The night my husband and I tried to have sex for the first time in six months was a date night. We rushed through dinner at our favorite Italian restaurant and returned home to a quiet house. The babysitter was paid and sent home early; our two children were fast asleep. There was nothing I wanted more than to be intimate with the father of my children, the man who loved me and whom I loved, who had taken care of me during and after my mastectomy, and who made my latte every morning. Only, when we got down to it, excruciating pain ripped through my body.
Five years prior, I was at Target picking out Halloween costumes for my two toddlers when a radiologist called me with my breast biopsy results. “The tumor is malignant,” she said. “But it looks early stage; we’ll know more in the next few days.” I stood frozen in the middle of the aisle, staring at the Paw Patrol costume in my cart as other moms pushed their way around me, grabbing last-minute items off the racks. I assumed the small lump I’d recently found on my right breast was something left over from breastfeeding my youngest son. I had no idea the havoc that mass of cells was going to cause.
Within a week, I went from being a healthy 37-year-old mother of two boys to a breast cancer patient. By Christmas 2017, I was recovering at my mother-in-law’s house in Lincoln, Massachusetts, from a unilateral mastectomy. My cancer was hormone-receptor positive (ER+), meaning it was receptive to hormone therapy. Following my surgery, my oncologist explained that given my age and type of breast cancer, it would be most effective to treat my cancer with something called an aromatase inhibitor (AI), which works by blocking the enzyme (aromatase) that helps make estrogen in the body.
“If we kill the estrogen in your body, then the cancer most likely can’t grow back,” he said. “But these medications will induce premature medical menopause.”
“Okay,” I said, relieved to learn I wouldn’t need chemotherapy. At the time, the prospect of an early, induced menopause was abstract to me, like trying to understand childbirth before going into labor.
My oncologist prescribed a five-year treatment plan that wiped out all the estrogen in my body and shut down my ovaries. Within weeks, I was a hot-flashing, mood-swinging insomniac. In some ways, I was prepared for the onslaught of symptoms. I remember my mother driving me around town in the dead of winter in Vermont with all the windows down. My doctor also warned me about the likelihood of having intense mood swings and night sweats. But my worst symptom of all, and the one no one ever mentioned, was vaginal atrophy.
Vaginal atrophy, the thinning and drying of vaginal tissues brought on by a decrease in estrogen, is a very common symptom of menopause. It is often more severe during hormone therapy and causes uncomfortable symptoms, like itching, burning, and pain during sexual intercourse. My heart dropped. That’s why sex has been so painful.
When I finally told my primary-care doctor about the pain I’d been experiencing, she recommended a vaginal-rejuvenation treatment that uses a laser to stimulate collagen production and cellular regrowth in the vaginal wall. The treatment was not covered by insurance, but I decided to try it. It helped with many of my symptoms, but sex was still extremely painful. Vaginal-rejuvenation treatments—including lasers, sound-wave therapy, and platelet-rich-plasma (PRP) therapy—are gaining popularity, although few are covered by insurance. “We are moving into an era of talking about menopause and medically induced menopause more openly,” said Rachel Goodman, MD, FACOG, of Second Spring MD in Santa Fe. She adds that there are multiple ways to treat the symptoms that come along with it, including vaginal pain.
Over the next few years, I tried many: refined and unrefined coconut-oil suppositories, hyaluronic-acid lube, CBD oils, and lidocaine numbing cream (which does help). I got acupuncture and tried vaginal steaming. But none of these homeopathic remedies fixed the vaginal atrophy wreaking havoc on my psyche and sex life.
“I’m at a loss,” I finally told my gynecologist after years of unsuccessful treatments. “Nothing is working.”
“Unfortunately, there isn’t a quick fix for breast cancer survivors,” she said. “The only thing proven to be effective is vaginal estrogen cream.”
I was wary of using an estrogen cream to treat my symptoms. After all, my breast cancer was hormone sensitive, meaning it needed estrogen to grow. I was taking heavy-duty medications to proactively kill all the estrogen in my body. I’d even stopped eating edamame.
But I was desperate. So I went home and researched vaginal estrogen therapy (VET). A 2022 Danish cohort study seemed to show VET was safe for survivors with ER+ breast cancer who took Tamoxifen, a different hormone therapy than mine. However, the research indicated a slight increased rate of recurrence with survivors on aromatase inhibitors—and who wants to get cancer again?
According to Brian Burnette, medical oncologist and hematologist at Green Bay Oncology, there is no clear or convincing evidence that vaginal estrogen therapy increases the risk of breast cancer recurrence. “Vaginal atrophy directly affects a patient’s sexual health, most intimate relationships, and quality of life,” Dr. Burnette said. “Vaginal estrogen has minimal absorption into the body. While there is a theoretical risk that this small amount of systemic estrogen could potentially increase the risk of breast cancer recurrence, it should be considered in the context of the marked improvement vaginal estrogen can achieve for symptoms. As with any medical decision, it is important to have a balanced discussion with a health care provider to enable an informed and shared decision.”
I found myself at a crossroads: Should I use the vaginal estrogen cream, despite the potential for a slight increased risk of recurrence? Or not use the cream and possibly never have enjoyable sex again? Most importantly, if my cancer were to come back, would I ever be able to forgive myself for using an estrogen product?
The decision is impossible and begs the question: Why isn’t there an alternative? The lack of treatment options for the millions of survivors like me, suffering from vaginal atrophy, would seem to make it ripe for clinical trials and research. It is hard to imagine a world in which men suffered the same kind of sexual consequences and there was not an insurance-covered solution. Why should I have to choose between risking a cancer recurrence or giving up sexual intercourse forever?
It’s clear more long-term clinical trials and widely dispersed information on the safety and efficacy of various treatments is necessary. Research shows 32% of breast cancer survivors choose to stop taking aromatase inhibitors due to adverse side effects. With early-onset breast cancer diagnoses on the rise—due in part to better screening and detection methods—more and more young women are going to be pushed into medically induced menopause. It should be mentioned that early menopause comes with other significant medical risks, such as loss of bone density and early onset Alzheimer’s.
Recently, I underwent a bone-density scan that showed progressive bone loss in my hips. The news brought momentary excitement. The choice may be made for me; I might have to go off the AI earlier than planned. But there is no guarantee, my doctor told me, that my body will revert to its original condition. How little we can control.