Sexual dysfunction and aromatase inhibitor use in survivors of breast cancer

Aromatase inhibitors (AIs) are now an integral component in the management of postmenopausal adjuvant therapy for breast cancer in women with hormone receptor-positive disease; however, the AI-associated reduction in estrogen levels can increase vaginal/vulvar symptoms and adversely influence sexual function. Although non-hormone-containing local agents with demonstrated efficacy are available, optimal therapy for estrogen deprivation-associated vaginal/vulvar symptoms might require local or systemic estrogen use. However, the safety of systemic estrogen use in the breast cancer setting, especially for women on AIs, has been challenged by recent randomized clinical trial evidence. In addition, maintenance of estrogen levels in the postmenopausal range cannot be assured with local estrogen use. Thus, for postmenopausal women with limiting vaginal/vulvar symptoms on adjuvant AIs that are not manageable with non-hormone-containing agents, a switch to tamoxifen might be preferred rather than adding local or systemic estrogens to the AI regimen.