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.

Keywords: Genitourinary syndrome of menopause; Breast cancer survivors; Aromatase inhibitors; Vaginal moisturizers and lubricants; Vaginal estrogens; Laser

Core Tip: Genitourinary syndrome of menopause (GSM) is commonly experienced by breast cancer survivors (BCSs) receiving antiestrogen therapy, specifically aromatase inhibitors. Vaginal dryness, itching, irritation and dyspareunia produce impairment of sexual function and negatively impact on the quality of life. Healthy women, and even more so BCSs, are reluctant to discuss this problem with their general practitioner or oncologist. Safety of vaginal estrogen therapy for management of GSM refractory to other nonhormonal treatment in BCSs has not been definitively established, and recommendations for use remain controversial. This review aims to summarize the clinical approach and emerging therapeutic alternatives, considering the efficacy and potencial adverse effects in this population.