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

Table 5 Treatment options for management of genitourinary syndrome of menopause in specific patient populations: Consensus recommendations of the The North American Menopause Society[65]

General guidelines
Individualize treatment, taking into account risk of recurrence, severity of symptoms, effect on QoL, and personal preferences
Moisturizers and lubricants, pelvic floor physical therapy, and dilator therapy are firstline treatments
Involve treating oncologist in decision making when considering the use of local hormone therapies1
Ospemifene, an oral SERM, has not been studied in women at risk for breast cancer and is not FDAapproved for use in women with or at high risk for breast cancer
Offlabel use of compounded vaginal testosterone or estriol is not recommended
Laser therapy may be considered in women who prefer a nonhormonal approach; women must be counseled regarding lack of longterm safety and efficacy data
Women at high risk for breast cancer2
Local hormone therapies are a reasonable option for women who have failed nonhormonal treatment
Observational data do not suggest increased risk of breast cancer with systemic or local estrogen therapies beyond baseline risk
Women with ERpositive breast cancers on tamoxifen
Tamoxifen is a SERM that acts as an ER antagonist in breast tissue; small transient elevations in serum hormone levels noted with local hormone therapies in women on tamoxifen are less concerning than in women on AIs
Women with persistent, severe symptoms who have failed nonhormonal treatments and who have factors suggesting a low risk of recurrence may be candidates for local hormone therapy
Women with ERpositive breast cancers on AI
AIs block conversion of androgen to estrogen, resulting in undetectable serum estradiol levels; transient elevations in estradiol levels may be of concern
GSM symptoms are often more severe
Women with severe symptoms who have failed nonhormonal treatments may still be candidates for local hormone therapies after review with the woman’s oncologist vs consider switching to tamoxifen
Women with triplenegative breast cancers
Theoretically, the use of local hormone therapy in women with a history of triplenegative disease is reasonable, but data are lacking
Women with metastatic disease
QoL, comfort, and intimacy may be a priority for many women with metastatic disease
Use of local hormone therapy in women with metastatic disease and probable extended survival may be viewed differently than in women with limited survival when QOL may be a priority

¹Local hormone therapies are vaginal estrogen and intravaginal DHEA (prasterone).

²Lifetime risk > 20%, carriers of the BRCA mutation, atypical ductal hyperplasia, lobular carcinoma in situ, or ductal carcinoma in situ. AI: Aromatase inhibitor; ER: Estrogen receptor; GSM: Genitourinary syndrome of menopause; QoL: Quality of life; SERM: Selective estrogen-receptor modulator.