Supportive Care in Cancer

https://doi.org/10.1007/s00520-019-04684-6

ORIGINAL ARTICLE

The effect of vitamin D and E vaginal suppositories

on tamoxifen-induced vaginal atrophy in women with breast cancer
Zahra Keshavarzi 1 & Roksana Janghorban 2 & Shohreh Alipour 3 & Sedigheh Tahmasebi 4 & Azam Jokar 5

Received: 26 February 2018 / Accepted: 29 January 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Purpose Vaginal atrophy is one of the most common side effects of using tamoxifen in women with breast cancer. Hormone
therapy for vaginal atrophy is prohibited in these women. The present study was conducted to investigate the effect of vitamin D
and E vaginal suppositories on vaginal atrophy in women with breast cancer receiving tamoxifen.
Methods Women under breast cancer management receiving tamoxifen and showing symptoms of vaginal atrophy were ran-
domized triple-blind to an 8-week trial on vaginal suppository vitamin E or vitamin D or placebo administered every night before
bedtime. The genitourinary atrophy self-assessment tool was administered, and pH was measured in all three groups before the
intervention and at the end of weeks 2, 4, and 8 of the intervention. The Vaginal Maturation Index (VMI) was also measured
before the intervention and at the end of the eighth week. Data were analyzed with paired t tests, repeated measures analysis of
variance, and chi-square test.
Results Thirty-two patients were randomized in each group. The results obtained showed an increase in the VMI by the end of the
eighth week of the intervention in the groups receiving the vitamin D and E vaginal suppositories compared with the placebo
group (P < 0.001). The vaginal pH also reduced in both groups compared with that in the placebo group (P < 0.001). The
symptoms of self-reported genitourinary atrophy also improved in the two intervention groups compared with those in the
placebo group by the end of the eighth week (P < 0.001).
Conclusion These data support that vitamin D and E vaginal suppositories were beneficial in improving vaginal atrophy in
women with breast cancer receiving tamoxifen. Given the prohibition on hormone therapy in these women, the suppositories can
be used as an alternative therapy to improve these symptoms.

Keywords Breast cancer . Tamoxifen . Atrophic vaginitis . Vitamin D . Vitamin E . Vaginal suppository

* Roksana Janghorban 1
Department of Midwifery, School of Nursing and Midwifery, Student
Janghorban@sums.ac.ir; roksana542002@yahoo.com Research Committee, Shiraz University of Medical Sciences,
Shiraz, Iran
Zahra Keshavarzi 2
Department of Midwifery, School of Nursing and Midwifery,
keshavarzi.zahra1990@gmail.com Community Based Psychiatric Care Research Center, Shiraz
University of Medical Sciences, Nemazee Square, Zand Blv.,
Shohreh Alipour Shiraz 7193613119, Iran
Alipour_sh@sums.ac.ir 3
Department of Pharmaceutical Quality Control, School of Pharmacy,
Shiraz University of Medical Sciences, Shiraz, Iran
Sedigheh Tahmasebi 4
Tahmasebis@sums.ac.ir Department of Surgery, School of Medicine, Breast Diseases
Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
5
Azam Jokar Department of Midwifery, School of Nursing and Midwifery, Shiraz
Jokarhs@yahoo.com University of Medical Sciences, Shiraz, Iran

Introduction
Breast cancer is the most common type of cancer in women
and the second leading cause of cancer-related death in wom-
en after lung cancer [1]. In Iran, too, breast cancer is the most
common cancer diagnosed and the fifth most common cause
of death in women. Studies show that the mean age of patients
with breast cancer is over 55 in western countries and 10 years
less in Iran [2]. The adjuvant treatment of breast cancer, which
is a combination of chemotherapy and hormone therapy, can
induce symptoms of early menopause by affecting the ovarian
reserves and vaginal tissue in women with breast cancer [3].
As a chosen hormone therapy for breast cancer with estrogen
receptor positive (ER-positive), tamoxifen is a selective regu-
lator of estrogen receptors that act as estrogen agonist in some
body tissues and an antagonist in others, including the breast
[4]. With its antiestrogenic effects in the vagina, tamoxifen can
cause vaginal atrophy and related sexual problems in premen-
opausal women. In female rats, tamoxifen creates an estrogen-
deficient medium and causes functional changes in the vaginal
tissues, which ultimately cause vaginal atrophy, dryness, pain,
and sexual dysfunction [5]. The administration of tamoxifen is
most beneficial in women younger than 50 with breast cancer
and positive estrogen receptors, because this age group is
more sexually active than older women, and vaginal atrophy,
which is a common complication of this medication, affects
their sexual function more severely [1].
By causing changes in the vaginal mucosal membranes and
tissues, vaginal atrophy creates symptoms such as burning,
itching, vaginal dryness, dyspareunia, dysuria, postcoital
bleeding, and frequent urination and urge [6]. Various hor-
monal and non-hormonal methods have been proposed for
improving vaginal atrophy, including estrogen therapy as a
highly effective method for improving its symptoms in post-
menopausal women, since it plays a major role in the treat-
ment of dyspareunia and vaginal dryness [7]. Alternative hor-
mone therapies can cause complications such as increased risk
of endometrial, breast, and ovarian cancer and thromboembo-
lism [8–11]. Systemic treatment with estrogenic products,
which is one of the most effective treatments for vaginal atro-
phy in postmenopausal women, is not generally the right op-
tion for breast cancer patients [12], and the harms of systemic
hormone therapy outweigh its benefits in these women [13].
Additionally, The American College of Obstetricians and
Gynecologists (ACOG), the Endocrine Society, and The
North American Menopause Society (NAMS) cautiously sup-
port the use of low-dose local hormone therapies for genito-
urinary symptoms in consultation with the woman’s oncolo-
gist to consider the benefits and potential risks in women with
ER-positive breast cancers on tamoxifen [14, 15]. Given the
discussed points, non-hormonal methods are being recom-
mended as the first line of treatment for vaginal atrophy in
women with a prohibition on estrogen [16–22]. Vitamin D is
Support Care Cancer
involved in regulating cell development and differentiation,
especially in the stratified epithelium tissue of the vagina,
and can increase the maturation of the vaginal cells by affect-
ing vitamin D receptors in the vagina [23, 24]. Lee et al.
showed that vitamin D proliferates vaginal epithelium through
RhoA expression. The expression of cell-to-cell junction pro-
teins was higher in women with symptoms of atrophic vagina
tissue compared with that in women without the symptoms.
Vitamin D stimulated the proliferation of the vaginal epitheli-
um by activating p-RhoA and Erzin through the vitamin D
receptor (VDR). The results suggested that vitamin D posi-
tively regulates cell-to-cell junction by increasing the VDR/p-
RhoA/p-Ezrin pathway [25]. Vitamin E also has an anti-
inflammatory and antioxidant role and healing properties
and can be effective in improving the symptoms of vaginal
atrophy. Studies showed that it takes part to the metabolism of
all cells and prevents the degradation of the tissue due to
oxidant agents [16, 26].
Some preclinical studies support the vitamin D effect on
the vaginal epithelium such as Abban et al. study. They
showed that treatment with exogenous vitamin D3 in ovariec-
tomized rats led to expression of vitamin D receptor in the
superficial layers of the vaginal epithelium [27]. But preclin-
ical studies are not found about vitamin E effect on the vaginal
epithelium. Most studies have focused on the oral or vaginal
effects of vitamins D and E on postmenopausal vaginal atro-
phy, and there is a lack of adequate information on the use of
this therapy in tamoxifen-induced vaginal atrophy in women
with breast cancer [23, 24, 26, 28]. Given that breast cancer
affects Iranian women a decade earlier than their western
peers, they are more likely to receive tamoxifen and thereby
experience complications such as vaginal atrophy. Given that
these women are sexually active and since vaginal atrophy
causes sexual problems and given the prohibition on the use
of estrogen for the treatment of this complication in this group,
the present study was conducted to investigate the effects of
vitamin D and E vaginal suppositories on tamoxifen-induced
vaginal atrophy in women with breast cancer.
Methods
Study design
The present triple-blind, controlled, randomized clinical trial
was conducted on women with breast cancer receiving tamox-
ifen and presenting to Shahid Motahari Breast Clinic affiliated
to Shiraz University of Medical Sciences (a referral center in
the south of Iran) from October 2016 to July 2017. The re-
search project was approved by the ethics committee of Shiraz
University of Medical Sciences (IR.SUMS.REC 94-01-08-
11247) and registered at the Iranian Registry of Clinical
Support Care Cancer
Trials (IRCT2016100229683N2). Written informed consent
was obtained from all the participants.
Patient eligibility
The inclusion criteria consisted of being married, having stage
1 or 2 breast cancer based on the surgery stage, age below 50,
receiving tamoxifen, not undergoing chemotherapy or radio-
therapy during the study, a normal Pap smear during the last
3 years, no proven malignancies in other parts of the body,
being sexually active during the study, meeting at least one of
the criteria set in the genitourinary atrophy self-assessment,
vaginal pH ≥ 5 according to Chollet et al. study [29] at the
time of the study, and a Vaginal Maturation Index (VMI) ≤ 52
according to Speroff’s study [30]. The exclusion criteria
consisted of unwillingness to participate in the study, vaginal
infection, estrogen therapy in the last 8 weeks, idiopathic vag-
inal bleeding, and disease recurrence based on the diagnosis
recorded in the patient’s file.
Procedures
First, the patients’ details were recorded based on the ques-
tionnaire and included their demographic details; pregnancy
history; medical history and disease history, including the time
of breast cancer diagnosis based on the pathology results and
the type and stage of breast cancer; and also the status of
tamoxifen administration, including the duration of use at
the time of beginning the research and the daily dose used.
To verify the subjects in terms of meeting the last three inclu-
sion criteria, the patients who met the other criteria had a
speculum inserted into the vagina and a pH strip (Sigma-
Aldrich Co., Germany) with a precision of 0.5 placed to touch
the depth of the vagina for 1 min. Immediately after removal,
changes in the color of the pH strip were compared with those
of the reference strip and the vaginal pH was thus recorded. If
pH ≥ 5, a sample was taken from the inner and outer cervix by
a spatula and placed on a slide for a Pap smear. To assess the
VMI, a sample was taken by cytobrush from the vaginal pos-
terior fornix cells and also from the upper-third side walls of
the vagina and placed on a slide. Slides were read by one
pathologist. The subjective symptoms of vaginal atrophy were
assessed according to the 15 criteria set in the genitourinary
atrophy self-assessment tool for patients with breast cancer,
which has had its validity and reliability confirmed by Lester
et al. [31], and were scored based on a 7-point Likert scale
(from totally disagree = 1 to totally agree = 7). The tool was
assessed symptoms of vaginal atrophy in three areas as fol-
lowing: urologic (burning with urination, urge, leakage, in-
complete emptying, nocturnal urination), genital (external ir-
ritation, itching, vaginal dryness, odor, vaginal discharge), and
sexual (dyspareunia, interest/desire in sexual activity, partner
communication, happy with partner).The self-assessment
scores ranged from 15 to 105. The patients who had normal
Pap smear results, no vaginal infection or cervical malignan-
cies and a confirmed vaginal atrophy with VMI ≥ 52, and at
least one of the criteria set in the genitourinary self-assessment
tool were contacted over the phone and invited to visit the
clinic to take part in the study.
In the first session, a package containing 14 vaginal sup-
positories and 14 applicators was given to each patient. The
patients were instructed on how and when to use the suppos-
itories and told when to next visit the clinic for follow-up. One
suppository was to be inserted deep into the vagina by the
applicator every day before bedtime. The patients were
instructed not to use any oral or vaginal hormones during this
time and were asked to visit the clinic in the case of problems
or irritation and burning following the use of the suppositories
or to contact the numbers given to them. During the study, the
patients were contacted on a telephone every 3 days, and in
addition to reminding and following up on the use of suppos-
itories, their possible questions were also answered. The dates
for the next visits were arranged as follows: the second visit in
the second week, the third visit in the fourth week, and the
fourth visit in the eighth week of beginning the use of the
suppositories. In the second visit, in addition to distributing
the next 14 suppositories, the patients’ subjective symptoms of
vaginal atrophy were assessed by the 15-point self-assessment
tool and their vaginal pH was measured. In the third visit, in
addition to distributing the remaining 28 suppositories, the
subjective symptoms of vaginal atrophy and pH value were
again assessed as in the second visit. In the fourth visit, the
subjective symptoms of vaginal atrophy, pH, and VMI were
controlled.
Randomization and intervention
A total of 96 patients were randomly assigned into three
groups (Fig. 1) using permuted block randomization. The
groups were identified with letters A to C, and each group
was given one of the three types of suppositories coded
by the manufacturer that contained either vitamin D, vita-
min E, or placebo. The researcher, patients, pathologist,
and data analysts were blinded to the groupings. The vi-
tamin D, vitamin E, and placebo suppositories were pre-
pared at the School of Pharmacy of Shiraz University of
Medical Sciences using the base substance including fatty
acid bases (Hard Fat Suppocire AS2) and semi-synthetic
glyceride fatty acid (Gattefossé SAS, France). The place-
bo suppository contained only 2 g of the base substance.
The vitamin D suppository contained 2 g of the base sub-
stance plus 1000 IU of vitamin D (0.025 mg), and the
vitamin E suppository contained 1 mg of vitamin E plus
2 g of the base substance. The suppositories and applica-
tors were put in similar packages and coded by the
manufacturer.
 Support Care Cancer

Enrolment Assessed for eligibility

(n=170)

Excluded (n=74)

Not meeting inclusion criteria (n=68)

Declined to participate (n=5)
Other reasons:
Randomized (n=96) Husband's dissatisfaction (n=1)

Allocation Allocation

Allocated to intervention group A Allocated to intervention group B Allocated to intervention group C

(n=32) (n=32) (n=32)
Received allocated intervention Received allocated intervention Received allocated intervention
(n=32) (n=32) (n=32)
Did not receive allocated intervention Did not receive allocated intervention Did not receive allocated intervention
(n=0) (n=0) (n=0)

Follow-up Follow-up

Lost to follow-up Lost to follow-up Lost to follow-up

(n=0) (n=0) (n=0)
Discontinued intervention Discontinued intervention Discontinued intervention
(n= 0) (n= 0) (n= 0)

Analysis Analysis

Analysed (n=32) Analysed (n=32) Analysed (n=32)

Excluded from analysis(n=0) Excluded from analysis(n=0) Excluded from analysis(n=0)

Fig. 1 Patient flow diagram

Statistical analysis Results

Data were analyzed in SPSS-16 using descriptive statistics The results showed no significant differences among the
and the paired t test, the ANOVA, Tukey’s post hoc test, the three groups in terms of participants’ demographic de-
chi-square test, and the repeated measures ANOVA at the tails such as age, age at marriage, age at menarche,
significance level of 0.05. gravidity, parity, number of abortions, number of living
Support Care Cancer

Table 1 The demographic background details of the participating women in the vitamin E, vitamin D, and placebo groups

Variable Vit E (mean ± SD) Vit D (mean ± SD) Placebo (mean ± SD) P valuea
Age (years) 44.1 ± 4.6 43.7 ± 3.9 42.0 ± 6.3 0.223
Age at marriage (years) 21.0 ± 5.5 20.8 ± 7.1 21.3 ± 5.1 0.945
Age at menarche (years) 12.8 ± 1.1 12.6 ± 1.2 13.4 ± 1.3 0.066
Gravidity 2.7 ± 2.0 3.0 ± 1.3 2.5 ± 1.5 0.626
Parity 2.1 ± 0.9 2.5 ± 0.9 2.1 ± 1.2 0.298
Number of abortions 0.62 ± 1.4 0.46 ± 0.87 0.40 ± 1.0 0.740
Number of living children 2.1 ± 0.9 2.5 ± 0.98 2.1 ± 1.2 0.254
BMIb (kg/m2) 25.5 ± 2.6 26.6 ± 2.5 26.6 ± 2.4 0.134
Variables Vit E, Nc (%) Vit D, N (%) Placebo, N (%) P valued
Education Primary school 6 (18.8) 8 (25) 6 (18.8) 0.180
Secondary school 6 (19.4) 9 (28.1) 5 (16.7)
High school diploma 6 (19.4) 7 (21.9) 14 (46.7)
University degree 14 (45.2) 8 (25) 7 (23.3)
Occupation Housewife 23 (71.9) 26 (81.3) 27 (84.4) 0.440
Employed 9 (28.1) 6 (18.8) 5 (15.6)
a
P values based on the ANOVA
b
Body mass index
c
32 patients per group
d
P values based on the chi-square test

children, body mass index (BMI), education, and occu-
pation (Table 1).
No significant differences were observed among the three
groups in terms of the stage of the disease, type of malignancy,
and history and frequency of chemotherapy and radiotherapy.
The duration of use of tamoxifen varied from 2 to 89 months
in the participants, with significant differences observed
among the three groups. The vitamin E group had used
tamoxifen for a longer period. The difference observed based
on Tukey’s post hoc test was only due to the difference be-
tween the vitamin E and placebo groups (P = 0.008) (Table 2).
At first, we used repeated measures analysis of covariance
(RMANCOVA) for controlling the duration of tamoxifen use
(month). Results showed that there was a significant differ-
ence between the three groups (P = 0.027). The results obtain-
ed showed a significant difference among the three groups in

Table 2 The disease status and clinical history in the vitamin E, vitamin D and placebo groups

Variable Vit E, Na (%) Vit D, N (%) Placebo, N (%) P valueb

Stage
Stage I 14 (43.8) 11 (34.4) 8 (25) 0.287
Stage II 18 (56.3) 21 (56.6) 24 (75) 0.287
Type of malignancy
Infiltrative ductal carcinoma 26 (81.3) 27 (84.4) 28 (87.5) 0.779
Invasive ductal carcinoma with 2 (6.2) 3 (9.4) 3 (9.4)
medullary features
Otherc 4 (12.5) 2 (6.2) 1 (3.1)
A history of chemotherapy 31 (96.9) 31 (96.9) 31 (96.9) > 0.999
A history of radiotherapy 31 (96.9) 30 (93.8) 29 (90.6) 0.587
Variable Vit E (mean ± SD) Vit D (mean ± SD) Placebo (mean ± SD) P valued
Chemotherapy sessions 7.3 ± 2.0 6.9 ± 1.6 7.4 ± 2.3 0.547
Radiotherapy sessions 23.9 ± 6.9 24.2 ± 6.6 22.6 ± 7.7 0.638
Duration of tamoxifen use (month) 30.4 ± 21 23.6 ± 17.5 16.6 ± 12.5 0.008
a
32 patients per group
b
P values based on the chi-square test
c
Other might include invasive mucinous carcinoma, invasive lobular carcinoma, carcinoma in situ, and ductal carcinoma with neuroendocrine features
d
P values based on the ANOVA

terms of the mean vaginal pH before the intervention. The
inter-group comparison in terms of the mean vaginal pH
showed a significant difference among the three groups
8 weeks after the intervention. The intra-group comparison
of the mean pH also showed significant differences before
and after the intervention, and the mean pH reduced by
1.59 units in the vitamin E group and by 1.53 units in the
vitamin D group, but increased by 0.04 units in the placebo
group (Table 3).
At first, we used repeated measures analysis of covariance
(RMANCOVA) for controlling the duration of tamoxifen use
(month) on VMI. Results showed that there was a significant
difference between the three groups for VMI in superficial and
parabasal cells (P ≤ 0.001). But there was no significance in
intermediate cells (P = 0.416).
The inter-group comparison of the VMI before the inter-
vention showed no significant differences in terms of the per-
centage of superficial and parabasal cells, but the difference
among the groups was statistically significant at the end of the
eighth week of the intervention. The results showed that the
mean VMI increased significantly only in the vitamin E and
vitamin D groups by the end of the eighth week, and this
difference was due to the increase in the mean percentage of
superficial cells and the decrease in the mean percentage of
parabasal cells in these two groups compared to before the
intervention, while no such change was observed in the pla-
cebo group. The intra-group comparison of the mean VMI
showed significant differences in the percentage of superficial
and parabasal cells in the vitamin E and D groups before and
after the intervention. The inter- and intra-group comparison
of the mean percentage of intermediate cells before and after
the intervention showed no significant differences (Table 4).
The inter-group comparison of the mean score of the gen-
itourinary atrophy self-assessment showed no significant dif-
ferences before the intervention, but the difference was signif-
icant at the second, fourth, and eighth weeks of the interven-
tion, which suggests improved subjective symptoms of vagi-
nal atrophy in the vitamin E and D groups on these occasions.
The intra-group comparison of the mean score of genitouri-
nary atrophy self-assessment in the three groups showed a
significant reduction in the mean score in the vitamin E and
D groups compared with that in the placebo group (Table 5).
Table 3 The pH measured on
different occasions in the vitamin Time
E, vitamin D, and placebo groups
Before the intervention
Second week
Fourth week
Eighth week
P valueb
a
P values based on the ANOVA
b
P values based on repeated measures analysis of variance
Support Care Cancer
Discussion
The results showed a significant reduction in the vaginal pH,
an increase in the VMI, and improvements in the subjective
symptoms of vaginal atrophy with the use of vitamin E and D
vaginal suppositories in women with breast cancer using ta-
moxifen compared with those in the placebo group. Before
beginning the study, vaginal pH differed significantly among
the three groups, and its mean numerical value was higher in
the vitamin E and D groups compared with that in the placebo
group, which appears to be due to the longer period of using
tamoxifen in these two groups. By the end of the intervention,
the mean pH decreased significantly in these two groups com-
pared with that in the placebo group. The significant differ-
ence in pH in the placebo group by the end of the study was
due to the increase in the mean pH, which suggests the exac-
erbation of the status of vaginal atrophy due to the longer
period of tamoxifen use in this group. By the end of the study,
the VMI increased significantly in the vitamin E and D groups
compared with that in the placebo group as a result of the
increase in superficial cells and the decrease in parabasal cells
in these two groups. The descending trend of the mean score
of the genitourinary atrophy self-assessment in the vitamin E
and D groups compared with that in the placebo group from
the second week to the end of the intervention was indicative
of a reduction in the symptoms of atrophy in these two groups.
The present findings agree with the results obtained in pre-
vious studies on the effect of vitamin E and D on vaginal
atrophy in postmenopausal women. In a study conducted by
Yildirim et al. in Turkey to assess the effect of a daily dose of
0.500 μg of calcitriol for 1 year on vaginal atrophy in post-
menopausal women, an improvement was observed in the
symptoms of vaginal atrophy, the VMI increased and pH de-
creased; however, this study only assessed the effect of oral
vitamin D on the symptoms of vaginal atrophy in physiolog-
ically postmenopausal women, while the present study inves-
tigated the effect of vitamins E and D on tamoxifen-induced
vaginal atrophy in women with breast cancer. The cited study
showed a significant difference between the intervention and
control groups in terms of the percentage of superficial and
parabasal cells, but no significant differences were observed
between them in terms of intermediate cells at the end of the
Vit E (mean ± SD) Vit D (mean ± SD) Placebo (mean ± SD) P valuea
6.07 ± 0.75 5.93 ± 0.57 5.59 ± 0.53 0.008
5.68 ± 0.69 5.53 ± 0.58 5.56 ± 0.5 0.544
5.12 ± 0.62 5 ± 0.53 5.42 ± 0.52 0.011
4.48 ± 0.49 4.4 ± 0.34 5.64 ± 0.66 < 0.001
< 0.001 < 0.001 < 0.001
Support Care Cancer

Table 4 The mean VMI before

the intervention and at the end of Variable Time Vit E (mean ± SD) Vit D (mean ± SD) Placebo (mean ± SD) P valuec
the eighth week in the vitamin E,
vitamin D, and placebo groups VMI T1a 44.2 ± 6.5 44.3 ± 5.7 47.1 ± 5.2 0.081
T2b 76.2 ± 5.6 76.1 ± 4.5 47.8 ± 5.0 < 0.001
P valued < 0.001 < 0.001 0.074
Superficial cells T1 14.6 ± 8.3 13.1 ± 6.9 16.9 ± 7.7 0.143
T2 51.4 ± 10.4 50.5 ± 9.7 17.7 ± 7.1 < 0.001
P valuee < 0.001 < 0.001 0.110
Intermediate cells T1 31.9 ± 12.3 34.7 ± 11.5 34.3 ± 7.7 0.522
T2 37.1 ± 10.9 39.1 ± 11.3 35.4 ± 7.7 0.343
P valuef 0.071 0.141 0.341
Parabasal cells T1 53 ± 12.1 51.4 ± 11.0 47.84 ± 7.3 0.125
T2 11.3 ± 6.9 10.2 ± 5.9 46.15 ± 6.8 < 0.001
P valueg < 0.001 < 0.001 0.060
a
T1: before the intervention
b
T2: the eighth week of the intervention
c
P values based on the ANOVA and Tukey’s post hoc test
d, e, f, g
P values based on the paired t test

intervention. In the present study, too, a significant increase
was observed at the end of the intervention in the mean per-
centage of superficial cells and a significant reduction in the
percentage of parabasal cells in the vitamin E and D groups,
but no significant changes were observed in the percentage of
intermediate cells. Just as the oral vitamin D used in Yildirim’s
study, the vitamin D vaginal suppositories used in the present
study were able to improve the symptoms of vaginal atrophy
[23].
The present results also agree with those obtained in a
study conducted by Zeyneloglu et al. in Turkey to assess the
effect of a 60-mg daily dose of raloxifene plus 400 IU of oral
vitamin D for 3 months on the VMI and genitourinary symp-
toms in postmenopausal women with osteoporosis. Just as in
the present study, Zeyneloglu’s study found a significant in-
crease in the VMI in the intervention group, and the changes
in the percentage of intermediate and parabasal cells were
statistically significant, but the percentage of superficial cells
did not change significantly. These findings are only consis-
tent with the present findings in terms of the changes in
parabasal cells and are inconsistent in terms of superficial
and intermediate cells. Moreover, no significant changes were
reported in the patients’ self-reported symptoms such as
dyspareunia, urination problems, vaginal burning, and hot
flushes, which disagrees with the results of the present study.
This disparity of findings could be due to the differences in the
causes of vaginal atrophy, type of intervention and method,
and dosage of supplements used [28].
The present findings concur with the results obtained in a
study conducted by Rad et al. in Iran to assess the effect of a
daily dose of 1000 IU of vitamin D in the form of vaginal
suppositories for 8 weeks on vaginal dryness and mucosal
discoloration in postmenopausal women. In the cited study,
the mean severity of dryness and discoloration decreased in
the intervention group after the intervention. Unlike the pres-
ent study, Rad et al. investigated only the state of parabasal
cells; yet, their results showed a significant reduction in the
mean parabasal cells of the vaginal mucosa in the intervention
group compared with those in the controls, which is consistent
with the present findings [24].
The present findings concur with the results obtained in a
study conducted in Iran by Ziaghami et al. to assess the effect
of vaginal suppositories of 1 mg of vitamin E for 8 weeks on
vaginal atrophy in postmenopausal women. In the cited study,

Table 5 The mean score of the

genitourinary atrophy self- Time Vit E (mean ± SD) Vit D (mean ± SD) Placebo (mean ± SD) P valuea
assessment in the vitamin E,
vitamin D, and placebo groups Before the intervention 64.4 ± 10.2 66.3 ± 12.6 62.0 ± 10.6 0.315
Second week 55.0 ± 9.2 56.9 ± 10.7 62.1 ± 10.1 0.017
Fourth week 45.4 ± 8.6 47.6 ± 9.7 61.6 ± 10.2 < 0.001
Eighth week 35.3 ± 7.2 37.6 ± 8.2 62.6 ± 11.2 < 0.001
P valueb < 0.001 < 0.001 0.564
a
P values based on the ANOVA
b
P values based on repeated measures analysis of variance

the effect of vitamin E suppositories was assessed exclusively
by objective criteria such as pH measurement and changes in
the vaginal maturation value (VMV) of the mucosal cells, and
no subjective criteria such as self-assessment tools were used;
nevertheless, the results showed an increase in the VMV and a
significant reduction in the vaginal pH in the intervention
group compared with those in the controls [26].
The results of another study conducted in Iran by Ziaghami
et al. to compare the effects of the daily use of hyaluronic acid
and 1-mg vitamin E vaginal suppositories in the treatment of
the symptoms of vaginal atrophy (burning, itching, dryness,
and dyspareunia) in postmenopausal women were also con-
sistent with the present findings. The cited study showed a
significant reduction in vaginal atrophy symptoms in both
groups after the intervention compared with baseline.
Although the scales used for measuring vaginal atrophy symp-
toms, the cause of atrophy and even the type of intervention
given were different from the present study, the improvement
in symptoms of the vaginal atrophy self-assessment showed
that using vitamin E vaginal suppository can improve the sub-
jective symptoms of vaginal atrophy [32].
A clinical trial was conducted in Iran by Golmakani et al. to
compare the efficacy of 100 IU of vitamin E vaginal suppos-
itory and 0.625 mg of conjugated estrogen vaginal cream on
quality of life in postmenopausal women in vasomotor, psy-
chological, physical, and sexual domains. By the end of the
intervention, the score of the menopause quality of life instru-
ment increased significantly to suggest an improvement in
symptoms. Regardless of the different atrophy symptom as-
sessment tools used in the cited studies, their results also sug-
gest an improvement in these symptoms due to the use of
vitamin E vaginal suppositories [33].
In a study conducted by Morali et al., 1-month use of a
medical product in the form of a 2.5-g vaginal gel of
hyaluronic acid, liposome, and phytoestrogen from Humulus
lupulus extract and vitamin E in postmenopausal women with
vaginal atrophy reduced dyspareunia significantly. In the cited
study, other symptoms of vaginal atrophy also improved, in-
cluding itching, burning, inflammation, edema, and redness,
and an increase was observed in the VMI, which supports the
present findings [34].
The study conducted by Costantino et al. to investigate 1-
month use of a vaginal suppository of hyaluronic acid, vitamin
A, and vitamin E on vaginal atrophy in postmenopausal wom-
en also showed an improvement in vaginal atrophy symptoms
such as itching, burning, and dyspareunia [16]. Dinicola et al.
investigated the vaginal smear of women with cervical cancer
and vaginal atrophy undergoing radiotherapy, and by the end
of month four of the daily use of two suppositories (vitamin A,
vitamin E, and hyaluronic acid), the intervention group
showed significant improvements in terms of inflammation,
cell deformity, fibrosis, mucus inflammation, and bleeding.
This intervention was also effective in reducing the
Support Care Cancer
complications of radiotherapy and brachytherapy and the se-
verity of pain and improving the symptoms of vaginal atrophy.
Although the individual effect of vitamin E on the vaginal
mucus was not investigated in the cited studies, using combi-
nation products containing vitamin E appears to have also
improved the symptoms of vaginal atrophy [35].
The limitations of the present study include the failure to
assess the effect of using vitamin E and D suppositories for
periods longer than 2 months due to the lack of enough funds
for preparing these vaginal suppositories; nevertheless, at-
tempts were made to assess the effect of using these suppos-
itories in this rather short period through objective criteria
such as pH and VMI measurement and subjective criteria such
as genitourinary symptoms through a vaginal atrophy self-
assessment tool for women with breast cancer. In the next
steps, we consider to design randomized trials to clarify the
result of the current study better. Our research team wants to
design these studies with different duration times of interven-
tion, doses of vitamin E and D vaginal suppositories, and
pattern of the suppositories used. Additionally, we think to
plan a study to compare the effect of vitamin E, vitamin D,
and the combination of vitamin D and E vaginal suppositories
on tamoxifen-induced vaginal atrophy and its effect on sexual
function in women with breast cancer.
Conclusion
The results supported that vitamin D and E vaginal supposi-
tories are beneficial in reducing vaginal pH, improving the
VMI and improving the genitourinary symptoms of vaginal
atrophy in women with breast cancer receiving tamoxifen.
Given the prohibition on hormone therapy in this group of
women, these vaginal suppositories can be used to improve
the symptoms.
Compliance with ethical standards
The research project was approved by the ethics committee of Shiraz
University of Medical Sciences (IR.SUMS.REC 94-01-08-11247) and
r e g i s t e r e d a t t he I r a n i a n R e g i s t r y of C l i ni c a l Tr i a l s
(IRCT2016100229683N2).
Conflict of interest The authors declare that they have no conflict of
interest.
Publisher’s note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
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