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I’d like to clear up some confusion regarding the use of estrogen to offset the symptoms of menopause. I won’t bury the lead; vaginal estrogen IS a safe menopause treatment for almost all menopausal women to use. Women using vaginally applied estrogen to minimize menopause symptoms do not increase their risk of heart disease, stroke, deep vein thrombosis, dementia or certain cancers including breast cancer in spite of what it might say in the Information for Patients (the package insert) which comes with this therapy.

But now, the back story.

The federally funded Women’s Health Initiative (WHI) Clinical Trials studies documented that oral estrogen or oral estrogen plus progesterone pills increased the risks for heart disease, stroke, deep vein thrombosis, dementia and certain cancers including breast cancer. These results from studies published in 2002 and 2004 have come into much clearer focus more recently. Unfortunately, the patient population evaluated in these studies included women who had pre-existing health conditions such as being overweight, having high blood pressure, etc., and most importantly the study participants outside of the “estrogen window” for safety FOR SYSTEMIC HORMONE THERAPY. This confounded the results of the study, since most of the study participants were over 60 years old, and some were 79 years old, when they started on their treatments. However, the WHI researchers continued to look into safer options for the correct patient population, in order to alleviate symptoms which hinder a women’s overall quality of life and sexual wellness.

The “Estrogen Window”

Following the confusing outcomes of the WHI Randomized Clinical Trials (referred to above), researchers began to closely review other WHI data. The latest publication from the Observational part of the WHI (Carolyn J. Crandall, MD, and colleagues. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. Menopause: The Journal of The North American Menopause Society. Vol. 25, No. 1, pp. 000-000, 2017. ePUB ahead of print) focuses on vaginal application of estrogen only for the treatment of vaginal symptoms of menopause. These included women’s experiences related to the deficiency of estrogen on the vagina, bladder and urethra, and particularly focused on the safety of vaginal estrogen treatments.

These symptoms investigated include:

  • dyspareunia (insertional or deep pain during sex)
  • lubrication/dryness issues during sex
  • vaginal atrophy
  • recurrent urinary tract infections
  • painful urination
  • generalized vulvar or vaginal discomfort
  • bleeding after sex

The one common group of symptoms that vaginal estrogen does not mitigate is hot flashes, night sweats, and disturbed sleep.

Risks and Rewards

The team aimed to find out if and how severe health risks affected women who were using this vaginal form of estrogen. Cardiovascular disease, breast, colorectal, and endometrial cancer, as well as deadly blot clots were health events that warranted a risk assessment in this study.

The data showed that among women with an intact uterus, the risks of stroke, invasive breast cancer, colorectal cancer, endometrial cancer, and pulmonary embolism/deep vein thrombosis were not significantly different between vaginal estrogen users and nonusers.

I will emphasize that this was estrogen-only administration of therapy and none were taken by mouth. Oral therapies that travel through a patient’s digestive system and blood stream may also be safe for many, but that is not the administration route under the microscope in this paper recently published in the Menopause journal; by the North American Menopause Society. The “take home” message: vaginal estrogen can be safely used without fear of cardiovascular events caused by such therapy, after menopause.

It is important to visit a practice like ours that understands hormones and the role that they play during each phase of a woman’s life. The fluctuations you experience are not only normal, but very treatable. If you have questions about hormones, the menopause window, or whether you can safely use hormones, please call our office at (202) 293-1000 to make an appointment with our compassionate and knowledgeable staff.

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Upon hearing a cancer diagnosis a person’s world changes immediately and forever. The person becomes a patient. The patient has to make myriad decisions about treatment plans, and the possibility of surgery, radiation, and chemotherapy. These treatments, while life-saving, are also life-altering. The side effects can modify body image, reduce or end fertility, change sexual identity and sexual function. Approximately 60 percent of cancer survivors have long-term sexual dysfunction. Oncology teams (who may focus more on the life-saving aspects of care) aren’t always taking the time to discuss fertility or sexual health matters as much as they should. But the good news is that our practice can help save a women’s eggs, or a man’s sperm for future use; mitigate and reverse most hormonal changes, and starting in September, we will also offer treatment for men with urological or sexual complaints in our practice. Our newest colleague, Rachel S. Rubin, MD, is specially trained to treat hormonal and sexual dysfunction in both men and women.

Talking about sexual health outside of the bedroom, in the office of a compassionate physician is key to holistic wellness. The emotions of being a cancer survivor can be overwhelming in and of themselves, but to add infertility or sexual dysfunction to the list of health issues can be daunting. We’re here to help you get back on track.

For Men
Following prostate cancer treatment, for example, the ability to have and maintain an erection becomes difficult and for some men, impossible, without help from a medical practice such as ours. Many men may not feel comfortable talking about these intimate issues, but there is help. Our compassionate and caring staff can help men who experiene treatable symptoms. It’s not just about physical symptoms, cancer affects sexual identity and when men are unable to perform as they could prior to cancer treatment, it can have a serious and detrimental effect on one’s psyche. Getting the courage to seek help is the first step to getting back to the “new normal.”

For Women
Breast cancer, when surgery is required, may alter a woman’s body and can hinder sexual identity and function. Breasts, once part of the sexual experience for both partners, are no longer the same. Even when reconstructed, the breasts may feel different, lack the pleasurable sensitivity they once had, or might even be painful and distracting. Sensation might even be completely gone. Partners may also feel hindered by the feeling of the new breasts. This can be uncomfortable for both partners. With any cancer treatment (i.e. chemotherapy, surgical removal of the ovaries or even hysterectomy) a patient may find herself in early/premature menopause with hot flashes, night sweats, disturbed sleep and weight gain. This is also accompanied by vaginal dryness, and pain with genital touching or intercourse. There are options to help enhance the sexual experience that we have available at the office, and that are not available anywhere else.

A wonderful Newsweek article about these issues does a deeper dive from both the patient and physician perspective that we welcome you to read for additional information.

If you are just starting cancer treatment, going through it, or are in the post-treatment phase and are facing future or current fertility concerns, hormonal deficiencies, or sexual dysfunction, we can help. Please call our office at (202) 293-1000 to make an appointment with one of our caring and compassionate members of Dr. James A Simon’s team.

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If you’re in the New York City area on April 7-9, 2017 join me and colleagues at the The Westin NY at Times Square for our annual Survival Skills for Today’s Gynecologist program. It’s a great time to catch up with friends and hear discussions about the latest in gynecologic patient care. Each day starts with breakfast and includes time for Q&A to deepen the knowledge-share among us.

Along with Steven R. Goldstein, MD who serves with me as Program Co-Director, we have a terrific faculty who will present on leading-edge therapies and topical issues. You might be interested in the most recent recommendations about cervical cancer screening or are wanting more information about HPV education, VVA treatment, hysterectomy procedures, urogynecology, and much more.

On Friday, I will discuss the following topics:

  • Menopausal Hormone Therapy: Primary Prevention of Disease or Not?
  • Office Management of Female Sexual Dysfunction: You CAN do this.
  • Flashes, Flushes, and Night Sweats: New and Non-Hormonal Approaches

My topic for Saturday is Pelvic Floor Biofeedback/Physical Therapy: Should I Offer This in My Office?

The treatment of our patient population is ever-changing, as new treatments and options become available. The business of medicine is changing too. Don’t miss this great CME opportunity, learn some Survival Skills, and thrive in the years to come.

View the entire course or to Register at www.WorldClassCME.com or by phone at (888) 207-9105, M-F 8:30 am – 5 pm EST

Hope to see you there!

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The phases of a cancer diagnosis might be compared with those of dealing with the death of a loved one: denial, bargaining, anger, and eventually acceptance. Fortunately for many, there IS life after cancer. A sexual life too, that part of one’s life may have been put on the back-burner during cancer treatment. The statistics on survivorship are astounding, creating a “before” and “after” picture for many.  It is important to understand both of them. Progression-free survival rates indicate no new tumors have formed. Whereas disease-free survival rates refer to remission, cancer free. The death rate from breast cancer has fallen 34% since 1991. Following the grueling chemotherapy, radiation, and/or surgery, it might not immediately occur to patients and their partners to re-connect through sexual activity.  I would encourage you or anyone you know in the survivorship phase, however, to make it a priority. Absent sexual activity, all genital tissues (skin, mucus membranes, and muscles), suffer from disuse atrophy. The good news is this: with the intention to connect or reconnect with your partner, and the use of various products available (if necessary), solutions to sexual activity may result in your “new normal.” Your body image, to the degree it suffered during cancer treatment may need a boost and a re-boot. A renewed sexual life can often help.

Sexual Healing
Whether due to cancer, certain medications that interfere with sexual response such as antidepressants, or menopause, sexual response changes during a lifetime. Menopause can be a premature consequence of cancer treatment. Both chemotherapy and pelvic radiation can result in menopause regardless of a woman’s age. Lubricants and vaginal moisturizers are readily available, but I caution you to look at the ingredients, as some may be irritants to those delicate tissues. Ingredients such as those found in spermicides, benzyl alcohol, and materials such as latex can cause discomfort for some.

With the sudden onset of menopause from surgery, radiation or chemotherapy, many women find that they experience intense vaginal dryness, and pain with sex (usually at the time of penetration). To mitigate this issue, vaginal moisturizers which are used on a routine basis whether one is having sex or not, can help to bring water into the vagina. Think about vaginal moisturizers like the moisturizer you use on your skin…you don’t just apply it when you are getting your picture taken. You use it on a regular basis. And lubricants (they aren’t the same as moisturizers) which come in oil, silicone, water-based, and mixtures of each of these can solve the dryness and lack of natural lubrication missing after some cancer treatments. Lubricants are used at the time one is having sex. They help the vagina operate as it once did naturally, and can make sexual activity more pleasurable by easing friction and lessening pain.

Enhance Sexual Pleasure
The marketplace has been flooded with sex-positive devices to enhance the sexual experience for both men and women. Toys, vibrators, dildos, and much more have piqued the curiosity of people who want to try something new. A medically accurate fantastic and friendly site middlesexmd.com/ can help educate you and your partner about new products, techniques and “tools” to keep your sensual side smoldering. Our office stocks a variety of such sexual aids and can help with proper selection, especially when sexual function is hampered. Keeping an open and honest discussion with your partner about your needs and interests, as they change in the “new normal” can alleviate anxiety and further build on a relationship that has endured and surpassed, the diagnosis of cancer. Get personal. Have fun. Explore.
To learn more please call the office at (202)293-1000 or email the practice at info@intimmedicine.com.

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As a reproductive specialist, board certified in reproductive endocrinology and infertility, this blog post has special significance for me. While you may not need the information provided here, you may know someone who does. Please “Pay It Forward”, “Pass It On”.

Women experiencing a cancer diagnosis is a life-altering experience; however, so is infertility. Breast cancer treatment is one cancer type that can have permanent effects on fertility because ovarian removal, injury (i.e., chemotherapy or radiation) and/or suppression is often part of the treatment strategy. Additionally, each year approximately 71,500 women in the United States are diagnosed with a gynecologic cancer, according to the Center for Disease Control (CDC). These cancers include cervical, gestational trophoblastic disease (GTD), primary peritoneal, ovarian, uterine/endometrial, vaginal and vulvar cancers. Because of the nature of cancer as it relates to fertility, I would like to provide more information about fertility options at the point of a cancer diagnosis so that patients can benefit from fertility preservation strategies before treatment begins because three out of four patients are interested in having a family one day.

How Treatment Affects Fertility
Treatment, including chemotherapy, radiation, and surgery can cause damage to organs involved in reproduction, such as the ovaries, fallopian tubes, uterus, and cervix. Ovarian suppression, used to slow or stop estrogen-receptor positive cancers, can be reversed following treatment. However, other treatments such as chemotherapy, radiation and some surgeries can cause women to experience early and permanent menopause.

Weighing the Options Before Treatment
There are several methods to preserve future fertility if patients are able to compete one of these prior to chemotherapy or radiation.

Embryo freezing is a primary method of fertility preservation for women, according to Cancer.Net a patient site from the American Society of Clinical Oncology (ASCO). After taking fertility drugs for two weeks a woman’s eggs are collected and fertilized by sperm though in vitro fertilization. The embryos are frozen until the woman is ready to become pregnant. Although fertility drugs increase estrogen during fertility treatment, aromatase inhibitors can keep the levels low for women with estrogen-sensitive cancers thereafter.

Oocyte (unfertilized egg) freezing is similar to embryo freezing, except that the eggs are frozen without being fertilized by sperm. This is a particularly important option for women who are not currently “partnered” or do not want to choose a sperm donor.
Fertility-preserving surgery is an option for cervical or ovarian cancer. Surgery can treat the cancer and help preserve a woman’s fertility. Surgery may also be used to “move the ovaries” out of harm’s way, should radiation be needed in an anatomically adjacent area. The ovaries can be “put back” in their normal location at a later time if needed for future fertility.

For girls who have not yet reached puberty, an experimental option is to try ovarian tissue cryopreservation, a process where an ovary or ovaries are actually removed from the body and frozen in pieces until needed following cancer treatment. At that time, the ovary or a part thereof can be re-implanted in the arm, abdomen or other easily accessible location for future egg retrieval. While this sounds like science fiction, some babies have already been born using this process.
During treatment, the oncology team may try ovarian shielding to ensure that the ovaries are not harmed during radiation therapy. In an effort to protect the ovary by reducing its exposure to chemotherapy an attempt can be made to “turn off/turn down” the ovary’s blood supply using other medications. This approach has had mixed results, but has few downsides. One cancer treatment has commenced and premature menopause results, patients may consider surrogacy or adoption in addition to the options listed above.

Guidelines Broaden the Discussion
In 2013 the American Society of Clinical Oncology (ASCO) updated its clinical practice guideline on fertility preservation. One of the pivotal updates to the guideline was the change from the word “oncologist” to “healthcare provider”, to broaden the responsibility to more members of the medical team who can help lead discussions with patients to help them better understand their fertility preservation options. While I applaud this approach, I prefer that these men and women be called “healthcare professionals”.

The Future of Oncofertility
Because patients with cancer are enjoying greater survival rates in large numbers, there is a need to address the whole person, not just the removal of the cancer, because survivorship, for many, also includes raising a family. Teresa K. Woodruff, PhD, of Northwestern University Feinberg School of Medicine in Chicago and Thomas J. Watkins, MD professor of obstetrics and gynecology at Northwestern, coined the term “oncofertility” to describe oncologists and reproductive specialists working together preserve patients’ fertility while treating their disease.

Medical professionals can ensure that patients and their families have all the decision-making tools available about fertility preservation. Members of the ob/gyn and also oncology teams should address the future fertility options with patients at the point of cancer diagnosis and prior to initiating treatment.

Top Tips for Discussing Fertility with Patients
1. Discuss fertility preservation with all patients prior to and of reproductive age if infertility is a potential risk of therapy.
2. Refer patients who express an interest in fertility preservation (and patients who are ambivalent) to reproductive specialists.
3. Address fertility preservation as early as possible, before treatment starts.
4. Document fertility preservation discussions in the medical record.
5. Answer basic questions about whether fertility preservation may have an impact on successful cancer treatment.
6. Refer patients to psychosocial providers if they experience distress about potential infertility.
7. Encourage patients to participate in registries and clinical studies.
Reference: Key Recommendations: Fertility Preservation for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Top 10 Questions to Ask your Doctor about Fertility and Cancer Care
1. How does cancer affect my fertility?
2. Which cancer treatments can affect my fertility?
3. Which fertility preservation methods should I consider before cancer treatment begins?
4. How does the process of egg preservation work?
5. How long does this procedure take?
6. How soon after cancer treatment can I plan for a pregnancy?
7. My cancer type requires ovarian suppression. When can I become pregnant after ovarian suppression is reversed?
8. What are the side effects of these procedures?
9. I’m already pregnant and diagnosed with cancer. Will I be able to have children in the future?
10. Will my insurance cover these procedures?

To learn more please call the office at (202)293-1000 or email the practice at info@intimmedicine.com.

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James A. Simon, MD, reproductive endocrinologist, menopausal medicine specialist and Clinical Professor at George Washington University in Washington, DC, has been treating women for gynecologic issues and seeks to re-educate women and the medical community about the importance of and safety of menopausal hormone therapy.

Dr. Simon wants to debunk the long-held belief that hormone therapy for women in the early menopausal years leads to breast cancer. It is not that simple. Women’s health status, breast cancer status, lifestyle, age and other factors contribute to the risk of cancer, including breast cancer. Estrogen, once lauded as providing great relief to women experiencing hot flashes and night sweats, became vilified when The Women’s Health Initiative hormone study appeared to demonstrate a cause and effect between menopausal use of hormone and the risk of breast cancer. About 8-10% of women are walking around with breast cancer and don’t know it. Either they haven’t had a mammogram or the cancer is still too small to be detected. According to Dr. Simon, when women who have undiagnosed breast cancer go on hormone therapy, and it shows up in the follow-up mammogram, some will attribute the cancer to the hormone therapy. But did the hormone therapy cause the cancer?

Estrogen alone may actually have a protective benefit from breast cancer while helping with all the uncomfortable symptoms of menopause, and yet estrogen plus synthetic forms of progesterone, like those used in the Women’s Health Initiative, may increase the apparent risk of breast cancer, but the drugs themselves are not carcinogenic.

Estrogen versus Estrogen Plus Progesterone
Joann Manson, MD, professor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, and Past President of the North America Menopause Society, echoes Dr. Simon’s point about the efficacy and safety of estrogen alone. Dr. Manson has worked for more than 20 years in the field of menopause. In a video on MyMenopause.com Dr. Manson who was involved in the Women’s Health Initiative (WHI) study offers key learning points from the WHI study:

  • Estrogen, given alone, without a progestogen to women who have undergone hysterectomy, had no increase in the risk of breast cancer.
  • In women who had an intact uterus and needed a progestogen to protect the uterine lining, who also took estrogen, were at higher risk for breast cancer. However, cancer was not detected until around year 4 or 5, so doctors do not recommend taking the combined medication for a prolonged period.

“I think it’s important to understand that all medications do have risks. It really comes down to the balance of benefits versus risk,” said Dr. Manson. “In a woman in early menopause who is having moderate to severe symptoms—hot flashes, night sweats, really worsening her quality of life, really interrupting her sleep and interfering with her daily activities, in most cases the benefits of hormone therapy outweigh the risk,” she adds.

Estrogen Timing Matters: The Estrogen Window
Dr. Simon recently spoke about this issue at the 2016 Annual Meeting of The American Congress of Obstetricians and Gynecologists (ACOG) and also in a video with Dr. Mache Seibel, a gynecologic expert and Editor of MyMenopause.com.

“Early use of hormone therapy…and by early I mean 50’s, is of overall benefit to women’s health in a variety of ways…If they are outside of the window, or late, they get mostly risk for being on estrogen only or hormone therapy,” says Dr. Simon.

So women should take hormone therapy early, during their late 40’s, or as close to menopause as possible, to benefit the most and experience fewer risks.

Women with BRCA Mutations
A portion of the women going through menopause carry BRCA gene mutations, which already puts them at an increased risk for breast and ovarian cancer. Susan Domchek, MD, of the University of Pennsylvania spoke at the 2015 North America Menopause Society Annual Meeting regarding this issue. Dr. Domchek’s recommendation is for women who have had their ovaries or ovaries and fallopian tubes removed to offset the risk of ovarian cancer, to add estrogen therapy in order to mitigate the risk of breast cancer.

“It’s important to know that women know that this is an option for them and they need to talk to their doctor about it,” Dr. Domchek.

Who May Have BRCA 1 or BRCA 2 Mutations?

  • Women with family members (sister, mother, aunt, or even father) who had early onset breast cancer (before the age of 40)
  • Women with family members who have had ovarian cancer
  • Women of Ashkenazi Jewish descent whose family members have had early onset breast, ovarian or pancreatic cancer.

SIDEBAR
Hormone Therapy and Breast Cancer Risk

  • Combination (estrogen and synthetic progestogen) hormone therapy increases breast cancer risk by about 26%. This sounds like a tremendous increase, but it represents the difference between 3.3 cases of breast cancer/1000 women increased to 4.1 cases of breast cancer/1000 for each year of hormone therapy…less than one women/year/1000.
  • Estrogen-only hormone therapy increases the risk of breast cancer, but only when used for more than 10 years. In the Women’s Health Initiative, estrogen-only hormone therapy reduced the risk of breast cancer by a similar amount (23%).
  • Whether an increase or a decrease, the size of these changes are considered to be rare. (=1/10,000 and < 1/1,000; =0.01% to < 0.1%; between 0.1 and 0.9/1000).
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92041723Woman who take fertility drugs like clomiphene (i.e. Clomid, Serophene) and follitropins or gonadotropins (i.e. Follistim, Bravelle, Gonal-F) in hopes of becoming pregnant will be relieved to learn they can cross one worry off their list: A recent study found these fertility drugs do not increase a woman’s chance of developing breast cancer.

Researchers evaluated medical charts and history of more than 9,800 women who took Clomid or gonadotropins between 1965 and 1988. They found that 749 women were diagnosed with breast cancer by 2010, which was not a significant difference from those not taking the drugs.

Fertility drugs, like clomiphene, follitropins,or gonadotropins, are a critical part of all fertility treatments to help stimulate egg production and ovulation. Depending on infertility factors, medical history and previous responses to fertility medicines, I prescribe Clomid or move onto a combination of follitropins and gonadotropins, like, Follistim or Bravelle, to the women I see for infertility.

I’m constantly assuring patients that there isn’t, and has never been, a correlation between breast cancer and fertility drugs and treatment. The main side effects of fertility medicines are generally mild and include symptoms such as mood swings, bloating, fatigue, dizziness and others.

Bottom line: Be sure to discuss all your questions and concerns with your fertility doctor before, during and after fertility treatment cycles. I can help walk you throw your options, and answer any infertility questions you may have.

 

Interested in women’s sexual health? Contact us for an appointment.

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A new study found a link between bra size, exercise levels and cancer mortality. Simply put: it found that women who met current exercise guidelines were about 40 percent less likely to die from breast cancer. Smaller bra cup sizes also seemed to lower the chance women would die from the disease. Specifically, this study demonstrated:

  • It only took about seven miles of brisk walking or five miles of running each week to reduce a woman’s chance of dying from breast cancer.
  • Women with a C cup bra size were four times the risk of breast cancer risk compared to women with A cups. That risk jumped to five times for women with a D cup or larger.

What does this mean to you? While you can’t change your bra cup size, you can change how much you exercise.  Just seven miles may help protect you from breast cancer mortality. That’s less than one mile a day. Just run one mile a day and take two days off. No matter how you do it, make exercise a priority. This study once again demonstrates the importance of exercise to your health.

 

Interested in women’s sexual health? Contact us for an appointment.

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The medical community has been a strong proponent of using screening mammography procedures for thirty years now – and that gives researchers a considerable amount of data from which to draw conclusions. Despite some back-and-forth recommendations regarding the frequency of the testing, and at what age women should begin an annual mammography, the practice is so widespread that an analysis of results is pretty meaningful.
Continue reading “Your Mammography Results Are In”

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breast cancer awareness

Breast cancer treatment can bring about urinary/vaginal issues

breast cancer awarenessAs if women with breast cancer haven’t endured enough already, they often develop painful changes in their vaginas or urethras — urogenital or vulvovaginal atrophy — as a result of their breast cancer treatment. The most common breast cancer treatments are tamoxifen and aromatase inhibitors. Tamoxifen works by blocking estrogen receptors on breast and breast cancer cells. Tamoxifen grabs that “parking space” (the breast/breast cancer estrogen receptor) so that estrogen can’t “park” there. Aromatase inhibitors are chemicals that work by suppressing estrogen production in the body. While women treated with aromatase inhibitors — Arimidex, Aromasin and Femara — tend to have more symptoms than those treated with tamoxifen, either approach can produce symptoms.

Symptoms of urogenital/vulvovaginal atrophy

The most common symptoms of urogenital or vulvovaginal atrophy include vaginal dryness, itching and irritation, painful intercourse/urination and frequent urinary tract infections. Unfortunately, these symptoms are often not diagnosed, and women continue to suffer in silence. And worse than that, even when diagnosed, symptoms are often left untreated, especially in breast cancer patients.

Don’t suffer — treatments are available

Typically, I recommend non-hormonal vaginal moisturizers/lubricants and lifestyle modifications — avoiding scented hygiene products as well as smoking cessation and stress management — to help relieve symptoms in women with a history of breast cancer. Believe it or not, regular intercourse can actually help if not too painful because the progressive stretching and increased blood flow improve a woman’s vaginal health. If none of these approaches provide adequate relief, topical estrogen therapy is a good alternative. Applied only to the affected area, a minute amount of estrogen is absorbed into the bloodstream through the vagina. Best of all, this low dose can be quite effective in relieving symptoms. It must be noted, though, that risk of breast cancer recurrence following localized estrogen therapy is uncertain. That’s why the decision to start this therapy should be made jointly with your gynecologist and oncologist.

 

Interested in women’s sexual health? Contact us for an appointment.

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