October is Breast Cancer Awareness Month, a time when conversations about breast cancer, early detection, treatment, and survivorship become more visible. Yet one important aspect of life after breast cancer remains underdiscussed: sexual health.
Breast cancer treatment can affect vaginal health, sexual comfort, intimacy, and overall quality of life. Vaginal dryness, irritation, and pain during intercourse are common concerns, but patients may hesitate to bring them up. Some assume these symptoms are an unavoidable consequence of treatment, while others worry that treating them could interfere with their cancer care.
As a urogynecologist, I work with patients experiencing changes in vaginal and pelvic health, including those related to cancer treatment. There are options available to help manage these symptoms, and understanding the benefits and limitations of each can help patients make informed decisions about their care.
Why Does Vaginal Dryness Occur After Breast Cancer Treatment?
Vaginal dryness after breast cancer treatment is often related to lower estrogen levels. Chemotherapy, hormone therapy, and ovarian suppression can all contribute to hormonal changes that affect vaginal tissue, reducing natural lubrication and elasticity. This can lead to dryness, irritation, and discomfort during intercourse. These symptoms are common, but they do not have to be accepted as an inevitable part of survivorship.
First-Line Treatment: Non-Hormonal Options
The American College of Obstetricians and Gynecologists (ACOG) recommends non-hormonal treatments as the first-line approach for managing vaginal and urinary symptoms in patients with a history of estrogen-dependent cancer, including breast cancer. These options can help relieve symptoms without introducing estrogen and are often a good starting point.
Vaginal Moisturizers and Lubricants
Vaginal moisturizers containing hyaluronic acid can help relieve dryness by attracting and retaining moisture in vaginal tissues. They are available as vaginal gels or suppositories inserted with an applicator and are used regularly to maintain hydration and improve comfort.
Vaginal lubricants reduce friction and discomfort during sexual activity. Water-based and silicone-based options are available, and the best choice depends on individual preferences and symptoms. If discomfort persists, consult a clinician about additional treatments.
Radiofrequency and CO2 Vaginal Laser Treatments
ThermiVa
Radiofrequency (RF) treatments use controlled energy to heat tissue, with the goal of stimulating collagen remodeling and changes in local circulation. In my practice, I use ThermiVa, a noninvasive radiofrequency device that delivers controlled heat to vaginal and vulvar tissues through a specialized applicator. Depending on the treatment protocol, the applicator may be used internally, externally, or both. The intended effect is to stimulate tissue responses that may improve tissue quality and symptoms such as dryness or discomfort.
CO2 Vaginal Laser Treatments
Fractional carbon dioxide (CO2) vaginal laser treatments are another energy-based approach sometimes offered for vaginal dryness and discomfort. The laser delivers controlled energy to the tissue, creating a localized thermal response intended to stimulate tissue remodeling.
Vaginal Estrogen and the Latest Research
How Does Vaginal Estrogen Work?
For patients whose symptoms do not improve with nonhormonal treatments, low-dose vaginal estrogen may be an option to discuss with their urogynecologist. Vaginal estrogen helps restore estrogen activity in vaginal tissues, improving moisture, elasticity, and tissue health. Vaginal estrogen is available in several formulations, including tablets, creams, and rings. These options differ in their dosing schedules and methods of application.
In my practice, I often consider vaginal tablets as a starting option because they provide a standardized dose and a straightforward administration schedule. This can make dosing easier to control. Creams and rings may also be appropriate, depending on the patient's symptoms, preferences, and treatment needs.
Does Vaginal Estrogen Increase the Risk of Breast Cancer Recurrence?
A systematic review and meta-analysis published in the American Journal of Obstetrics and Gynecology examined eight observational studies and found that vaginal estrogen use was not associated with an increased risk of breast cancer recurrence or breast cancer-specific mortality. ACOG supports considering low-dose vaginal estrogen when nonhormonal treatments are insufficient, with decisions individualized to each patient's cancer history and treatment plan. Patients taking aromatase inhibitors should make this decision in consultation with their gynecologist and oncologist.
Sexual Health Is Part of Breast Cancer Survivorship
Patients should not feel that they have to choose between protecting their breast cancer outcomes and addressing their sexual health. These conversations should be part of comprehensive survivorship care, with decisions made collaboratively and with an understanding of each patient's medical history. Survivorship involves more than monitoring for recurrence and managing the long-term effects of treatment. It also includes the everyday aspects of health that influence comfort, relationships, and quality of life.
Frequently Asked Questions
1. What is the difference between vaginal moisturizers and vaginal estrogen?
Vaginal moisturizers help maintain moisture and relieve dryness and are generally used regularly. Vaginal estrogen is a prescription treatment that addresses the effects of low estrogen on vaginal tissue. Nonhormonal moisturizers are generally tried first in breast cancer survivors. If symptoms persist, low-dose vaginal estrogen may be considered after an individualized discussion with the appropriate healthcare professionals.
2. What is ThermiVa, and can it help with vaginal dryness?
ThermiVa is a non-surgical treatment that uses controlled radiofrequency energy to gently heat vaginal and vulvar tissue. This stimulates natural deposition of collagen and elastin, and ingrowth of new blood vessels. As a result, patients may experience improved lubrication and a decrease in the sensation of vaginal laxity. The treatment is painless, performed in-office, and requires no downtime.
3. When should I see a urogynecologist for sexual health concerns after breast cancer?
Consider seeing a urogynecologist if you experience persistent vaginal dryness, pain during sex, urinary urgency, recurrent urinary tract infections, or other pelvic health symptoms after breast cancer treatment. A urogynecologist can evaluate the underlying causes and discuss treatment options based on your symptoms, medical history, and cancer treatment plan. You do not need to wait until symptoms become severe to seek care. If symptoms are affecting your comfort, intimacy, or quality of life, a specialist can help you understand your options.
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