important menopause information
Treating vulvovaginal atrophy in postmenopausal breast cancer survivors: efficacy of the fractional carbon dioxide laser
Many women experience symptoms of vulvovaginal atrophy after the menopause transition.
The symptoms include vaginal dryness, painful intercourse, vaginal itching and burning, vaginal bleeding with intercourse, painful urination, and decreased sensitivity with intercourse. Women can be prone to more vaginal and urinary infections. The cause is lack of estrogen in the vaginal and vulvar tissues, which are very sensitive to estrogen. The result of lack of estrogen is decreased lubrication which comes from the blood vessels beneath the epithelium of the vaginal wall. There is also a decrease in the collagen and elastic fibers of the vaginal wall, which leads to decrease elasticity, and narrowing and shortening of the vagina.
In women being treated for breast cancer, chemotherapy can cause premature menopause and a decrease in estrogen levels. Anti-estrogen drugs such as tamoxifen and aromatase inhibitors also decrease estrogen levels. The vulvovaginal atrophy in breast cancer patients is often worse than in women who transition to menopause naturally. Quality of life is often severely impacted by inability to have a normal sexual relationship, as well as other bothersome symptoms. These symptoms can be so bothersome that some women might consider discontinuing anti-estrogen treatments early, which can affect survival.
Treatments for women who have not experienced breast cancer include lubricants, local and systemic hormone therapy. Vaginal testosterone and DHEA are metabolized in the body to estrogen, although the level is very low. Many women are concerned about any treatment that might increase the estrogen level in the body.
In women who have had breast cancer, the treatments include vaginal moisturizers, vaginal dilators, and pelvic floor physical therapy. Many women resort to non-penetrative sexual activity, and become resigned to not having intercourse again. In 2014, the fractional carbon dioxide laser was introduced in the US, and was approved by the FDA for the treatment of vaginal dryness and painful intercourse. In women who experienced natural menopause, studies demonstrated that the affect of the laser was to increase vascularity of the vaginal wall, which increased lubrication. It also increased collagen and elastic fibers, which restored the integrity of the vaginal wall. Data regarding the benefit to women who have experienced menopause because of breast cancer chemotherapy or hormonal treatments had not been studied in any large trials.
In the latest issue of Menopause, a study was published from the University of Naples in Italy.
The study looked at 82 women who were affected by breast cancer and vulvovaginal atrophy, made worse by chemotherapy or anti-estrogen treatments. Almost two-thirds of these patients were younger than age 50. All of the women studied had failed treatment with non-estrogenic lubricants or moisturizers.
Patients in the study were treated with the vaginal laser three times, 30-40 days apart. A number of symptoms were evaluated with each treatment, including pain, dryness, painful intercourse, vulvar itching, and reduced sensation.
The results of the study demonstrated that many of the symptoms (vaginal dryness, itching, vaginal sensitivity, bleeding, painful intercourse, and pain with penetration with the laser probe) were significantly improved, although not completely in many patients. It is possible that more than three cycles should be used in these patients. The study did not demonstrate any systemic adverse effects. Although patients do not experience pain with administration of the laser treatment, the initial discomfort with the insertion of the laser probe appears to improve with subsequent treatments. There was evidence that starting treatments before symptoms are more severe, produced a greater reduction in symptoms.
Further studies should look at whether additional treatments will benefit women who continue to have symptoms after the initial three treatments, and how long the benefits lasts. It is recommended that women have a touch-up yearly, but in this unique population, a different treatment schedule might be more effective. Stay tuned as more data is collected and reported.
Marilyn C. Jerome, MD
Fractional microablative CO2 laser in breast cancer survivors affected by iatrogenic vulvovaginal atrophy after failure of nonestorgenic local treatments: a retrospective study.
Pagano, et al. Menopause, alum 25, Number 6, June 2018