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SHARI GOLDFARB
and friction with vaginal and anal intercourse and improve
the sensation of dryness, but are shorter-acting and tend to
dry quickly. Silicone-based lubricants tend to work better
than water-based lubricants for anal intercourse because they
are longer lasting and give a lusher feel. However, they can
not be used with silicone vibrators, dilators, or other silicone
toys. Both water- and silicone-based lubricants are safe to use
with latex condoms, but oil-based lubricants may render latex
condoms ineffective. Oil-based lubricants such as olive oil
and vegetable oil tend to be the lubricant of choice for oral
sex, but can increase risk of vaginal infections. Parabens and
glycerines in lubricants can cause contact dermatitis, skin irritation,
or a burning sensation. There are hundreds of lubricants
available and each woman can chose the one that works
best for her. Lubricants can also be used in combination with
moisturizers.
Moisturizers
For postmenopausal women taking an AI with subphysiologic
levels of estrogen, chronic vaginal dryness (e.g., genitals
feel dry, irritated, pruritic, and/or painful during
intercourse, gynecologic exams, and even with walking or sitting)
is common and lubricants are often not enough to treat
it. 33 Nonhormonal moisturizers are a safe treatment for vaginal
dryness and atrophy in both pre- and postmenopausal
women with breast cancer. 34-36 Intravaginal moisturizers
(gels, creams, suppositories, or ovules) should be used every
two to three nights to hydrate the vulvo-vaginal tissues,
achieve optimal absorption, and minimize leakage. They also
improve vaginal pH, dryness, elasticity, irritation, discomfort,
and pruritus and are not solely used for sexual contact.
33,37 Regular treatment for 8 to 12 weeks is needed to see
maximum benefıt. The most commonly used moisturizer in
the United States and Canada is Replens.
Replens is a polycarbophil-based gel that binds to the vaginal
epithelium and delivers water and electrolytes to the
underlying cells. 37 It normalizes vaginal pH, improves morphology
of epithelial cells in vaginal smears, and alleviates
vaginal symptoms. 37,38 Patients should be educated about the
differences between lubricants and moisturizers to ensure
proper usage of both types of treatment. In women with hormone
receptor–positive breast cancer receiving endocrine
therapy, there is currently limited information regarding the
effıcacy of moisturizers and if benefıts can be maintained
over time. Several small clinical trials performed in postmenopausal
women with vaginal atrophy evaluated the effıcacy
of Replens, but did not follow patients long enough to
determine effectiveness over time. 34,37 Clinical trial results
with Replens are variable. Two small studies in postmenopausal
women showed an improvement in vaginal discomfort,
pruritus, and dyspareunia equivalent to the relief seen
with intravaginal estrogen creams. 34,39 Two other small
double-blind studies (one in women with breast cancer) did
not show better effıcacy with Replens compared with lubricants.
40,41 Replens has also been used as part of a multifaceted
intervention to alleviate menopausal symptoms in women
with breast cancer, but the independent effect of Replens was
not analyzed. 42
Hyaluronic Acid
Hyaluronic acid is the main component of other moisturizers
such as Hyalogyn and Hyalofemme. It is a high molecular
weight glycosaminoglycan that moisturizes the vaginal epithelium
by retaining high amounts of water and creating an
extracellular water fılm with swelling. 43,44 By delivering water
and electrolytes into underlying cells, hyaluronic acid improves
epithelial elasticity and hydration. 45 In a group of
postmenopausal women without cancer, an intravaginal gel
containing hyaluronic acid was compared with vaginal 17-
estradiol tablets. Both treatments demonstrated an improvement
in vaginal pH and atrophy with relief of vaginal symptoms.
Two small pilot studies suggest possible benefıts of
hyaluronic acid in women with endometrial or breast cancer.
45 Further research on the effıcacy of hyaluronic acid in
the breast cancer population is needed.
Ospemifene
Ospemifene, a SERM with tissue-selective effects, was FDA
approved on February 26, 2013 for the treatment of dyspareunia
in postmenopausal women. Two phase III clinical trials
showed that the effıcacy of ospemifene was substantially
greater than placebo in terms of improving dyspareunia, vaginal
pH, and increasing superfıcial cells. 46,47 The most frequently
reported treatment-related adverse event was hot
flashes, which were reported in 6.6% of study participants in
the ospemifene cohort compared with 3.6% in the placebo
treatment group. Ospemifene can also increase the risk of endometrial
cancer and blood clots, including deep vein thrombosis,
pulmonary emboli, and cerebrovascular events. The
effect of ospemifene on breast tissue has never been studied
clinically and until it is evaluated, it should not be given to
women with a history of breast cancer.
Dilators
AIs can cause marked alteration of the vulvar and vaginal
anatomy causing vaginal stenosis from loss of rugae, which
transforms the vaginal canal into a smooth, inflexible tube.
Stenosis causes the vagina to feel stretched, painful, or taut
during vaginal penetration. Vaginal stenosis is best treated
with a multimodal approach using dilators, moisturizers, lubricants,
pelvic floor physical therapy, and patient education.
Dilators are available in sets of increasing size and are used
for a gradual stretching process starting with the smallest dilator.
They alleviate anxiety and improve a woman’s confıdence
that something can comfortably be placed into the
vagina without discomfort. 33 Dilators are essential for maintaining
vaginal health if a patient is not sexually active or
lacks a partner, treating vaginal pain, and improving tolerability
of pelvic examinations. 33 Compliance with dilators is
poor, but women are more likely to be compliant if they believe
dilators will make their pelvic exams more comfortable
48 or if they are using vaginal health promotion strategies,
such as lubricants (p 0.029) or vaginal moisturizers (p
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