The distress of Vaginal Atrophy

When you are dealing with the diagnosis of breast cancer and the stress of surgery, radiation and chemotherapy, sex is usually the last thing on your mind. But after the physical scars have healed and your hair has grown back, it can be very upsetting to find that what was once satisfying and enjoyable, is now intolerable and painful.

Chemotherapy and drugs like Tamoxifen, Femara and Zoladex reduce blood levels and estrogen circulation. Whilst this is a necessary benefit to reduce cancer recurrence, over time, the effect on the vagina, bladder and overall sexual health can be problematic.

Without estrogen, the vaginal lining undergoes a process called “atrophy”. This is when it loses its natural folds, elasticity, the ability to lubricate with intercourse and thins down making it easily traumatised. The acidic PH of the vagina also changes, increasing susceptibility to infections and odours. Dryness and painful intercourse is often the result. Altered vaginal sensation, decrease in sexual desire (libido), poor arousal and orgasm are further alterations that can impair sexual satisfaction.

In addition, the health of the urinary tract (bladder) is strongly interrelated with what happens in the vagina when estrogen levels are low. Symptoms such as painful urination, incontinence (urine leakage) and bladder infections particularly after sex, are also common problems.

All these problems are progressive and get worse as time goes by without intervention.

So what can be done and in the case of a breast cancer survivor, what can be done safely without increasing cancer recurrence risks?

One of the main ways to tackle the problem of vaginal atrophy is to understand why it occurs. Knowledge is power! Having an understanding and patient partner certainly helps too.

Having an understanding and patient partner certainly helps too.
Non hormonal alternatives

These products are safe and easy to buy over the counter.They will not increase cancer risk.

Vaginal lubricants 

While these work for some women, for most women they don’t bring enough relief. Astroglide and K-Y jelly are popular choices. Sometimes the lubricants themselves cause burning and itching. It is recommended that you test a small amount on the vaginal area before intercourse. Remember that Vaseline is not the best choice and can break down the latex in condoms.

Vaginal moisturisers

Replens is widely available in South Africa. This comes in a prefilled syringe and gets inserted into the vagina two or three times a week. It works because it is bio-adhesive, meaning the product attaches to the cells on the vaginal wall and attracts and retains water. It removes that feeling of extreme dryness either during intercourse or experienced even when not engaging in sexual activity. These products have proven to be more effective than lubricants alone.

Local hormone alternatives

The following products fall into this category:

Vagifem – Vaginal tablets inserted twice weekly.

Synapse – Cream inserted vaginally twice weekly.

Premarin – Cream inserted vaginally twice weekly.

Estring – A ring that is inserted into the upper third of the vagina and worn continuously for three months before needing to be replaced.

Studies have shown that estrogen preparations, when used in the vagina, are the most effective in combating the problems of atrophy. Unlike hormone replacement therapy taken orally, local estrogen avoids most adverse events related to oral usage and is more effective for vaginal or bladder problems.

The vaginal ring and tablets cause less discharge compared to creams which may be preferable to some women. However, when therapy is needed for sexual dysfunction, the added lubrication provided by the creams may be beneficial.

Estrogen is readily absorbed through the vaginal wall and in the beginning of treatment more is absorbed into the circulation. As the condition of the vagina starts improving as a result of therapy, absorption will decrease and less estrogen will be necessary to prevent recurring atrophy.

Estrogen, entering the circulation, even in small amounts can be worrisome especially in patients with hormone sensitive breast cancers. The risk of recurrence is always a concern. Remember that treatment is aimed at opposing the effect of any and all estrogen present in the circulation.

In these patients, caution needs to be exercised! Any decision to use local estrogen needs to be discussed carefully with the gynaecologist and oncologist. Despite this, it is not uncommon to find patients willing to take the risk of using local estrogen to improve the quality of their lives, especially patients who are still young and sexually active.

It is important to note that vaginal absorption will vary from one woman to another. Also, incorrect usage of estrogen (daily application as opposed to twice weekly application) will lead to higher blood levels.

Serious side effects are uncommon. Lesser serious problems include vaginal irritation or itchiness, vaginal discharge, vaginal bleeding, pelvic pain and breast tenderness.The occurrence of these sypmtoms vary according to the preparations used and it generally appears that the creams may be associated with more of these problems than the tablets, or the ring.


Dr Sumayya Ebrahim is a gynaecologist in private practice in Johannesburg. She is also a blogger. Check out her blog “vaginations by Dr E” on