Why Is This Study Important
After cancer treatments, some women experience survivorship issues such as vaginal dryness or soreness, painful sex, and urinary tract problems. Products containing estrogen are sometimes used to treat these symptoms in menopausal women. However, there is some concern that estrogen products might be unsafe for women with a history of certain breast cancers that are sensitive to estrogen . Vaginal estrogen has been shown to relieve symptoms while delivering a lower dose of estrogen.
Reducing The Cancer Risks Of Hormone Therapy
If you and your doctor decide that MHT is the best way to treat symptoms or problems caused by menopause, keep in mind that it is medicine and like any other medicine its best to use it at the lowest dose needed for as short a time as possible. And just as you would if you were taking another type of medicine, you need to see your doctor regularly. Your doctor can see how well the treatment is working, monitor you for side effects, and let you know what other treatments are available for your symptoms.
All women should report any vaginal bleeding that happens after menopause to their doctors right away it may be a symptom of endometrial cancer. A woman who takes EPT does not have a higher risk of endometrial cancer, but she can still get it.
Women using vaginal cream, rings, or tablets containing only estrogen should talk to their doctors about follow-up and the possible need for progestin treatment.
For women who have had a hysterectomy , a progestin does not need to be a part of hormone therapy because theres no risk of endometrial cancer. Adding a progestin does raise the risk of breast cancer, so ET is a better option for women without a uterus.
Women should follow the American Cancer Society guidelines for cancer early detection, especially those for breast cancer. These guidelines can be found in Breast Cancer Early Detection.
Minimize Exposure To Heavy Metals
Heavy metals including copper, cobalt, arsenic, cadmium, mercury and lead have been found to stimulate estrogen receptors. Sources of arsenic include some brands of rice, seafood, well water cadmium is high in cigarettes and can be found in some soils mercury is mainly prevalent in larger fish and old dental amalgams and lead contamination is a component of air pollution, paint and dyes, and ceramic glazes among other sources.
Essentially, heavy metal and toxin exposure is hard to completely avoid in our world, even with careful choices. Because of this, I advise my patients to use compounds that provide safe, gentle detoxification of heavy metals and other contaminants, on a daily or periodic basis.
Modified citrus pectin, is derived from the pith of citrus fruit and has been shown in human studies to remove harmful heavy metals and reduce toxic body burden over time. MCP is able to cross the intestinal barrier and circulate in the bloodstream, where it binds to toxins and heavy metals and helps safely excrete them, without removing essential minerals. I also recommend ingredients such alpha-lipoic acid, N-acetyl cysteine, garlic, cilantro and other herbs and nutrients that provide support for our bodys complex detoxification systems.
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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.
Thanks For Your Candor
Thanks for your candor Marilynn. Some of us probably had the same issues but felt funny voicing them. It is natural for dryness to occur after menopause. I haven’t had any experiences with Estring but will ask my gyno at my next visit. Hugs, Lili
Ps: I’m not blushing. LOL
Probably not! I am thinking if I am ALONE in the woods, the advice would be moot, anyway!
Hugs, and thanks for the laughs!
But, you do have a point, Claudia!!!
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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 .
Chemotherapy Can Cause Fatigue
Your body is still trying to heal, and usually we underestimate how long it will taks to get back to normal after your body has been assaulted by surgery, radiation, and chemotherapy. Much of the fatigue while on chemotherapy and after is caused by anemia. This can be treated by transfusions or by erythropoietin , a drug that stimulates the bone marrow to produce more red blood cells. Several studies also have found that aerobic exercise can help decrease the fatigue.
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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.
Chemotherapy And Hormone Treatments Can Lead To Bone Loss
Premenopausal women whose chemotherapy and hormone treatments lead to premature menopause and postmenopausal women who use aromatase inhibitors may experience accelerated bone loss. Women who have had breast cancer should follow the general recommendation from the National Osteoporosis Foundation: first bone density test at 65 or at the end of therapy.
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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.
Surgery Will Result In Scarring And Other Changes To Your Breast
Scarring is an inevitable consequence of breast surgery. The appearance of the scar depends not only on the extent of the surgery but on your skin, your body type, the size of your breast, and the type of surgery you had. It can take more than a year for a mastectomy incision to heal completely. After a lumpectomy, your breast may look foreign and disturbing to you it may have a dent, look shrunken, or appear to be pulled to one side. There is nothing wrong with being concerned about how you look. Youve been through a very unpleasant and life-changing experience youre entitled to do what you can to make its aftermath as comfortable as possible. If you are troubled by your appearance months or years after surgery, talk to a plastic surgeon about all the possibilities and decide whats best for you.
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Questions To Ask Your Health Care Provider
- I have vaginal issues and urinary tract problems after breast cancer treatment. What treatments can I try?
- I stopped using vaginal estrogen when my symptoms subsided, but they have now returned. Is it safe to resume using vaginal estrogen?
- I am taking tamoxifen after having ER-positive breast cancer. Can I use vaginal estrogen to treat some of my symptoms?
- I am taking an aromatase inhibitor after being diagnosed with ER-positive breast cancer. Can I use vaginal estrogen to treat some of my symptoms?
- Can you refer me to a sexuality expert?
- Can you refer me to a menopause expert?
Breast Cancer Survivors: Estrogen Ok’d For This
New recommendation is aimed at women who are fighting or have survived a hormone-linked tumor
MONDAY, Feb. 22, 2016 — Women who’ve battled or survived an estrogen-dependent form of breast cancer often encounter vaginal symptoms linked to their treatment, especially around the time of menopause.
Now, new guidelines from the American College of Obstetricians and Gynecologists advise that the use of symptom-relieving estrogen therapy is warranted for these patients.
“These new recommendations are especially important and helpful because they provide the patient with the information needed to make an informed decision with the input of her health care provider,” Dr. Diana Nancy Contreras, chair of ACOG’s Subcommittee on Gynecologic Oncology, said in a college news release.
One expert in women’s health explained that patients with an estrogen-dependent breast cancer often suffer vaginal symptoms linked to treatment.
“Many estrogen-dependent breast cancer treatments may bring about and exacerbate vaginal atrophy,” said Dr. Jill Rabin, who’s with Women’s Health Programs-PCAP Services, Northwell Health, in New Hyde Park, N.Y.
“Vaginal and urologic symptoms range from mild to severe and can include vaginal dryness, pain, bleeding, bacterial infections and dyspareunia ,” she noted. “These symptoms — which may arise for many women in menopause — may be multiplied for these patients in treatment and can worsen over time.
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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.
Finding Relief For Vaginal Dryness
When you’ve had breast cancer, non-hormonal options are the first choice for managing vaginal atrophy. This is particularly true if you’ve had a hormone dependent cancer. These options include:
- Vaginal moisturizers. Over-the-counter products like K-Y Liquibeads, Replens and Sliquid Satin can be used to restore moisture to the vaginal walls. These are typically applied several times a week, usually at bedtime.
- Lubricants. These nonprescription products improve discomfort from intercourse by reducing friction.Organic water-based or silicone-based hypoallergenic lubricants like Yes, Jo and Sliquid are less likely to cause vaginal irritation than are products that contain oil. Avoid products containing Vaseline.
- Allowing time for arousal. The natural lubrication created from sexual arousal can help reduce symptoms.
- Vaginal DHEA . Talk to your cancer specialist about weighing the pros and cons of the different types of estrogen therapy.
Systemic hormone therapy generally isn’t recommended. And cancers that are hormonally sensitive may also limit the use of vaginal estrogen options. This is especially true for women using aromatase inhibitor therapy to reduce the risk of cancer recurrence.
If your symptoms are bothersome even after trying the above steps, ask your health care provider about other options that may help. He or she can help you weigh your individual risks and decide on a specific plan.
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Collateral Damage: Symptom And Side Effect Management
More women are now living for many years after breast cancer treatments. But when treatment ends, new problems can begin.
For most women the end of treatment is accompanied by lingering side effects, including problems resulting from treatment that can come up years later. This is why you should keep records of your treatment and have regular contact with a health practitioner who knows about delayed treatment effects.
All cancer treatments can cause some long-term side effects. Be aware that:
Chemotherapy Can Result In Decreased Cognitive Function
Many women who have had chemotherapy complain of chemo brain. The most common difficulties include paying attention, learning new things, and speedily processing information. While it is unknown known why or how this happens, a 2015 study suggests the cognitive problems may be linked to cytokines released by the cancer and not actually a direct result of chemotherapy. For someone who needs the treatment to survive, the cognitive impairment may be worth it, but in cases where chemotherapy offers only a miniscule survival improvement, it may not be.
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Conservative Treatment Of My Menopause Symptoms Isnt Working But Im Not Comfortable Taking Local Estrogen Therapy Is There Hope For New Treatments
This is an active area of research, and new developments are likely on the way. In addition to ultra-low dose local estrogen therapy formulations, a variety of new drugs are under investigation , the most promising of which may be ospemifene.
Ospemifene, known by the registered trade name Osphena is an estrogen receptor modulator similar in structure to tamoxifen . It was approved by the U.S. FDA in 2013 for the treatment of vaginal atrophy in postmenopausal women who are not candidates for local estrogen therapy. It is not yet available in Canada.
The manufacturers of Osphena include a cautionary statement in their packaging that states that patients with estrogen-dependent cancers should not take this drug. This warning speaks to a lack of clinical data rather than contraindicating evidence. The class of drugs ospemifene belongs to typically have neutral or anti-estrogenic effects on breast cells, and some very early mouse studies suggest that opemifene may actually act like tamoxifen to prevent breast cancer development .
Osphena has the potential to be a safe and effective treatment for vaginal atrophy in breast cancer survivors, but clinical data on its safety is still absent.
Radiation Can Cause Some Delayed Problems Including Muscle Soreness
Radiation can result in muscle soreness, especially in the pectoralis major muscle, which runs above and behind the breast. Radiation causes inflammation of the muscle, and as it begins to regenerate, it can get sore and stiff. Many women commonly mistake this pain as the cancer spreading, since the radiation has been over for months and theyre not expecting new side effects from it. Exercise, with the assistance of a physical therapist if needed, can help you to develop strength and flexibility, while massage often can help to reduce this muscle soreness.
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Using Vaginal Estrogen Not Linked To High Breast Cancer Risk
An analysis of data collected as part of the Womens Health Initiative trial has found that postmenopausal women who use vaginal estrogen have the same risk of invasive breast cancer, stroke, blood clots, endometrial cancer, and colorectal cancer as women who dont use vaginal estrogen.
The research was published online on Aug. 14, 2017 by the journal Menopause. Read the abstract of Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Womens Health Initiative Observational Study.
The research is part of the very large Womens Health Initiative Observational Study, commonly called the WHI. Overall, the study includes information from more than 161,608 postmenopausal women who were ages 50 to 79 when they joined from 1993 to 1998. The WHI wants to find any links between health, diet, and lifestyle factors and health problems such as cancer.
For this study, the researchers looked at information from 45,663 women who were ages 50 to 79. The women had not taken any type of hormone replacement therapy. Information about vaginal estrogen use was self-reported in the regular questionnaires sent out as part of the WHI. Information about the specific dose or type of vaginal estrogen — ring, cream, or tablet, for example — wasnt reported.
For women who still had their uterus and used vaginal estrogen, the risk of:
- blood clots