Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women's Sexual Health

Abstract

The objective of The North American Menopause Society (NAMS) and The International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel was to create a point of care algorithm for treating genitourinary syndrome of menopause (GSM) in women with or at high risk for breast cancer. The consensus recommendations will assist healthcare providers in managing GSM with a goal of improving the care and quality of life for these women. The Expert Consensus Panel is comprised of a diverse group of 16 multidisciplinary experts well respected in their fields. The panelists individually conducted an evidence-based review of the literature in their respective areas of expertise. They then met to discuss the latest treatment options for genitourinary syndrome of menopause (GSM) in survivors of breast cancer and review management strategies for GSM in women with or at high risk for breast cancer, using a modified Delphi method. This iterative process involved presentations summarizing the current literature, debate, and discussion of divergent opinions concerning GSM assessment and management, leading to the development of consensus recommendations for the clinician.Genitourinary syndrome of menopause is more prevalent in survivors of breast cancer, is commonly undiagnosed and untreated, and may have early onset because of cancer treatments or risk-reducing strategies. The paucity of evidence regarding the safety of vaginal hormone therapies in women with or at high risk for breast cancer has resulted in avoidance of treatment, potentially adversely affecting quality of life and intimate relationships. Factors influencing decision-making regarding treatment for GSM include breast cancer recurrence risk, severity of symptoms, response to prior therapies, and personal preference.We review current evidence for various pharmacologic and nonpharmacologic therapeutic modalities in women with a history of or at high risk for breast cancer and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. Treatment of GSM is individualized, with nonhormone treatments generally being first line in this population. The use of local hormone therapies may be an option for some women who fail nonpharmacologic and nonhormone treatments after a discussion of risks and benefits and review with a woman's oncologist. We provide consensus recommendations for an approach to the management of GSM in specific patient populations, including women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

A systematic review of laser therapy for vulvovaginal atrophy/genitourinary syndrome of menopause in breast cancer survivors

“…Management for GSM symptoms includes topical treatment with vaginal moisturizers, lubricants, systemic and/or topical oestrogen therapy [2]. Specific treatments for the management of sexual dysfunction include the use of vaginal lubricants and dilators, local anaesthetics (topical/injected), physiotherapy and psychosexual counselling [12].…”

“…However, systemic hormone replacement therapy (HRT) is contraindicated in those with a history of breast cancer [23]. GSM is particularly bothersome in breast cancer survivors as there is often both clinician and patient reluctance to use topical oestrogen treatment [2]. The North American Menopause Society (NAMS) recommend an assessment by the oncology team considering risk and benefit on an individual patient basis.…”

Genitourinary syndrome of menopause treatment using lasers and temperature-controlled radiofrequency

“…Efficacy data may be considered in women who prefer non-hormonal treatments after a discussion of potential risks, benefits, and need for ongoing treatments, and costs. NAMS recommendations for management of GSM in specific patient populations: women at high risk for breast cancer, women with oestrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease – choose lasers as a first line therapy [15].…”

Effect of Vitamin D Supplement on Vulvovaginal Atrophy of the Menopause

“…Non-hormonal therapy and alternative treatment of VVA symptoms are often the preferred choice for many patients. These include lifestyle modifications, encouraging sexual activity, use of vaginal lubricants and vaginal moisturizers, vaginal oxytocin gel, vaginal laser therapy, and vitamin D supplementation [ 17 , 18 , 19 , 20 , 21 , 22 ].…”