*2.1.7 Protection from vaginal toxicity*

Vaginal toxicity is a significant complication of VB and it impairs the quality of sexual life due to vaginal atrophy, shortness and narrowness. The sexual activity frequency and satisfaction are reduced in patients undergoing surgery and VB [24]. In a study, having sexual intercourse during the VB treatment was reported to prevent vaginal shortness and narrowness; however, atrophy-related dyspareunia was reported in 2/3 of the patients and furthermore, it was emphasized that the distal 2/3 of the vagina was more susceptible to toxic effects rather than the proximal 1/3 of the vagina [22]. Use of vaginal dilator for 6 months following radiotherapy was shown to decrease the vaginal stenosis [25]. In the Cochrane database, use of vaginal dilator during radiotherapy was not shown to have sufficient evidence. However, it accepts the observational studies suggesting that use of the regular vaginal dilator may improve the vaginal stenosis rates reported by the patients [26]. Estrogen cream is another option for protection of the vagina. Despite the absence of sufficient and strong evidence about the use of estrogen creams, they were shown to prevent vaginal atrophy in small studies [27]. A selection should be made after discussing the benefits and harms of this treatment option with the patient.
