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The Elephant in the Room is Cancer. Tea is the Relief Conversation Provides.
The Elephant in the Room is Cancer. Tea is the Relief Conversation Provides.
Genito-What? Genitourinary Syndrome of Menopause Part III: When Over-The-Counter Options Aren’t Enough
Marloe’s article is featured in our March 2025 magazine issue. Click here to read “My Identity After Cancer.”
Disclaimer: This information is not a substitute for medical care. Always inform your healthcare team of any concerning symptoms you are experiencing, and consult with your provider before starting new treatments, therapies, or health routines.
Welcome to the last installment of our series all about genitourinary syndrome of menopause (GSM—the sneaky but significant side effect you’ve never heard of! Previously, in Part I, we reviewed that GSM is a collection of genital, sexual, and urinary side effects that can develop because of estrogen loss caused by certain cancer treatments. Part II looked at non-hormonal moisturizers and lubricants, two safe and effective treatment options that are often all that’s needed to keep symptoms at bay.
But for some people, GSM symptoms like genital and vaginal dryness, itching, discomfort, and pain with sexual activity can persist even when they’ve given these over-the-counter options a good run (at least 12 weeks of correct and consistent use). When these non-prescription options aren’t working, it’s time to explore what other treatments are available. Let’s review some of these alternatives so that you can start a conversation with your care team about what might be right for you. It is important to note that not all precautions or side effects for these treatments are mentioned here. Your provider can give you more detailed information on each.
Local Hormonal Treatments
Vaginal Estrogen
What it is: Low-dose vaginal estrogen applied to the vulvar and vaginal tissues is a very effective option for treating genital and vaginal dryness, itching, discomfort with sexual activity, and certain urinary symptoms caused by low levels of estrogen. These treatments are FDA-approved for use in postmenopausal women with no history of breast cancer.
How it works: Local vaginal estrogen comes as a cream, pill or tablet, or a ring that is inserted into the vagina. All of these forms work by delivering a low dose of estrogen to the vaginal tissues to improve symptoms. Adding estrogen back into the genital environment helps restore a healthy vaginal pH level, supports Lactobacilli (the “good” bacteria), and improves the thickness, elasticity, and moisture of the vaginal walls (remember our science lessons from Parts I and II?). An advantage to using creams is that they can also be applied to the outer genitals (vulva) to soothe and improve external symptoms. There is also less overall absorption of estrogen when preparations are used externally rather than inside the vagina.
Cancer cautions and controversies: When used at the lowest dose and frequency needed for symptom relief, local vaginal estrogen is a safe and recommended option for the treatment of GSM in postmenopausal women when non-hormonal options (moisturizers and lubricants) have failed to improve symptoms. Concerns about the use of local estrogen treatments are related to the potential for absorption of estrogen into the bloodstream. This concern is especially relevant to survivors with a history of estrogen-dependent cancers or those currently on antiestrogen therapy, where the goal is to keep estrogen levels in the blood as low as possible to prevent cancer from coming back.
While some systemic absorption does occur with the use of local vaginal estrogen, it is very small (especially with the use of rings or suppositories, in comparison to creams)8 and studies show that levels of estrogen in the blood do not rise above normal levels found in postmenopausal people who are not using vaginal estrogen. Available studies indicate that the use of local estrogen does not increase a person’s risk of overall breast cancer recurrence, although there may be some survivors for whom recurrence risk is slightly increased, such as those currently on aromatase inhibitors (AIs).
However, experts agree that under certain circumstances, local hormonal treatment options can be considered for people with a history of hormone-dependent cancer when non-hormonal options haven’t worked. The Menopause Society has outlined some factors to consider when deciding whether or not local hormonal treatment options are a reasonable next step for treating GSM; check out the side bar accompanying this article. It is always important to have an honest discussion with your healthcare provider about the risks and benefits of any treatment so that you can make informed choices about your healthcare.
Vaginal Androgens
DHEA
What it is: DHEA (dehydroepiandrosterone, sold as Prasterone daily vaginal inserts) is another FDA-approved topical hormonal choice for the treatment of vaginal dryness and pain with sexual activity in postmenopausal women.
How it works: It turns out that vulvovaginal tissues have estrogen and testosterone receptors, making both types of receptors possible targets for treating GSM symptoms. DHEA is a steroid hormone that converts to both testosterone and estrogen locally in the genital and vaginal tissues, which can then interact with these hormone receptors to exert their effects. DHEA has been studied in postmenopausal women and in cancer survivors and has been found to improve GSM symptoms as well as sexual desire, arousal, and overall sexual function.
Cancer cautions and controversies: There is limited research that has explored the risks and benefits of DHEA use in cancer survivors and people on endocrine therapy. Because DHEA is converted into estrogen and testosterone in the body, there is concern that this may increase cancer recurrence risk for individuals with hormone-dependent cancers. Still, DHEA may be an option for survivors, including those with estrogen-dependent cancers who are currently on an AI5 or tamoxifen, after careful consideration and consultation with their provider and if non-hormonal options have failed or if vaginal estrogen is not an option.
Testosterone
What it is: A cream containing the hormone testosterone that can be applied locally to the vulvar and vaginal tissues. Topical testosterone is currently not FDA-approved for the treatment of vaginal dryness or GSM symptoms. However, some providers may prescribe compounded vaginal testosterone preparations off-label for this purpose.
How it works: Local testosterone treatment may improve symptoms by directly interacting with testosterone receptors in genital tissues, and by converting into estrogen to interact with estrogen receptors.
Cancer cautions and controversies: Many of the concerns about the use of local estrogen and DHEA in people with hormone-dependent cancers also apply to the use of local testosterone in these populations, because of the ability of testosterone to convert to estrogen. Interestingly, this hormone conversion (a process called aromatization) can be blocked by aromatase inhibitors (AIs), medicines which are often used to treat estrogen-dependent breast cancers. In theory, people taking AIs should be able to use testosterone without concerns for increasing estrogen levels, and a few studies have found that local testosterone improves GSM symptoms in people currently on AI therapies. However, there is not enough evidence at this time to support the overall long-term safety of using testosterone to treat vaginal symptoms. And again, there are currently no FDA-approved testosterone preparations available for women.
Oral Prescription Treatments
Ospemifene
What it is: Ospemifene is an oral pill taken daily that is FDA-approved to treat vaginal dryness and pain with sexual activity after menopause. It is not approved for use in individuals with a history of breast cancer.
How it works: Although it is not an estrogen, the selective estrogen receptor modulator (SERM) ospemifene acts like estrogen at a cellular level by activating estrogen receptors in the vaginal tissues to treat vaginal dryness, irritation and itching, and pain with sexual activity.
Cancer cautions and controversies: There is limited evidence supporting the use of ospemifene in cancer populations, and more studies are needed to better understand the benefits and risks. Because ospemifene interacts with estrogen receptors, there is some concern about the safety of its use in people with a history of estrogen-dependent cancers. However, it does not appear to have an estrogenic effect on breast tissue and may possibly even protect against breast cancer. Notably, other SERMs (specifically tamoxifen) are used to treat and prevent breast cancer recurrence. All that said, caution in cancer survivors is recommended when considering this drug for the treatment of GSM.
Vaginal Energy-Based (Laser) Therapies
What it is: Vaginal energy-based therapies are localized non-hormonal, non-surgical treatments using laser technologies to treat symptoms associated with GSM, including vaginal dryness, irritation, discomfort, and pain with sexual activity. However, these laser therapies are not FDA-approved for this indication.
Types of laser treatments include fractional microablative carbon dioxide (CO2) laser therapy and non-ablative photothermal Erbium:YAG (erbium-doped yttrium aluminum garnet) laser therapy. Treatments are administered using a probe inserted into the vagina, and sometimes to the external genital tissues as well. Treatment regimens usually consist of up to three short treatment sessions about four to six weeks apart.
How it works: Laser therapies are thought to work by causing very small injuries that induce a healing process with increased collagen and elastin formation and improved blood flow, resulting in healthier vaginal tissues.
Cancer cautions and controversies: Available research looking at the effectiveness and safety of these treatments is promising but is not yet established, and more high-quality and long-term studies are needed to help determine the risks and benefits of using laser therapies for GSM symptoms. The FDA warns against possible harmful side effects, which may include vaginal burns and scarring, chronic pain or discomfort, the development of vaginal tears with sex, vaginal infections, reactivating genital herpes, and increased pain with sexual activity.
For survivors who cannot or do not wish to use hormonal treatments, vaginal laser therapies are seen as a possible non-hormonal alternative. Yet, treatments are not covered by insurance and can be very expensive. Plus, we don’t know yet if these therapies are any more effective at improving GSM symptoms than using a simple non-hormonal moisturizing regimen. Taking into consideration the huge price-tag for these treatments, along with uncertain long-term safety and effectiveness, laser therapies are currently not recommended for cancer survivors.
So . . . What Should I Do?
It’s quite possible that the information presented here leaves you with more questions than answers! That’s because our understanding of the safety and effectiveness of these treatments are only as good as the science that is available for us to interpret. Unfortunately, the high-quality and long-term research that experts need to be able to make evidence-based recommendations for the use of these treatments in cancer survivors often just doesn’t exist—yet! See the sidebar on contributing to our scientific understanding by participating in clinical trials.
This is one reason why your active participation in the decision-making process with your provider is so important. One of the criteria that needs to be considered when deciding how to manage your GSM symptoms is . . . you! This includes being honest with your provider about the severity of your symptoms and how much they impact your life. It’s never wrong to ask questions, seek clarity and understanding, or to advocate for yourself. Consider finding a menopause specialist near you, such as a certified practitioner through The Menopause Society, who should be well-versed in treating GSM symptoms. They can work with your oncology team to create a plan of care that will work for you!
To start the conversation, check out some previous articles in the Elephants and Tea archives for tips on communicating about sensitive and sexy issues with your cancer care provider and building a sexual wellness recovery team.
What Does the Science Say?
If you are interested in what the science says (or doesn’t say) about treating GSM in cancer survivors or you’d like more information on the clinical guidelines that medical professionals use to inform their recommendations for GSM symptom management, I would recommend digging into any or all of these trusted resources:
The American College of Obstetricians and Gynecologists (ACOG)
American Society of Clinical Oncology (ASCO)
The Menopause Society (previously the North American Menopause Society or NAMS):
The National Comprehensive Cancer Network (NCCN)
I Have Breast Cancer. Are Hormonal Treatment Options for GSM Out of the Question?
If you have been diagnosed with a hormone-dependent cancer like breast cancer, some of what you hear or read about the benefits and harmful effects of using hormones after cancer can be scary or confusing. Your provider can help you make sense of when hormone treatment options might be a reasonable choice for the treatment of your GSM symptoms. The Menopause Society has summarized factors that can be considered during this decision-making process:
Local hormone therapy to treat GSM may be a possibility for you if . . .
Local hormone therapy to treat GSM may not be an ideal option for you if . . .
Thankfully, medical experts recognize that not all people or situations are the same and that individualizing care is essential. Therefore, your unique circumstances and needs should always be a part of the conversation when you are discussing with your provider what treatment options might be best for you. If you are feeling dismissed or unheard by your care team, it might be time for a second opinion!
Study Me!
Quality research studies can help answer questions that we have about the effectiveness and safety of available treatment options for GSM symptoms in cancer survivors, including AYAs. Participating in a clinical research trial is one way to contribute to the scientific knowledge that will affect the care of people like you with cancer in the future!
You can learn more by visiting the National Institutes of Health website on clinical research trials. This website provides tips on how to search for clinical studies that you can use to explore the NIH website ClinicalTrials.gov, a database of studies being conducted in the United States and around the world. The simple search tool can help you find trials that you might be interested in and eligible for (try combining the terms “cancer” and “genitourinary syndrome of menopause,” into the search, for example). General information about each study, including any eligibility requirements and contact information, is available to review.
While doing your own search can give you insight into potential opportunities, it is important to discuss the information you find with your care team. Your oncology providers can help bring insight into the potential risks and benefits of taking part in a clinical trial, and how doing so might impact your care and your current treatment plan.
References:
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