause at later ages.
Hot flashes can also be a side effect of hormone therapy.
Ways to relieve hot flashes in women whove had breast cancer are under study. These include :
Adapted from the North American Menopause Society .
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Presentation With Mike Riepl About Dhea Research
I also spoke with Mike Riepl, a pharmacist and researcher, about this research. We were together at a conference on Hormone Replacement Therapy in Las Vegas, sponsored by the Professional Education Services Group.
We had a brief opportunity to talk about the DHEA Bioadhesive vaginal gel in the noted study as having been found effective for women who have had breast and other gynecologic cancers for the treatment of atrophic vaginitis, vaginal dryness, low libido, and dyspareunia.
Specifically, the study looked at an alternative for estrogen preparations for the treatment ofatrophicvaginitis, vaginaldryness, lowlibido, anddyspareunia. In June of 2011, at the request of North Central Cancer Treatment Group , in collaboration with the National Cancer Institute and Mayo Clinic, the DHEA bioadhesive vaginal gel was developed by Gateway Pharmacy for the FDA-approved, Phase III clinical trial . The abstract was released from embargo in June 2014 at the ASCO meeting in Chicago and is currently in the peer review process for publication.
There are other studies in the works as well.
Ill continue to post new updates on this blog.
Diet Supplements And Plant
Theres little evidence that diet supplements or plant-based remedies reduce hot flashes or vaginal symptoms.
Randomized controlled trials of the following dietary supplements have found no benefit over a placebo for hot flashes or vaginal symptoms :
- Black cohosh
|For a summary of research studies on other supplements for menopausal symptoms, visit the Breast Cancer Research section.|
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Found A Couple More Options
Of course these are in addition to the spit suggestion. And that was Jenna Jamison that said spit was the best lube. However, it was said with the intent of…ahem…encouraging oral sex. LOL Where was I? Oh, Vagifem and Premarin were two others that have been mentioned to me. Creams that you apply 2-3 times per week. Small amount of absorbtion into the system. It’s arguable that it is not enough to cause any harm, plus, you can control the dosage. With estring it’s inserted for three months at a time.
Back to lube… I would have to say that it is important to use a silicone based lube. A lot of them are sugar based and end up sticky. There is a very popular one out there called “Pink”. It comes in a fancy glass pump bottle ,it is hypo-allergenic, you can also use it like a moisturizer, too, without fear of yeast infections.
www.goodvibes.com has it…and yes, they deliver in nice plain packaging
Dos And Donts For Estrogen
Breast cancer is not just one disease it comes in many variations.
One of the primary factors in determining the type of breast cancer is the sensitivity of the tumor cells to estrogen. If a breast tumor is hormone-sensitive or estrogen receptor-positive, it means there are specific estrogen receptors on the tumor cells, and when estrogen binds with these receptors, it transfers a message to the cancer cells. Like a lock and key effect, the breast tumor cells are stimulated by estrogen to grow and reproduce. Therefore, one of the main goals of therapy or intervention with hormone-positive cancer is to reduce hormonal stimulation as much as possible.
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Topical Oestrogen Therapy For Vaginal Atrophy
Topical ET is a widespread and common routine treatment option for patients withvaginal atrophy.
Several meta-analyses have shown that, independently of its application form, topicalET can improve the signs of vaginal atrophy and its symptoms ,. The use of topical ET, however,also makes possible the administration of lower estrogen dosages in comparison tosystemic HT. It has been shown that a low-dose topical ET has the same efficacy as asystemic administration . Thus, in cases with a soleindication for the treatment of vaginal atrophy, a topical vaginal ET should bepreferred to a systemic therapy. This is also reflected in the currentrecommendations of the German S3 guidelines as well as in a position paper of theNorth American Menopause Society ,,.
The efficacy of a fractionated estriol administration was already demonstrated in 48postmenopausal patients in 2005. Through the fractionated application of anestriol-containing vaginal cream there was a rapid and significant improvement ofthe atrophic vaginitis with a reduction of the pH value and an increase of the VMI.The fractionated administration consisted in the 1st week of 2 applications atintervals of 28 hours. In the weeks 24 the application interval amounted to 3 or,respectively, 4 days .In the daily routine the use of topical estriol in the form of a once dailyapplication for the first 34 treatment weeks followed by a maintenance therapy of23 applications per week has become established.
Vaginal Ring Or Testosterone Cream Could Reduce Sexual Dysfunction In Breast Cancer Patients
Despite showing benefit in 69 breast cancer patients, researchers say hormonal treatment for vaginal atrophy should only be used where non-hormonal therapy has failed until more evidence on safety is available
Use of a vaginal ring or intravaginal testosterone cream reduced vaginal dryness and sexual dysfunction in post-menopausal women with breast cancer receiving aromatase inhibitors without showing persistent elevation in estradiol levels, research has shown.
AIs are the preferred adjuvant therapy for post-menopausal women with hormone receptorpositive early-stage breast cancer, but sexual dysfunction is a common side effect, with up to half of women taking them reporting low libido and three quarters experiencing vaginal dryness. Aromatase inhibitors include drugs such as anastrazole and letrozole.
Vaginal oestrogens are an effective treatment for urogenital atrophy, but there are concerns about their safety in patients with breast cancer because of potential systemic absorption.
There are a number of non-hormonal treatments currently on the market for vaginal dryness including lubricants and moisturisers. Hormonal treatments are often a last resort when women have exhausted all other avenues, because they contain oestrogen. If non hormonal approaches are found to be unhelpful and quality of life is suffering, then options such as this and other hormonal treatments need to be considered by patients and their hospital teams, she says.
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Conjugated Estrogens Plus Bazedoxifene
The combination of conjugated estrogens and bazedoxifene is a progesterone-free alternative for treating various menopausal symptoms. Bazedoxifene is another estrogen receptor agonist/antagonist, and it was added to counteract estrogens effects on the endometrium, thus replacing progesterone. This protective effect has been validated in clinical trials, which also found a favorable safety profile in breast tissue.18,19
SMART trials. The efficacy of this combination was studied in a series of large phase 3 multicenter trials called the SMART trials.2023 Treated patients had markedly fewer vasomotor symptoms at 1 year, along with an increase in superficial cells and intermediate cells of the vaginal epithelium and a decrease in parabasal cells. They also had a substantial decrease in the incidence of dyspareunia.
Its effects on breast tissue were evaluated in the SMART-5 trial. Therapy had no net impact on breast density, suggesting that it has an estrogen-neutral effect on the breast.23
These results suggest that combined conjugated estrogens and bazedoxifene could be a noteworthy treatment option for GSM in women with a history of estrogen receptor-positive breast cancer, particularly in those with vasomotor symptoms and bone loss. However, the combination has not been studied specifically in breast cancer survivors.
Dosage. The FDA-approved dosing is 20 mg/0.45 mg per day orally to treat vasomotor symptoms, GSM, and osteoporosis in postmenopausal women with a uterus.
Androgens For Vaginal Atrophy
Beside the described estrogen receptors, vulva and vagina also possess androgenreceptors. On the basis of recent data it can be assumed that estrogen receptors areimportant in the regulation of the number of androgen receptors in vaginalepithelium. The receptor density correlates well with the VMI and is lower in casesof vaginal atrophy .
However, only very few data are available on vaginal testosterone treatment afterbreast cancer. In a small phase I/II trial, 21 postmenopausal breast cancer patientsunder AI therapy with symptomatic vaginal atrophy were treated with a topicaltestosterone ointment in various doses for 28 days. A significant improvement of theatrophy complaints in the absence of elevated estradiol or estrone serum levels wasobserved . Further results of prospective randomisedtrials on larger patient numbers are still lacking.
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Chemicals And Additives To Avoid
Many chemicals used in agriculture, body care products, food packaging and plastic water bottles are estrogenic, called xenoestrogens or estrogen mimics. In addition to binding with estrogen receptors, these toxins are fat soluble, so they tend to accumulate in fat cells. We know that breast tissue has a high concentration of fat, particularly after menopause. Studies have shown that breast milk often contains dangerous levels of these chemicals. Reduce exposure by avoiding plastic food and beverage containers, canned foods, and body products with these common chemicals. For a list of chemicals to avoid, visit the Environmental Working Group site.
Managing Menopausal Symptoms In Breast Cancer Survivors
With an estimated 5-year survival rate of 90%, most breast cancer cases have a very favorable prognosis.1 In developed countries, the 5-year survival rate for patients with localized disease is approximately 99%.2 It is not surprising then that approximately 6 million women worldwide live with a past breast cancer diagnosis and are focused on managing the long-term consequences of their treatment.3
Additionally, many women face menopausal symptoms or symptoms associated with estrogen deficiency during or on completion of breast cancer treatment.4 These include sleep disturbances, hot flashes, vulvovaginal atrophy, depressive symptoms, mood swings, bone loss, and cardiovascular disease. In certain women, menopausal symptoms after treatment are more severe than the symptoms of natural menopause in women who never had breast cancer.3,5
Complicating things further, many clinicians advise the discontinuation of hormone treatment in breast cancer survivors for fear of its mitogenic effects and the risk for triggering recurrent disease,4,6 which one trial estimated to be threefold in women receiving hormone replacement therapy.7
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Are Collagen Supplements Safe For Breast Cancer Survivors
My subscribers also get a treasure trove of info on nutrition, supplements and lifestyle tips on surviving breast cancer.
The Role of Collagen The ScienceCollagen is used to support and protect, so naturally tumors twist it to their advantage. Tumors are often full of fibroblasts, the major cell type responsible for producing collagen. These cells pump out huge amounts of collagen, swaddling little pockets of tumor cells, called tumor nests, in blankets of collagen that keep damaging agents away. These collagen-rich regions form a physical barrier around tumor cells that keep chemotherapeutics, immune cells, antibodies, and other therapies from reaching the cells to kill them. The particular shape and character of collagen in a tumor has even been linked to how easily the tumor grows and spreads.Tumour BiologyScience SignalingBreast Cancer ResearchThe Bottom Lineand your doctor agrees with that
Incidence Of Cancer Recurrence Very Low Adverse Outcomes Rare
With a median follow-up was 80 months, we found that the incidence of cancer recurrence was not increased in women with endometrial, cervical and ovarian cancers, says Laura Chambers, DO. Rates of recurrence for endometrial, ovarian and cervical cancer were 7.2%, 18.2% and 9.7%, respectively. Of the endometrial cancers that recurred, 2.4% were stage I/II and 4.7% were stage III/IV.
We also found that the rate of secondary adverse outcomes including development of breast cancer, other secondary cancer and blood clots were very rare. Regarding adverse events, four patients were diagnosed with venous thromboembolism, four with deep venous thrombosis and two had simultaneous pulmonary emboli. Incidence of strike was 1.2% and of myocardial infarction was 0.8%. Incidence of secondary diagnosis of breast cancer was 1.6%.
Dr. Chambers acknowledges that, because of the retrospective nature of the research, the study may be limited by selection bias. These women had no evidence of cancer at the time that vaginal estrogen was started, it is conceivable that they are a lower-risk population, she says. Provider bias may be another limitation, according to Dr. Chambers: Some physicians may have been more likely to prescribe estrogen to women they thought were low risk.
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