Q. I have stage IV breast cancer and take an Aromatase Inhibitor (Letrozole) as part of my treatment. I have severe vaginal dryness and atrophy, continuous UTIs and pain in the urogenital area. I recently read an article saying "Intrarosa 0.5% DHEA nightly vaginal suppository contains NO estrogen and is safe to use in women who have to avoid estrogen." None of my doctors agree that Intrarosa would be safe for me to use because of my ER/PR+ cancer. They claim that DHEA turns into estrogen, so I should not take it.
One gynecologist did suggest the possibility of me using Intrarosa (vaginal DHEA) when my regular gynecologist was out. What are your thoughts?
A. In women in menopause especially on “estrogen blockers” like aromatase inhibitors there can be marked symptoms, particularly the following:
- Vaginal symptoms such as dryness and pain with sexual intercourse
- Bone loss/osteoporosis
The good news is that there are options to treat breast cancer survivors and those being actively treated for breast cancer. The local treatments for these vaginal symptoms that are generally safe and effective. The North American Menopause Society has recently released new guidelines on treating genitourinary syndrome of menopause in women with breast cancer.
- Low-dose vaginal estrogen therapy (the lowest dose now available is 4mcg in the form of Imvexxy vaginal insert that contains a very low dose of estrogen with coconut oil) which does not increase blood levels of estrogen.
- NON-estrogen non-hormonal prescriptions, including intravaginal DHEA. DHEA is a vaginal treatment that is believed to act locally to improve symptoms without influencing systemic physiology. Oral DHEA does go through the liver and can increase estrogen levels, but low dose local VAGINAL DHEA does not. After menopause, DHEA from the adrenal glands becomes a major source of sex steroid hormones that plays a role in overall sexual function. However, women on aromatase inhibitors (AI) have suppressed levels and usually have marked vaginal symptoms.
A study published in November 2017 by Barton et. al that specifically looked at women diagnosed with breast or gynecological cancer who were either treated with tamoxifen or aromatase inhibitors (AI). The study showed that estrogen levels did NOT significantly increase in those on AIs with the use of VAGINAL DHEA 6.5 mg/day and 3.25 mg/day. It also showed improvement in maturation of vaginal tissue and also improved vaginal pH.
There are also so-called “vaginal rejuvenation treatment options” as well that still need to be further studied, including radiofrequency therapies involving vaginal mucosa with the CO2 laser Mona Lisa Touch. HOWEVER, the FDA has recently issued warnings about these laser therapies.
There are risks of NOT treating the genito-urinary syndrome of menopause which includes pain, urinary tract infections requiring antibiotics which have risks and real distressing personal and relationship issues.
All My Best,
Speaking of Women’s Health Nurse
September 1, 2018 at 6:00am