Managing Genitourinary Syndrome of Menopause in Breast Cancer Survivors Receiving Endocrine Therapy

Abstract

Patients with breast cancer receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM). GSM can decrease quality of life and is undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy because of unknown levels of systemic absorption of estradiol. In this article, we review the available literature for treatment of GSM in patients with breast cancer and survivors, including nonhormonal, vaginal hormonal, and systemic hormonal therapy options. First-line treatment includes nonhormonal therapy with vaginal moisturizers, lubricants, and gels. Although initial studies showed significant improvement in symptoms, the US Food and Drug Administration recently issued a warning against CO2 laser therapy for treatment of GSM until additional studies are conducted. In severe or refractory GSM, after discussing risks and benefits of vaginal hormonal therapy, the low-dose 10-μg estradiol-releasing intravaginal tablet or lower-dose 4 μg estrogen vaginal insert and intravaginal dehydroepiandrosterone (prasterone) are options for treatment, because studies show minimal elevation in serum estradiol levels and significant improvement in symptoms. The decision to offer vaginal estrogen therapy must be individualized and made jointly with the patient and her oncologist.

Aromatase Inhibitors—Induced Musculoskeletal Disorders: Current Knowledge on Clinical and Molecular Aspects

“…Some genitourinary disorders may also be associated, that is, urogenital or vulvovaginal atrophy settling the so-called genitourinary syndrome of menopause (GSM), which includes vaginal dryness, itching, irritation, dyspareunia, dysuria and recurrent urinary infections. GSM is a serious concern that may strongly affect quality of life in these patients [25]. In case of moderate to severe menopausal symptoms, selective serotonin reuptake inhibitors, gabapentin or pregabalin and clonidine can be successfully used [24].…”

Time for Action: Managing Genitourinary Syndrome of Menopause

“…Although studies to date have not demonstrated an increase in the risk of breast cancer recurrence associated with the use of vaginal estrogen, studies have demonstrated an increase in serum estradiol in women using vaginal estrogens that may be of concern to many breast cancer survivors and their providers. 4 In the accompanying article, Sussman et al 5 reviewed the available literature for use of nonhormonal, vaginal hormonal, and systemic therapy options for the treatment of GSM. The authors advocate for an individualized approach to treatment of GSM.…”

“…Topical prasterone is another option that can be helpful in some women. 5 There are several other options to consider if women are still experiencing symptoms with vaginal lubricants and moisturizers. Hyaluronic acid or lidocaine are additional topical therapies that are options for GSM.…”

Genitourinary Syndrome of Menopause in Breast Cancer Survivors: A Common Complication With Effective Treatment Strategies

“…The increased risk of recurrence of breast cancer has swayed oncologists from prescribing estrogen replacement. As highlighted in the accompanying review article by Sussman et al, 4 this is an important complication of endocrine therapy for breast cancer, which has multiple effective and fairly safe treatment options. 3 The choice of treatment of GSM depends on the severity of symptoms.…”

“…Vaginal moisturizers and lubricants work effectively by reducing friction and irritation, whereas pH-balancing gels help by reducing the vaginal pH and restoring vaginal mucosa. 4 Hyaluronic acid gel and CO 2 laser therapy are other options, which are still being studied.…”