I've heard it so many times: "Sex is so painful since my breast cancer treatment and I can't use any estrogens." The first part of that sentence is 100% true, the second part is partially true. Why is sex painful after breast cancer treatment? The most common reason is atrophic vaginitis. (Yet another complimentary medical term for women.) Basically atrophic vaginitis is thinning of the vaginal walls usually because of low or absent estrogen. The thin vaginal walls are more sensitive, don't lubricate as well or at all, and are prone to tearing during sexual activity. It's no surprise that a woman who experiences this loses any remaining libido she had following her breast cancer treatment.
A woman with a current or past history of breast cancer should not take systemic estrogen (pill, patch, or cream meant to go through the bloodstream), but she can safely use certain vaginal estrogens. In 2016, the American College of Obstetricians & Gynecologists published their opinion that "Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms." Over the years, the best analogy I have used to get this point across to patients is topical versus systemic steroids. A steroid pill is meant to go throughout your body to treat an allergic reaction or other condition wherever it is in your body. On the other hand, a steroid cream will only work where it is applied (assuming you use the recommended amount). Similarly, an estrogen pill or patch will distribute estrogen throughout your body while a topical vaginal estrogen will have effects only in the vagina. Along those lines, while a vaginal estrogen can significantly improve vaginal dryness, it doesn't improve things like hot flushes or your mood.
Right now you might be thinking, "That's interesting, but I'm just not comfortable with using any type of estrogen." No problem! There are plenty of other alternatives. Non-prescription alternatives include regular use of over the counter vaginal moisturizers and lubricants at the time of sexual activity. There are many different moisturizers and lubricants, and my advice regarding these is to stay with chemical-free, natural products to avoid further irritation of the vagina. I have to give a plug for GLISSANT lubricants. They aren't just lubricants--they contain natural ingredients that improve a woman's own lubrication and sensation by increasing blood flow to the vagina (yep, that's what happens during arousal and what Viagra does for men).
Another option is ospemifine. This daily tablet is a SERM (selective estrogen receptor modulator) that stimulates the walls of the vagina to thicken, similar to estrogen. It's a once daily pill that is generally well tolerated. As a potential added bonus, it has antiestrogen effects on the breast like tamoxifen, which is also a SERM and is commonly prescribed to prevent breast cancer recurrence.
And for those of you ladies who don't want to deal with putting something in your vagina all the time or taking a pill, there is a fractional CO2 laser treatment (Mona Lisa Touch) that induces collagen production to improve the function of the vagina. It's a quick, relatively painless procedure performed in the office. Many of my breast cancer patients have seen significant improvement after just one treatment (which makes me very happy for them).
Breast cancer is hard enough to deal with let alone the negative impact it can have on your sexuality and relationships. I just wanted you to know that there are ways to deal with it, and breast cancer is NOT the end of your sex life.