Vaginal estrogen is safe for breast cancer survivors suffering from such urogenital symptoms as vaginal atrophy, vasomotor symptoms, and lower urinary tract infections, and there is no evidence of increased risk of cancer recurrence with the treatment, according to a statement from the American College of Obstetricians and Gynecologists (ACOG).

However, the decision to use vaginal estrogen should be made in consultation with a woman's oncologist, and only if "first-line choices" for managing urogenital symptoms -- which should be nonhormonal products such as lubricants -- are ineffective for breast cancer patients, reported ACOG's Committee on Gynecologic Practice, writing in Obstetrics and Gynecology.

Sexual medicine specialist Lauren Streicher, MD, of Northwestern University, who was not involved with the statement, said that although the treatment clearly eases vaginal dryness, many physicians are reluctant to prescribe it for breast cancer patients. But she said the response is quite different when gynecologists are asked about it.

"In 2011, I surveyed board-certified gynecologists about decisions they make regarding their own health care and asked, 'If you had breast cancer and had vaginal atrophy, would you personally use vaginal estrogen?' Ninety-three percent of female gynecologists said they would," Streicher wrote in an email to MedPage Today. "ACOG's position statement that it is safe to prescribe vaginal estrogen to women with breast cancer is long overdue, supported by solid data and is in fact a recommendation that many clinicians are already solidly behind."



The committee cited several studies that showed no increase in recurrence in cancer for breast cancer survivors using vaginal estrogen cream, and that vaginal estrogen may be appropriate for women using tamoxifen. The group cautioned, though, that "concerns remain about recurrence risk in women ... who use aromatase inhibitors." For this group, the statement said, urogenital symptoms not responding to nonhormonal therapies may benefit from "short-term use of estrogen with tamoxifen to improve symptoms, followed by a return to normal aromatase inhibitor therapy."

"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," Diana Nancy Contreras, MD, chair, ACOG's Subcommittee on Gynecologic Oncology, said in a statement.

But there remains one major stumbling block to wider use of vaginal estrogen for breast cancer survivors: the current boxed warning on all estrogen products, including topical agents, indicating that increased risk of breast and endometrial cancer is a side effect.

"Even if a woman is given the go-ahead [to use vaginal estrogen], one look at the FDA black box warning is enough to dissuade all but the most motivated woman," said Streicher.

The North American Menopause Society (NAMS) recently presented evidence to the FDA in an effort to change the warning label. They argued that low-dose vaginal estrogen products, such as the type used to treat vulvar and vaginal atrophy, do not pose the same risk as higher doses of systemic hormone therapy.

The ACOG committee emphasized that decisions about treatment should include discussion of risks as well as benefits between a patient and her healthcare providers, so a patient can make an informed choice for herself. Vaginal estrogen should then be prescribed at the lowest dose and for a limited time, until symptoms improve.