Management of genitourinary syndrome of menopause in breast cancer survivors: An update

Abstract

There is increasing attention about managing the adverse effects of adjuvant therapy (Chemotherapy and anti-estrogen treatment) for breast cancer survivors (BCSs). Vulvovaginal atrophy (VVA), caused by decreased levels of circulating estrogen to urogenital receptors, is commonly experienced by this patients. Women receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM), that it can in turn lead to pain, discomfort, impairment of sexual function and negatively impact on multiple domains of quality of life (QoL). The worsening of QoL in these patients due to GSM symptoms can lead to discontinuation of hormone adjuvant therapies and therefore must be addressed properly. The diagnosis of VVA is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Systemic estrogen treatment is contraindicated in BCSs. In these patients, GSM may be prevented, reduced and managed in most cases but this requires early recognition and appropriate treatment, but it is normally undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy (VET) because of unknown levels of systemic absorption of estradiol. Lifestyle modifications and nonhormonal treatments (vaginal moisturizers, lubricants, and gels) are the first-line treatment for GSM both in healthy women as BCSs, but when these are not effective for symptom relief, other options can be considered, such as VET, ospemifene, local androgens, intravaginal dehydroepiandrosterone (prasterone), or laser therapy (erbium or CO2 Laser). The present data suggest that these therapies are effective for VVA in BCSs; however, safety remains controversial and a there is a major concern with all of these treatments. We review current evidence for various nonpharmacologic and pharmacologic therapeutic modalities for GSM in BCSs and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. We include recommendations for an approach to the management of GSM in 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.

Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer

“…However, several of the systemic treatments for breast cancer, including endocrine therapy, chemotherapy, and radiotherapy, can result in a new or worsened hypoestrogenic state. 1 Lack of circulating estrogen can lead to genitourinary syndrome of menopause, which encompasses symptoms associated with decreased sex steroids related to the urinary and genital systems and can include sexual dysfunction. [2][3][4] More than 70% of postmenopausal women who survive breast cancer and are treated with systemic therapies subsequently experience genitourinary syndrome of menopause.…”

“…[2][3][4] More than 70% of postmenopausal women who survive breast cancer and are treated with systemic therapies subsequently experience genitourinary syndrome of menopause. 1 Although there are many treatments for genitourinary syndrome of menopause, one of the most effective options for vulvovaginal atrophy is vaginal estrogen therapy. 5 Vaginal estrogen therapy provides a low dose of estrogen locally to the genitourinary tissues.…”

Therapeutic Choices for Genitourinary Syndrome of Menopause (GSM) in Breast Cancer Survivors: A Systematic Review and Update

“…However, the available data are short-term, and the efficacy, as well as the safety of repeated applications, are unclear. Furthermore, CO 2 laser treatment is very expensive and a procedure that is not yet widely performed by gynecologists; therefore, access to this method may be limited [71].…”

Diagnosis, causes, and treatment of dyspareunia in postmenopausal women

“…112 Although trials evaluating testosterone in postmenopausal women with breast cancer showed improvement in GSM symptoms, women who use testosterone to avoid estrogen need to be informed that estrogen is a metabolite of testosterone, and use may result in a measurable systemic estrogen level. [113][114][115][116][117] In women who use aromatase inhibitors, this conversion to estrogen may be blocked.…”