Vulvovaginal atrophy (VVA) is a common and underreported condition which is suffered by close to 50% of postmenopausal women and 23%-61% of breast cancer survivors. It is associated with decreased supply of oestrogen to the vulvovaginal tissue.
Vulvovaginal atrophy sufferers may experience:-
- Initially, lack of lubrication during sex.
- Eventually, persistent vaginal dryness.
- Itchiness, soreness, and a stinging pain in the vaginal and vulvar area, which, in turn, may further contribute to pain during sex.
- Vaginal spotting of blood, due to small tears in the vaginal skin surface.
- Thin yellow or grey watery discharge.
- Urgency, frequency, getting up during the night to pass urine, and urge incontinence.
- Recurrent urine infections.
Breast cancer treatment increases the prevalence of Vulvovaginal atrophy because:-
- Tamoxifen is an oestrogen antagonist or agonist, depending on the target organ and menopausal status.
In premenopausal women, tamoxifen may cause Vulvovaginal atrophy by acting as an oestrogen antagonist and blocking the naturally high levels of endogenous oestrogen.
In postmenopausal women, it acts as an oestrogen agonist on the urogenital tract.
- Aromatase inhibitors (AIs) In the ATAC (Arimidex, Tamoxifen, Alone or in Combination) study, designed to compare outcomes in postmenopausal breast cancer survivors taking tamoxifen, anastrozole (an AI), or a combination of both, Cella et al10 demonstrated that vaginal dryness was more common in the group taking anastrozole than in the group taking tamoxifen (18.5% vs 9.1%). Pain during sex was also more common in the anastrozole group (17.3% vs 8.1%)
- Chemotherapy can result in vaginal dryness and pain during sex.
- Chemotherapy-induced ovarian failure
- Gonadotropin-releasing hormone agonists or bilateral oophorectomy
Local oestrogen treatment for survivors of breast cancer remains controversial so symptoms may be very difficult to control.
So what can women who have had breast cancer do about Vulvovaginal atrophy?
Oestrogen containing treatments are not appropriate so first-line Vulvovaginal atrophy treatments available are:
- Vaginal moisturisers – water based. These need to be applied regularly and are available to buy over the counter at a pharmacy.
- Vaginal lubricants – water or silicone based. Lubricants can also be easily purchased over the counter at a pharmacy and are used during intercourse. They may need to be re-applied several times during sexual activity and silicone based products may lead to loss of erection in a male partner.
For a significant proportion of women suffering from Vulvovaginal atrophy, the above treatments alone or in combination do not give relief from their symptoms and/or the treatments are not felt to be acceptable.