Many in the breast cancer community are now in menopause due to chemotherapy or surgically induced. The side effects can deeply affect our sex life and cause our bodies to have far less interest in sexual activities of any kind. Our guest speaker Dr. Rachel S. Rubin, is a board-certified urologist and sexual medicine specialist. Dr. Rubin will discuss the hallmarks of female aging or chemotherapy/surgically induced menopause and why it can change our vaginal lining, including the potential of recurrent UTI’s. She will also address vaginal estrogen and what that means for hormone driven breast cancer.

1. 9/10/23
1
PERIOD
OF CHANGE
rachelrubinmd.com
M E N O P A U S E E V E N T S E R I E S
How Vaginal Estrogen Therapy Can Reduce Risk of UTIs".
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
Dr. Rachel Rubin
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Estrogen Loss and Manifestation
of Health Risks Over Time
40 45 50 55 60 65 70 75+
Thacker HL. The Cleveland Clinic Guide to Menopause. New York, NY: Kaplan; 2009.
Age (years)
Development of subclinical disease
Estrogen
Secretion
Urogenital symptoms
Short-Term Symptoms Long-Term Symptoms
Hot flushes, sleep, mood
Osteoporosis
100-110 pg/ml
10-20 pg/ml
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Anatomy
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Hormones matter
estrogen and androgens
• Oral contraceptives
• Breast feeding
• Infertility treatments
• Menopause
• Oophorectomy
• Breast cancer treatments
– SERMS
– Aromatase Inhibitors
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Characterization of vaginal and vulvar vestibule
biopsies on healthy premenopausal women
Squamous epithelium
Lamina propria
Blood vessels
Collagen
Vaginal lumen
50 µm
Vaginal mucosae Vestibular mucosae
25 µm
Estrogen Receptor α
Vaginal mucosae Vestibular mucosae
25 µm
12 µm 12 µm
Androgen Receptor
Immunohistochemistry of androgen and estrogen receptors in the
vaginal vs vulvar-vestibule mucosae of the same patient.
• All the enzymatic machinery necessary to the conversion of
adrenal precursors such as DHEA into active sex steroids was
detected both in the vaginal and vulvar vestibule’s mucosae.
• Both the androgen and the estrogen receptors were expressed
in the vaginal and the vulvar vestibule’s mucosae
• As previously reported2, AR had a robust expression in the
vulvar-vestibule.
1. Bouchard C. Poster presented at the 19th world congress of Gynecologal Endocrinology, Dec. 2020 2. Palacios S, Menopause. 2020 Nov;27(11):1336-42
Exemples of cells positively-marked by the specific antibody
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Jin J. JAMA. 2017;317(13):1388
Portman et al, The journal of sexual medicine 11.12 (2014): 2865-2872.
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Prendergast Obstetrics and Gynecology Clinics, (2017). 44(3), 509-522.
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• Symptoms
• Survival
• Quality of life
WHY WHAT
• 4 options
• Safety & efficacy data
HOW
• Self-advocacy
• Resources for
providers
WHERE
• Price shopping
• Accessibility
4 Safe & Effective Local Vaginal
Hormone Therapies
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Genitourinary Syndrome
of Menopause
• Genital dryness
• Discomfort or pain
• Decreased arousal
• Diminished orgasm
• Irritation, burning, or itching of
the vulva or vagina
• Decreased elasticity
• Post-coital bleeding
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
• Pain with urination
• Urinary frequency
• Urinary urgency
• Urethral prolapse
• Recurrent urinary tract infections
• Urinary incontinence
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Estradiol Vaginal Cream
Estradiol 0.01%
Insert 1 gram vaginally every night for
2 weeks
Then decrease to twice weekly
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Estradiol Vaginal Inserts
Estradiol 10 mcg
Insert 1 tablet vaginally every night for
2 weeks
Then decrease to twice weekly
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Estradiol Vaginal Ring
Estradiol 7.5 mcg / day
Insert 1 ring vaginally every 3 months
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Intrarosa Vaginal Inserts
DHEA and palm oil
Insert 1 suppository vaginally every
night
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
Impact of Vaginal Prasterone on the Rate of
Urinary Tract Infections in GSM patients and
those with a History of Breast Cancer: A
Retrospective Cohort Analysis.
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But CANCER!!!!
Safety conversation.
Find out what they are most afraid of and drown them with data and
reassurance
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Estradiol Preparations and Maximum Annual Delivered Dose
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Boxed Warning
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CONCLUSIONS: The risks of cardiovascular disease and cancer were not elevated among
postmenopausal women using vaginal estrogens, providing reassurance about the safety of
treatment.
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Laser based therapy
is there consensus yet?
….of course not
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CO2 fractionated laser
Karram et al, OBG Manag. 2015; 27 (8): e1–e6.
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CO2 fractionated laser
• 1 month after laser: thicker epithelium with wide columns of large epithelial
cells rich in glycogen.
• reorganization of connective tissue, both in the lamina propria and the core of
the papillae
Karram et al, OBG Manag. 2015; 27 (8): e1–e6.
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Aromatase inhibitors
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
• International Society for the Study of Women’s
Sexual Health (ISSWSH)
⚬ isswsh.org
• The Menopause Society
⚬ menopause.org
Self-advocacy and resources
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
• Estradiol Cream, Inserts, and Tablets, generic
⚬ Any pharmacy, using insurance or a GoodRx coupon
⚬ CostPlusDrugs.com with a prescription
• Estradiol Ring, Estring
⚬ Any pharmacy, using insurance and/or savings card from estring.com
• Intrarosa
⚬ Any pharmacy, using insurance and/or savings card from intrarosa.com
Where can I get vaginal
hormones?
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• Can premenopausal women use this?
• Do I need progesterone?
• What if I have bleeding?
• When can I stop?
• What are the side effects?
• What if I get a yeast infection?
• What if I still have symptoms?
• Can I use this with systemic therapy?
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
FAQ
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• Sign up for our Menopause Group Visit Day
• October 13th 10-11:30am lecture, 1-4pm visits
• 1.5 hour lecture on menopause: the genitourinary system AND the
whole body
• Head the events page on rachelrubinmd.com
• Reach out to Sophia at office@rachelrubinmd.com to get scheduled.
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
Want a customized plan?
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