HRT is a complex issue in cancer survivors. The NICE guideline Menopause: Diagnosis and Management (2015; short version) recommends an individualized approach at all stages of cancer diagnosis, investigation and management of menopause.

Women who are likely to go through menopause because of medical or surgical treatment (including women at high risk because of hormone‐sensitive cancer or having gynaecological surgery) should be offered information about menopause and fertility before they commence their treatment.

Referral to a healthcare professional with an expertise in menopause should be considered if the patient has menopausal symptoms and contraindications to HRT or there is uncertainty about the most suitable treatment options for their menopausal symptoms (NICE [197]).

Vagifem tablets, Estring (silicon ring) and topical oestrogen creams are the most common vaginal oestrogen treatments. These preparations re‐oestrogenize the vaginal epithelium (Goldfarb et al. [115]). Topical local oestrogen preparations are preferred to systemic oestrogen therapy for the symptoms of vulvo‐vaginal atrophy as these formulations result in less systemic absorption (Wiggins and Dizon [285]). However, intravaginal oestrogens can cause a transient oestradiol elevation and their use is controversial in women with breast cancer or hormone‐sensitive cancers (Goldfarb et al. [115]). Non‐hormonal approaches are the first‐line choice for the management of urogenital symptoms in women during or after treatment for breast cancer (American and Farrell [6]).

Oncological review and referral to a healthcare professional with menopause expertise should be considered prior to commencement of vaginal oestrogen treatments (NICE [197]).

The fall in oestrogen levels associated with menopause can cause vaginal atrophy and thinning of the vaginal walls and vulval tissues resulting in decreased vaginal lubrication (Edwards and Panay [96]).

The use of vaginal moisturizers is aimed at improving the balance of intracellular fluids in the vaginal epithelium and restoring a premenopausal vaginal pH. Vaginal moisturizers are non‐hormonal preparations available in gels, tablets or liquid beads and can be administered in an applicator or as a vaginal suppository. They need to be used several times per week and last 2–3 days before reapplication. Best absorption occurs when used prior to bedtime (Carter et al. [41]).

The two vaginal moisturizer products widely available in the UK are:

Vaginal lubricants provide lubrication to minimize dryness and pain during sexual activity and in gynaecological examinations. They are available over the counter in liquid or gel form and are applied in the vagina and around the genitals prior to sexual activity. There is no evidence that they have any long‐term therapeutic benefit (Sunha and Ewies [263]).

Water‐ and silicon‐based lubricants are recommended; water‐based lubricants are more easily washed away. Petroleum‐based lubricants are more difficult to wash away and can be incompatible with latex condoms. Perfumed or flavoured lubricants may irritate or be atrophic to delicate tissues (Carter et al. [41]).

The use of vaginal dilators for the management of sexual dysfunction related to pelvic radiotherapy (cervical, endometrial or rectal cancers) is promoted and evidence based. However, dilator therapy benefits may not be limited to patients undergoing this treatment. This intervention may also be useful in managing vaginal atrophy subsequent to treatment‐induced hormonal deprivation, for use in vaginal reconstruction patients, and for women with vaginal graft‐versus‐host disease (Carter et al. [41]).

Vaginal dilators (Figure 27.6), available in sets of increasing size, provide a gradual vaginal stretching process for managing vaginal pain, stenosis and adhesions (Goldfarb et al. [115]) as well as improving control over pelvic floor muscles (Carter et al. [42]).

The pelvic floor muscles provide structural support to the pelvic organs (the vagina, urethra and rectum). Dysfunction of the pelvic floor may result from disruption of the pelvic anatomy and local nerve supply to the pelvic floor muscles caused by cancer or various cancer treatments. This disruption may lead to problems such as urinary incontinence and sexual arousal difficulties (Candy et al. [40]).

Pelvic floor exercises (Box 27.5) can increase pelvic floor strength and draw blood flow to the pelvic floor, improving circulation. Pelvic floor control can aid in maintaining relaxation of pelvic and vaginal muscles, reducing reflexive tightening (and associated pain) during penetration. Pelvic floor exercises may be prescribed to aid incontinence issues by strengthening the pelvic floor muscles (Goldfarb et al. [115]).