Vaginal Atrophy in Breast Cancer Survivors: Attitude and Approaches Among Oncologists

The effects of various therapies on vulvovaginal atrophy and quality of life in gynecological cancer patients: a systematic review

PURPOSE

Tumors affecting the female genital tract and their treatments have the potential to induce adverse modifications in vaginal health and impact personal aspects of patient's lives. Vulvovaginal atrophy is one of the morphological changes observed in individuals with a history of gynecological cancer, influenced both by the biological environment of tumors and the main therapeutic modalities employed. Therefore, the purpose of this study was to identify approaches to treat vulvovaginal atrophy while assessing the impact on the emotional and sexual health of women diagnosed with gynecological cancers.

METHODS

To achieve this goal, a systematic review was conducted following the methodological guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The databases used for literature research were PubMed and Web of Science.

RESULTS

Initially, 886 articles were obtained. After eliminating duplicates and applying inclusion/exclusion criteria, seven articles were selected for analysis. The period of highest publication activity spanned from 2017 to 2020, with the majority conducted in Italy. Five treatment modalities were identified and categorized as vaginal suppository, oral medication, surgical procedure, CO2 laser therapy, and vaginal dilator. Twenty-four outcomes related to vaginal health and 30 outcomes related to overall, sexual, and emotional quality of life were analyzed.

CONCLUSION

In general, all interventions demonstrated the ability to improve vaginal health or, at the very least, the sexual health of patients. Thus, despite limitations, all treatments have the potential to address vulvovaginal atrophy in patients with a history of gynecological cancer.

Managing sexual health challenges in breast cancer survivors: A comprehensive review

The significant advancements in breast cancer management have led to an increase in the prevalence of breast cancer survivors. Despite their efficacy, these treatments can cause a variable range of side effects, significantly deteriorating the patients' quality of life. Sexual dysfunction, and in particular the genitourinary syndrome of menopause, represent one of the major causes of quality-of-life impairment among breast cancer patients, potentially affecting treatment adherence and compliance. If in the general population, hypoestrogenism-related symptoms are typically managed through systemic or topical estrogen administration, this approach is contraindicated in breast cancer patients for the potential increased risk of disease recurrence, urging the investigation of alternative measures. The aim of this review is to summarize the most up-to-date pharmacological and non-pharmacological interventions, as well as supportive measures, available for the management of sexual dysfunctions in breast cancer patients and survivors.

Vulvovaginal atrophy in women with and without a history of breast cancer: Baseline data from the PatiEnt satisfactiON studY (PEONY) in Italy

OBJECTIVES

To assess clinical characteristics of postmenopausal women with moderate/severe vulvovaginal atrophy, as well as its impact on sexual function, well-being, and quality of life, and to provide an overview of most used treatments.

STUDY DESIGN

Ongoing longitudinal, observational study conducted in 17 Italian gynecology centers, involving women already treated or initiating a local vaginal estrogen therapy or ospemifene. We report baseline data for women with and without a history of breast cancer. Participants filled in self-reported questionnaires at study entry.

MAIN OUTCOME MEASURES

Severity of vulvovaginal atrophy; ongoing treatments; patient-reported outcomes, including severity of symptoms, Day-to-Day Impact of Vaginal Aging (DIVA), Female Sexual Function Index (FSFI), Female Sexual Distress Scale-Revised (FSDS-R), and SF-12® Health Survey.

RESULTS

Overall, 334 women (20.4 % with a history of breast cancer) started or continued local therapy (61.1 %) or ospemifene (38.8 %) at study entry. Vulvovaginal atrophy was severe in 28.6 %, and was responsible for severe symptoms, particularly vulvar dryness with burning or irritation and pain during sexual intercourse. Both sexual dysfunction (FSFI≤26) (81.5 %) and sexual distress (FSDS-R ≥ 11) (74.4 %) were common. A reduction in the SF-12 mental component score was documented. Women with breast cancer more often had severe vulvovaginal atrophy (41.2 %), had more severe symptoms, and the impact of vaginal symptoms on emotional well-being, sexual functioning and self-concept/body image was greater. The majority of them (83.8 %) received ospemifene as a treatment.

CONCLUSIONS

Moderate/severe vulvovaginal atrophy is a common, often neglected condition with an impact on QoL and sexuality, particularly in women with a history of breast cancer. It is important to alleviate the burden associated with the disease.

Genitourinary syndrome of menopause in patients with breast cancer treated by hormonotherapy: women's perception in ITAC, a French web-based survey

OBJECTIVE

To describe frequency, intensity and impact of genito-urinary syndrome of menopause (GUSM) in breast cancer (BC) survivors receiving hormonotherapy (HT).

METHODS

Web-based survey hosted on the Seintinelles website (database of patients and caregivers). Specific questionnaire of 43 questions, including sociodemographic characteristics, history of BC, characteristics of HT, side effects other than GUSM, symptoms of GUSM (frequency, intensity, treatment, and impact) and overall expectations regarding treatment.

RESULTS

Among 1157 participants, 96.4% had at least one GUSM symptom. Percentages with at least one urinary, gynecological, or sexual symptom were 56.0%, 85.6% and 86.1% respectively while 70.3% and 10% declared at least 5 and 10 symptoms respectively. Mean (SD) and median (range) numbers of symptoms were 5.9 (2.8) and 6 (0-14) respectively. Most frequently reported symptoms were decreased desire (77.8%), decreased arousal (71.4%), and vaginal dryness 68.4%). On a scale from 0 (no impact) to 10 (maximal impact), the most important impact was reported for sexual life (mean: 6.6±3.5) followed by psychological condition/self-image (mean 5.4±3.1), and relations with partners (mean: 5.1±3.4). Only 13.6% of participants had received information on GUSM prior to the survey.

CONCLUSIONS

GUSM remains underdiagnosed and underestimated in BC survivors who receive HT, although it is among most frequent and disabling side effects of HT. Awareness should be increased among physicians, along with information to women. Early detection and treatment of symptoms and prophylaxis of GUSM in at-risk women should be implemented.

Health-Related quality of life by 31-item Cervantes scale in breast cancer survivors undergoing adjuvant endocrine therapy

INTRODUCTION

Instruments to manage adverse effects of endocrine therapy with Aromatase inhibitors (AI) may improve adherence and persistence to treatment and Health-Related Quality of Life (HRQL). The 31-item Cervantes Scale (CS-31) is an HRQL questionnaire with particularities of the perimenopausal and postmenopausal period that could be an appropriate instrument to assess HRQL in Breast Cancer (BC) survivors.

OBJECTIVE

This study aimed to perform additional validation of the CS-31 for BC survivors undergoing adjuvant endocrine therapy.

METHODS

This prospective study was performed at three time points named T0, T1, and T2: initial, intermediate, and final follow-up period, respectively, totaling 24 months of follow-up. At each time point, the participants completed the CS-31, Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F), and Hospital Anxiety and Depression Scale (HADS). The internal consistency, construct validity, responsiveness analyses, and known-group validity of CS-31 were evaluated.

RESULTS

This study included 89 postmenopausal women diagnosed with hormone receptor-positive early BC in adjuvant endocrine therapy with AI. The internal consistency was good (Cronbach's alpha = 0.89). Construct validity received a positive rating, with 100% of results consistent with prior hypotheses. A prospective improvement in HRQL was identified for the CS-31 Global Score and FACIT-F Total Score and for most of their domains. Furthermore, women with anxiety and depression by HADS presented worse HRQL by CS-31.

CONCLUSION

The authors identified that the CS-31 seems to be appropriate for use in oncology medical routine and may help to monitor adverse effects and HRQL of BC survivors during adjuvant endocrine therapy.

Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer

Importance

Genitourinary syndrome of menopause can be treated with vaginal estrogen therapy. However, there are concerns about the safety of vaginal estrogen therapy in patients with breast cancer.

Objective

To determine whether the risk of breast cancer-specific mortality was higher in females with breast cancer who used vaginal estrogen therapy vs females with breast cancer who did not use hormone replacement therapy (HRT).

Design, Setting, and Participants

This cohort study analyzed 2 large cohorts, one each in Scotland and Wales, of females aged 40 to 79 years with newly diagnosed breast cancer. These population-based cohorts were identified from national cancer registry records from 2010 to 2017 in Scotland and from 2000 to 2016 in Wales and were followed up for breast cancer-specific mortality until 2020. Females were excluded if they had a previous cancer diagnosis (except nonmelanoma skin cancer). Data analysis was performed between August 2022 and August 2023.

Exposure

Use of vaginal estrogen therapy, including vaginal tablets and creams, was ascertained from pharmacy dispensing records of the Prescribing Information System for the Scotland cohort and from general practice prescription records for the Wales cohort.

Main Outcomes and Measures

The primary outcome was time to breast cancer-specific mortality, which was obtained from national mortality records. Time-dependent Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% CIs for breast cancer-specific mortality, comparing vaginal estrogen therapy users with HRT nonusers and adjusting for confounders, including cancer stage and grade.

Results

The 2 cohorts comprised 49 237 females with breast cancer (between 40 and 79 years of age) and 5795 breast cancer-specific deaths. Five percent of patients with breast cancer used vaginal estrogen therapy after breast cancer diagnosis. In vaginal estrogen therapy users compared with HRT nonusers, there was no evidence of a higher risk of breast cancer-specific mortality in the pooled fully adjusted model (HR, 0.77; 95% CI, 0.63-0.94).

Conclusions and Relevance

Results of this study showed no evidence of increased early breast cancer-specific mortality in patients who used vaginal estrogen therapy compared with patients who did not use HRT. This finding may provide some reassurance to prescribing clinicians and support the guidelines suggesting that vaginal estrogen therapy can be considered in patients with breast cancer and genitourinary symptoms.

Safety and Serum Estradiol Levels in Hormonal Treatments for Vulvovaginal Atrophy in Breast Cancer Survivors: A Systematic Review and Meta-Analysis

Vulvo-vaginal atrophy (VVA) or genitourinary syndrome of menopause (GSM) is a common condition among breast cancer (BC) patients, especially those undergoing antiestrogen therapy. Despite being an option in refractory cases, the safety of hormonal treatment remains uncertain in this population. The aim of this study was to review the safety and serum estrogen levels of hormonal therapy in patients with BC history presenting with VVA symptoms. Pubmed, Embase, and Cochrane were searched for studies comparing different hormonal treatment options for VVA in breast cancer survivors. Statistical analysis was performed using a random effects model and heterogeneity using Cochran's Q-statistic and the I2 index. We included 17 studies, of which 5 were randomized controlled trials (RCTs). Treatment modalities included in this study were topical vaginal estradiol and estriol preparations, vaginally applied testosterone, DHEA, and ospemifene. We found that, among patients treated with the estriol and estradiol preparations, there was an average increase of 7.67 pg/mL (SMD 7.67 pg/mL; 95% CI -1.00, 16.35; p < .001). Analysis of the testosterone group found temporary peaks of serum estradiol levels, but 1 study showed persistent elevation above normal postmenopausal levels. One study with prasterone revealed no elevation of serum estradiol concentration. One study with ospemifene demonstrated no increase in the risk of BC recurrence. In conclusion, among treatments available for BC survivors, low-dose vaginal estrogen showed the smallest changes in serum estradiol levels and had the most evidence, but safety remains unclear, especially for patients on aromatase inhibitors. Alternative treatments such as ospemifene need more data supporting safety and efficacy. These results suggest that concerns related to cancer recurrence should keep aiming for the lowest possible concentration.

CO 2 laser, radiofrequency, and promestriene in the treatment of genitourinary syndrome of menopause in breast cancer survivors: a histomorphometric evaluation of the vulvar vestibule

OBJECTIVE

This study aimed to compare the efficacy of CO 2 laser, radiofrequency, and promestriene in treating genitourinary syndrome of menopause in women with breast cancer receiving adjuvant therapy and to analyze the clinical and histological findings of the vulvar vestibule.

METHODS

Women with moderate-to-severe symptoms of vulvar atrophy were enrolled. The participants were evaluated according to pretreatment and posttreatment protocols using the visual analog scale and clinical assessments, which included a gynecological examination and vestibular biopsy. Participants were randomly assigned into the laser, radiofrequency, or promestriene groups. Participants in the energy treatment groups underwent three consecutive monthly outpatient vulvovaginal treatment sessions, whereas those in the control group were administered promestriene for 4 months. During a follow-up visit 30 days posttreatment, the participant global posttreatment impression of improvement was evaluated using a Likert scale.

RESULTS

Seventy women completed treatment. Histological vulvar atrophy was identified in four (5.7%) of the pretreatment vulvar samples. Postintervention, all histological parameters were normalized. Significant improvements in symptoms were observed, as all three groups showed a reduction in the visual analog scale score, with no statistically significant differences among them. A high level of satisfaction was reported posttreatment in all groups. No damage to the histological structure of the vulvar vestibule or relevant clinical adverse events were identified posttreatment.

CONCLUSIONS

Laser, radiofrequency, and promestriene delivered comparable, significant symptom improvements among women with breast cancer receiving adjuvant therapy. These treatments did not cause structural tissue damage or other clinical complications.

Vaginal CO2 laser therapy for genitourinary syndrome in breast cancer survivors-VagLaser study protocol: a randomized blinded, placebo-controlled trial

BACKGROUND

Vaginal CO2 laser therapy is a new treatment option for genitourinary syndrome of menopause. Its potential is particularly interesting in breast cancer survivors, where existing treatment options often are insufficient as hormonal treatment is problematic in these women. The objective of this study is to investigate the effectiveness of vaginal laser treatment for alleviation of genitourinary syndrome of menopause in breast cancer survivors treated with adjuvant endocrine therapy. The secondary objective is to explore the importance of repeated vaginal laser treatment and the long-term effects in this patient population.

METHODS

VagLaser consist of three sub-studies; a dose response study, a randomized, participant blinded, placebo-controlled study and a follow-up study. All studies include breast cancer survivors in adjuvant endocrine therapy, and are conducted at the Department of Obstetrics and Gynecology, Randers Regional Hospital, Denmark. The first participant was recruited on 16th of February 2023. Primary outcome is vaginal dryness. Secondary subjective outcomes are vaginal pain, itching, soreness, urinary symptoms and sexual function. Secondary objective outcomes are change in vaginal histology (punch biopsy), change in vaginal and urine microbiota, and change in vaginal pH.

DISCUSSION

More randomized controlled trials, with longer follow-up to explore the optimal treatment regimen and the number of repeat vaginal laser treatments for alleviation the symptoms of genitourinary syndrome of menopause in breast cancer survivors treated with endocrine adjuvant therapy, are needed. This study will be the first to investigate change in vaginal and urine microbiota during vaginal laser therapy in breast cancer survivors.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06007027 (registered 22 August, 2023).

PROTOCOL VERSION

Version 1, Date 13.11.2023.

Laser and radiofrequency for treating genitourinary syndrome of menopause in breast cancer survivors: a systematic review and meta-analysis protocol

INTRODUCTION

Breast cancer survivors (BCSs) experience more severe symptoms of genitourinary syndrome of menopause (GSM) than healthy postmenopausal women. As hormonal therapy with oestrogen should be avoided in BCSs, finding an effective and safe therapy to address vaginal symptoms and sexual dysfunction is urgently needed. Physical methods may be promising alternatives for the specificities of this group of women. This review aims to evaluate the efficacy and safety of physical methods (laser and radiofrequency) for treating GSM in BCSs.

METHODS AND ANALYSIS

The PubMed, Embase, Web of Science, SciELO, LILACS, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases will be searched. A search strategy was developed to retrieve clinical trials that evaluate the efficacy and safety of any physical method (laser or radiofrequency) used for GSM in BCSs. No date or language restrictions will be imposed. Two authors will independently select studies by title, abstract and full text to meet the inclusion criteria. Data will be extracted, and the risk of bias will be evaluated using the Cochrane risk-of-bias tool (RoB 2). Review Manager 5.4.1 will be used for data synthesis. The Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the strength of the evidence.

ETHICS AND DISSEMINATION

This study reviews the published data; thus, obtaining ethical approval is unnecessary. The findings of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023387680.

Pharmacokinetics, safety and preliminary pharmacodynamic evaluation of DARE-VVA1: a soft gelatin capsule containing tamoxifen for the treatment of vulvovaginal atrophy

OBJECTIVE

This study aimed to measure safety, systemic pharmacokinetics and preliminary efficacy of a vaginal tamoxifen capsule (DARE-VVA1) among postmenopausal women with moderate-to-severe vulvovaginal atrophy.

METHODS

This was a randomized, placebo-controlled, double-blind, phase 1/2 study of DARE-VVA1, in four doses (1, 5, 10 and 20 mg).

RESULTS

Seventeen women were enrolled and 14 completed the 8-week treatment. DARE-VVA1 was safe. All adverse events were of mild or moderate severity and distributed similarly among active and placebo groups. Plasma tamoxifen concentrations were highest among women using DARE-VVA1 20 mg, but the maximum mean (standard deviation) plasma tamoxifen concentrations on day 1 (2.66 ± 0.85 ng/ml) and day 56 (5.69 ± 1.87 ng/ml) were <14% of those measured after one oral tamoxifen dose. Active study product users had significant decreases from pre-treatment baseline in vaginal pH and proportion of vaginal parabasal cells (p = 0.04 for both endpoints), with women randomized to the 10 mg or 20 mg dose experiencing the largest treatment impact. The severity of vaginal dryness and dyspareunia decreased significantly from baseline with active study product use (p = 0.02 for both endpoints).

CONCLUSIONS

DARE-VVA1 is safe and results in minimal systemic exposure to tamoxifen. Preliminary efficacy data support further development of this product.

Comparable Efficacy of Submucosal Platelet-Rich Plasma and Combined Platelet-Rich Plasma Noncrosslinked Hyaluronic Acid Injections in Vulvovaginal Atrophy: A Cancer Survivorship Issue

Background: Cancer survivors are often reluctant to discuss sexual complaints with their oncologists and treatment is frequently unsatisfactory due to paucity of controlled studies and inapplicability of vaginal estrogen. We aimed to evaluate efficacy and tolerability of platelet-rich plasma (PRP) injections alone or in combination with noncrosslinked hyaluronic acid compared with standard therapy with topical hyaluronic acid gel in the management of cancer therapy-induced or aggravated vulvovaginal atrophy. Materials and Methods: This prospective, parallel-group comparative study was conducted on 45 female patients with a history of cancer and complaining of symptoms of vulvovaginal atrophy either induced or aggravated by cancer treatment. Patients were randomly divided into three groups (A, B, and C). Group A patients received two submucosal vaginal PRP injections, group B patients received two similar injections of PRP combined with noncrosslinked hyaluronic acid, and group C received a topical vaginal hyaluronic acid gel applied three times weekly for 2 months. Main outcome measures were vulvovaginal atrophy symptom severity and vaginal health index (VHI) scores before treatment (v0), 1 month from baseline (v1), 2 months from baseline (v2), and 3 months after the last visit (v3). Results: Both groups A and B showed greater improvement of frequency of intercourse avoidance than group C. Group A showed greater improvement of dyspareunia than group C. Groups A and B demonstrated greater improvement of vaginal pH, fluid volume, and total VHI scores than group C. Short-term topical hyaluronic acid (HA) was not associated with any significant improvement of vaginal elasticity. Group B showed greater improvement of vaginal dryness and moisture scores than group C. Reported adverse events were injection-related pain in all patients of groups A and B and vaginal spotting in groups A and B. Conclusion: Both PRP and PRP-HA have comparable efficacy and patient-reported treatment satisfaction. PRP injections were better tolerated by patients than PRP-HA. Clinical trial registration number: NCT05782920.

Vaginal Laser Treatment for the Genitourinary Syndrome of Menopause in Breast Cancer Survivors: A Narrative Review

Vulvovaginal atrophy (VVA) is a chronic condition resulting from reduced estrogen levels during menopause. The North American Menopause Society and the International Society for the Study of Women's Sexual Health suggested the term "genitourinary syndrome of menopause" (GSM) to indicate the broader aspects of VVA. Breast cancer treatments, such as chemotherapy and endocrine therapy, can induce early and abrupt menopausal symptoms, including GSM, which negatively affects sexual function and the quality of life of the survivors. Vaginal laser therapy has emerged as a safe and effective option for the management of GSM in breast cancer survivors (BCSs). Two main types of lasers, the non-ablative erbium:YAG laser and fractional microablative CO2 vaginal laser, have been evaluated for GSM treatment. While there are few randomized controlled trials (RCTs) on the subject of BCSs, a wealth of prospective and retrospective studies have highlighted the beneficial effects of vaginal laser therapy on the symptoms of VVA, vaginal health, sexual function, and overall quality of life. More comprehensive research is essential to confirm its enduring effectiveness and safety, with a focus on conducting standardized and meticulously controlled investigations. This study is a narrative review that summarizes clinical trials ranging from the earliest to the most recent ones on laser treatment for GSM in BCSs.

[Photobiomodulation and vulvovaginal disorders after anticancer treatments]

Anticancer treatments induce vulvovaginal complications that alter the quality of life and sexuality of patients. New technologies, such as photobiomodulation, could address this problem, for which few effective therapeutic solutions exist. The objective of this study was to describe the characteristics of patients seeking treatment and to observe the effects of photobiomodulation. This is a prospective cohort of patients treated for cancer, in failure of first-line medical treatment, managed at the University Hospital of Nîmes. The history, symptoms and impact of the disorders on their quality of life were collected. At follow-up, improvement was assessed using the PGI-I and FSFI questionnaires. Twenty-eight patients were treated. They were all menopausal, half of them after anticancer treatments [chemotherapy (78%), radiotherapy (36%), hormone therapy (36%)]. The main symptom reported was vaginal dryness (72%). Seventy-one percent of patients (n=20) felt that their daily life was affected≥8/10. All patients had sexual dysfunction. Twenty-two patients received at least 6 sessions of photobiomodulation. Seventy-two percent (n=18) of patients felt better or much better after treatment (PGI-I≤2). The median improvement estimated by the patients was 65% (Q1=50%; Q3=72.5%). There was also a significant clinical improvement. No serious adverse events were reported. Due to the small number of patients in a heterogeneous population with no control group, we cannot extrapolate our results. However, the objective was to assess the status of these pathologies and the contribution of photobiomodulation in patients who have failed first-line treatment; and these results are encouraging.

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

OBJECTIVE

To assess the risk of recurrence of breast cancer associated with vaginal estrogen therapy in women diagnosed with genitourinary syndrome of menopause with a history of breast cancer using a large U.S. claims database.

METHODS

A U.S. health research network (TriNetX Diamond Network) was queried from January 2009 to June 2022. Our cohort consisted of women diagnosed with breast cancer within 5 years before the initial genitourinary syndrome of menopause diagnosis. Patients with active disease , defined as those undergoing mastectomy, radiation treatment, or chemotherapy within 3 months before diagnosis of genitourinary syndrome of menopause, were excluded. Recurrence was defined as mastectomy, radiation, chemotherapy, or secondary malignancy within 3 months to 5 years after the initiation of vaginal estrogen therapy for genitourinary syndrome of menopause. The study cohort included those with three or more vaginal estrogen prescriptions. The control cohort included women with breast cancer without any vaginal estrogen prescriptions after genitourinary syndrome of menopause diagnosis. Propensity matching was performed. A subanalysis by positive estrogen receptor status, when available, was performed.

RESULTS

We identified 42,113 women with a diagnosis of genitourinary syndrome of menopause after breast cancer diagnosis with any estrogen receptor status, 5.0% of whom received vaginal estrogen. Of the initial cohort, 10,584 patients had a history of positive estrogen receptor breast cancer, and 3.9% of this group received vaginal estrogen. Risk of breast cancer recurrence was comparable between those who received vaginal estrogen and those who did not in both the any estrogen receptor (risk ratio 1.03, 95% CI 0.91-1.18) and positive estrogen receptor (risk ratio 0.94, 95% CI 0.77-1.15) status analyses.

CONCLUSION

In a large, claims-based analysis, we did not find an increased risk of breast cancer recurrence within 5 years in women with a personal history of breast cancer who were using vaginal estrogen for genitourinary syndrome of menopause.

Effects of Non-Ablative Solid-State Vaginal Laser (SSVL) for the Treatment of Vulvovaginal Atrophy in Breast Cancer Survivors after Adjuvant Aromatase Inhibitor Therapy: Preliminary Results

BACKGROUND

One of the side effects of anti-estrogen treatments in breast cancer survivors (BCSs), especially with aromatase inhibitor (AI) treatment, is the frequent appearance of vulvo-vaginal atrophy (VVA). We aim to evaluate the efficacy, safety and feasibility of a new type of non-ablative Solid-State Vaginal Laser (SSVL) treatment in BCSs with VVA.

METHODS

A total of 30 BCSs with a history of AI use and symptoms of VVA were treated with a non-ablative SSVL (LASEmaR 1500™-EUFOTON)in this non-randomized pilot study. The effects of the laser have been evaluated at baseline, 10 wk and 24 wk using a visual analogue scale (VAS), the Vaginal Health Index (VHI), the Vulvar Health Index (VuHI), the Female Sexual Function Index (FSFI), the EORTC QLQ-BR23, the Vaginal Maturation Index (VMI) and vaginal pH.

RESULTS

At 10-week follow-up vs. baseline there were no statistically significant differences in FSFI, lubrication and EORTC QLQ-BR23. In all the subjective (dyspareunia, VHI, VuHI, FSFI, QLQ) and objective parameters (VMI and pH) there was a statistically significant improvement at the 6-month follow-up. Satisfaction was very high (4.7 out of 5), with 95.7% of patients being satisfied, more than or very satisfied.

CONCLUSIONS

Preliminary results of SSVL treatment of VVA and dyspareunia in BCSs after AI treatment suggest clinical improvement, without relevant side effects and with a high degree of satisfaction.

Genitourinary Syndrome of Menopause in Breast Cancer Survivors: Current Perspectives on the Role of Laser Therapy

Genitourinary syndrome of menopause (GSM) is a frequent consequence of iatrogenic menopause or anti-estrogenic adjuvant therapies in breast cancer survivors (BCSs). GSM may profoundly affect sexual health and quality of life, and a multidimensional unique model of care is needed to address the burden of this chronic heterogeneous condition. Severe symptoms may be insufficiently managed with non-hormonal traditional treatments, such as moisturizers and lubricants, recommended as the first-line approach by current guidelines, because concerns exist around the use of vaginal estrogens, particularly in women on aromatase inhibitors (AIs). Vaginal laser therapy has emerged as a promising alternative in women with GSM who are not suitable or do not respond to hormonal management, or are not willing to use pharmacological strategies. We aim to systematically review current evidence about vaginal laser efficacy and safety in BCSs and to highlight gaps in the literature. We analyzed results from 20 studies, including over 700 BCSs treated with either CO2 or erbium laser, with quite heterogeneous primary outcomes and duration of follow up (4 weeks-24 months). Although evidence for laser efficacy in BCSs comes mostly from single-arm prospective studies, with only one randomized double-blind sham-controlled trial for CO2 laser and one randomized comparative trial of erbium laser and hyaluronic acid, available data are reassuring in the short term and indicate effectiveness of both CO2 and erbium lasers on the most common GSM symptoms. However, further studies are mandatory to establish long-term efficacy and safety in menopausal women, including BCSs.

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

(1) Background: Genitourinary syndrome of menopause (GSM) is a medical condition that can affect breast cancer survivors (BCS). This is a complication that often can occur as a result of breast cancer treatment, causing symptoms such as vaginal dryness, itching, burning, dyspareunia, dysuria, pain, discomfort, and impairment of sexual function. BCS who experience these symptoms negatively impact multiple aspects of their quality of life to the point that some of them fail to complete adjuvant hormonal treatment; (2) Methods: In this systematic review of the literature, we have analyzed possible pharmacological and non-pharmacological treatments for GSM in BCS. We reviewed systemic hormone therapy, local hormone treatment with estrogens and androgens, the use of vaginal moisturizers and lubricants, ospemifene, and physical therapies such as radiofrequency, electroporation, and vaginal laser; (3) Results: The data available to date demonstrate that the aforementioned treatments are effective for the therapy of GSM and, in particular, vulvovaginal atrophy in BCS. Where possible, combination therapy often appears more useful than using a single line of treatment; (4) Conclusions: We analyzed the efficacy and safety data of each of these options for the treatment of GSM in BCS, emphasizing how often larger clinical trials with longer follow-ups are needed.

Safety and effectiveness of a novel home-use therapeutic ultrasound device for the treatment of vaginal dryness in postmenopausal women: a pilot study

A home-use, therapeutic ultrasound device was safe and effective for treating vaginal dryness after 12 weeks, and effectiveness was maintained to 1 year. Therapeutic ultrasound could offer a new, nonhormone treatment option for postmenopausal women with vulvovaginal atrophy.

Objective

To evaluate safety and effectiveness of therapeutic ultrasound for treatment of postmenopausal vaginal dryness.

Methods

In a pilot study, postmenopausal women with self-reported vaginal dryness were randomized (1:1) to double-blind ultrasound treatment (n = 21) or sham (n = 21) for 12 weeks. Primary effectiveness endpoint was change from baseline to week 12 in Vaginal Assessment Scale symptoms (dryness, soreness, irritation, dyspareunia). Secondary effectiveness endpoint was scoring of clinician-reported Vaginal Health Index (elasticity, fluid, pH, mucosa, moisture). After 12 weeks, participants received open-label ultrasound treatment to 1 year. Safety endpoint was treatment-emergent adverse events.

Results

In the modified intent-to-treat population, women showed (mean ± standard error) reduction in Vaginal Assessment Scale with ultrasound treatment versus sham (n = 15, −0.5 ± 0.2 vs n = 15, −0.4 ± 0.3; P = 0.9) and improved Vaginal Health Index (n = 9, 2.7 ± 0.9 vs n = 9, 0.6 ± 1.4; P = 0.3). In the per-protocol analysis population, ultrasound treatment (n = 9) versus sham (n = 8) significantly reduced symptoms score (−0.6 ± 0.3 vs −0.0 ± 0.4; P = 0.05) and significantly improved Vaginal Health Index (2.7 ± 0.9 vs −0.4 ± 1.2; P = 0.03). Improvement in effectiveness endpoints were seen at 1 year compared with baseline. There were no differences in treatment-emergent adverse events between ultrasound treatment versus sham and no serious adverse events.

Conclusions

Home-use ultrasound was safe and effective for treating vaginal dryness after 12 weeks. Effectiveness was maintained to 1 year. Therapeutic ultrasound could offer a new, nonhormonal treatment option for postmenopausal women with vulvovaginal atrophy.

Treating genitourinary syndrome of menopause in breast cancer survivors: main challenges and promising strategies

Many breast cancer survivors (BCS) suffer the consequences of antineoplastic treatments that induce a hypoestrogenic state, leading to chronic climacteric symptoms such as genitourinary syndrome of menopause (GSM), arousing significant alteration in their quality of life. Non-hormonal therapies (NHT) are first-line treatments, safe but with mild efficacy. When facing moderate-severe GSM, the options for BCS are limited: local estrogen therapy, considered the 'gold standard' but with concerns about safety; vaginal androgens and prasterone, which seem to trigger an activation of estrogen and androgen receptors of the vaginal epithelium layers, without activating estrogen receptors on other tissues, being potentially safe but still without strong evidence in favor of BCS; vaginal lasers, which appear to improve vascularization of vaginal mucosa by stimulating the remodeling of the underlying connective tissue, but with contradictory results of efficacy in recent randomized clinical trials; and ospemifene, an oral selective estrogen receptor modulator presenting mild vaginal estrogenic potency and anti-estrogenic effect at the endometrial and breast level, but still not recommended for use in BCS in recent North American Menopause Society guidelines. There is a need for further studies evaluating objectively the efficacy and safety of these promising therapeutic options. On the other hand, sexuality must be seen as a multifactorial issue, where GSM is only part of the problem; evidence shows that sexual counseling improves the quality of life of BCS. Finally, there is a need to limit the underdiagnosis and undertreatment of GSM in BCS; the primary goal of physicians treating BCS regarding this issue has to be the provision of information of what to expect regarding genital and sexual symptoms to BCS and to counsel on early first-line treatments that may help prevent more severe GSM.

Emerging Use of Vaginal Laser to Treat Genitourinary Syndrome of Menopause for Breast Cancer Survivors: A Review

Breast cancer treatment, such as chemotherapy and endocrine therapy, can cause earlier and more sudden menopausal symptoms. Genitourinary syndrome of menopause (GSM) is one of the most bothersome side effects of breast cancer treatment, resulting in sexual dysfunction and impaired quality of life. GSM includes genital, urinary, and sexual symptoms. However, alleviating symptoms of GSM for breast cancer survivors may be challenging due to ineffectiveness, contraindications, and low adherence to treatment. The most recent data show the feasibility and safety of vaginal laser to treat GSM for breast cancer survivors. This narrative review provides the aspects of GSM in breast cancer patients, putting the focus on the efficacy and safety of vaginal laser therapy.

Chemotherapy and Related Female Sexual Dysfunction: A Review of Literature

Context: Cancer is a detrimental illness that affects patients’ quality of life and other aspects of a healthy life. Chemotherapy has been shown to have a direct and indirect effect on the sex organs of women. Evidence Acquisition: We searched in databases including PubMed, Scopus, and Google scholar. The keywords for our search were as follows: “Chemotherapy” OR “Cancer treatment” AND “Sexual dysfunction “OR “Sexuality” OR "libido” OR "dyspareunia" OR "orgasmic disorder" OR "sexual disorder". We evaluated the articles based on their abstract and 92 studies were selected and used in the present study. Results: Chemotherapeutic agents damage ovaries and could cause premature ovarian failure. Furthermore, chemotherapy disturbs the femininity aspects of patients and reduces their libido. In this review article, we aimed at a better understanding the effect of chemotherapy on the sexual function of female cancer survivals. Conclusions: In conclusion, chemotherapy is one of the most common cancer treatments affecting sexual health aspects, such as decreased libido, arousal and orgasm, dyspareunia, dysfunction of the sexual response cycle before puberty, and vulvovaginal atrophy. However, many patients are reluctant to discuss their sexual problems.

Management of Breast Cancer Survivors by Gynecologists

Breast cancer patients commonly present to their OBGYN during the process of diagnosis and treatment of breast cancer both for specific gynecologic needs and for primary care follow up. These patients require counseling on contraception, hormone use, and fertility at diagnosis. During treatment and survivorship, patients will face a variety of side effects from treatments leading to vasomotor symptoms, vulvovaginal discomfort, sexual dysfunction, osteoporosis, and vaginal bleeding. This chapters aims to enlighten providers on the unique range of issues a gynecologist may face when caring for breast cancer patients.

Efficacy of intradermal hyaluronic acid plus polynucleotides in vulvovaginal atrophy: a pilot study

OBJECTIVE

This study aimed to evaluate the safety and efficacy of vulvovaginal intradermal injections of polynucleotides (PN) combined with hyaluronic acid (HA) in postmenopausal women affected by vulvovaginal atrophy (VVA).

MATERIALS AND METHODS

Postmenopausal women affected by VVA were treated with vulvar and vaginal intradermal injections of one prefilled syringe of 2 ml PN/HA every 2 weeks for four sessions. Patients were evaluated at T0 (baseline), T1 (after session 4) and T2 (1 month after session 4). Evaluation of the treatment was assessed by three international validated questionnaires: Vaginal Health Index (VHI), Vulvar Health Index (VuHI) and Female Sexual Function Index (FSFI). The Wilcoxon matched-paired signed-rank test was used to compare the differences in VHI, VuHI, FSFI and FSFI domains within the groups. Statistical significance was set at p < 0.05.

RESULTS

Fifty patients were included in the study (mean age 59.9 ± 7.6 years). Overall, the VHI, VuHI and FSFI reported statistically significant differences between baseline and T1 (p < 0.001) and between baseline and T2 (p < 0.001). All FSFI domains registered a statistically significant increase between baseline and T2 (p < 0.001). No complications or side effects were observed.

CONCLUSIONS

Vulvovaginal intradermal injection of PN/HA is a safe, effective treatment, is not expensive and is a reproducible procedure in postmenopausal women with VVA.

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

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.

Art of prevention: The importance of dermatologic care when using aromatase inhibitors

As of January 2021, there are more than 3.8 million women in the United States with a history of breast cancer. The current standard of care for breast cancer involves surgical resection, radiation therapy, adjuvant endocrine therapy, and/or adjuvant chemotherapy. Aromatase inhibitors (AIs) are the gold standard for endocrine therapy in postmenopausal women. Dermatologic adverse events (dAEs) associated with AIs are rare but have been reported in the literature. Commonly reported dAEs include unspecified rash, pruritus, alopecia, vulvovaginal atrophy, vasculitis, and autoimmune/connective tissue disorders. Appropriate preventative strategies and careful management considerations have the potential to optimize the comprehensive care of patients with cancer and improve quality of life. Furthermore, prevention of dAEs can lead to a reduction in cancer treatment interruptions and discontinuations. Herein, we characterize dAEs of AIs and discuss preventative management to reduce the incidence of AI therapy interruption.

Clinical manifestations and evaluation of postmenopausal vulvovaginal atrophy

INTRODUCTION

It is estimated that 50% of women will suffer a severe form of vulvovaginal atrophy (VVA) related to menopause. Equally, young women may temporarily present this clinical problem while receiving various pharmacological or endocrine treatments or radiotherapy.

AIM

To determine clinical and diagnostic exams required to confirm the presence of VVA (also referred to as atrophic vaginitis, urogenital atrophy, or genitourinary syndrome of menopause) and rule out other genital or pelvic clinical conditions.

MATERIALS AND METHODS

Literature review searches were carried out on the main scientific article search engines (PubMed, SciELO, Cochrane) using different clinical terms, treatments or interventions and comorbidity related to VVA.

RESULTS

The development and severity of VVA depend mainly on the duration of hypoestrogenism. Hypoestrogenism causes changes in the urogenital tissue, generating signs and symptoms, such as dryness, burning, soreness, itching, and irritation of the genital skin. The diagnosis can be made through anamnesis (patient history), questionnaires, physical exam, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be completed with the Vaginal Health Index, the Vaginal Maturation Index, or vaginal pH in the absence of infection or semen. The exclusion of other vulvovaginal organic pathology is essential to reach an accurate diagnosis and provide adequate treatment.

CONCLUSIONS

The specialist should be able to identify VVA, rule out other pathologies that make a differential diagnosis and conduct proper management.

Urogenital atrophy: The 'unknown factors' challenging current practice

Urogenital atrophy occurs as a result of the effect of estrogen deficiency on the tissue quality in the vulva, vagina, urethra and bladder. It is a common consequence of the menopause, with possibly up to 80% of women experiencing symptoms. Despite a number of different diagnostic methods, there is no validated objective method by which to confirm the diagnosis in clinical practice and research settings. Education, for women and clinicians, is called for to support diagnosis and treatment. However, before this can be of global benefit, development of an accessible and reproducible diagnostic test is required. Current assessment methods include routine history and clinical examination, with the clinician's opinion based on their subjective observations. A vaginal smear to assess the ratio of superficial to parabasal cells and measurement of the pH of the vaginal secretions is more commonly used in research settings. A number of formulae have been postulated to facilitate the diagnosis including the Vaginal Health Index, the Vulval Health Index, the Genitourinary Syndrome of the Menopause assessment tool, the Genital Health Clinical Evaluation and vaginal biopsy and assessment of the vaginal microbiome. However, none of these potential methods of assessment has been validated. This article focuses on what we do not know about urogenital atrophy including the prevalence, the most appropriate terminology, aetiology, pathogenesis and the most objective and reproducible method of assessment.

Genitourinary symptoms in women with breast cancer: what do oncology health professionals think and do about them?

OBJECTIVES

We aimed to improve understanding of health professional knowledge and management of genitourinary symptoms (GUS) in women with early breast cancer (EBC).

METHODS

A survey was sent to 872 health professionals caring for women with EBC. Questions addressed most common GUS seen, experience treating GUS, and attitudes to treatment options.

RESULTS

144 surveys were completed. Respondent characteristics: median age 50 years; 76% female; 42% medical oncologists; 24% nurses; 20% breast surgeons; 8% radiation oncologists. Most (68%) reported prescribing endocrine therapies for EBC, 99% were aware endocrine therapies can cause GUS, and 55% reported "often" or "always" asking patients on endocrine therapy if they have GUS. Respondents thought vaginal dryness was the most bothersome symptom for their patients (66%), followed by dyspareunia (11%). 81% of respondents reported seeing women stop endocrine therapy prematurely due to GUS. Respondents reported receiving "none" (19%) or "a little" (46%) training or education in managing GUS and only 16% reported feeling "very confident" managing GUS. The proportions of respondents reporting "often" and "very often" recommending the following vaginal treatments were: lubricants (81%); moisturisers (68%); oestrogens (21%); and laser (3%). Vaginal oestrogens were considered "safe" or "probably safe" by 77% and 90% of respondents for women with hormone receptor positive and negative EBC, respectively.

CONCLUSIONS

Despite health professionals frequently encountering GUS in women with EBC and seeing patients stop endocrine therapies prematurely, only 16% felt confident managing these symptoms. Education and training for health professionals are needed to better address this common problem.

Improving the identification of genitourinary syndrome of menopause through the utilization of the Day-to-Day Impact of Vaginal Aging questionnaire

OBJECTIVE

Genitourinary syndrome of menopause (GSM) affects nearly 50% of postmenopausal women. Yet women fail to recognize GSM as a chronic condition and are reluctant to discuss their vaginal or sexual complaints with a health care provider. This quality improvement project implemented the Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire to improve the identification and diagnosis of GSM in women ≥ 45 years of age presenting for an annual wellness examination or a vulvovaginal/genitourinary complaint.

METHODS

From October 2019 to February 2020, the DIVA questionnaire was distributed in a large women's health practice setting to women ≥ 45 years of age, for completion before their annual wellness visit or for evaluation of a GSM-related complaint. GSM diagnosis rates during the implementation period were compared with diagnosis rates during a 4-month period immediately preceding the implementation. Data collected during the implementation period were examined to evaluate if GSM diagnosis was more likely in patients who completed the DIVA questionnaire when compared to those women who did not complete the questionnaire.

RESULTS

Of the 175 women who met the inclusion criteria, 113 completed the DIVA questionnaire. Completion of the DIVA questionnaire demonstrated a relative percentage increase in GSM diagnosis by 30.7% when compared to the 4-month preimplementation period (10.1% to 13.2%, P = 0.231). This change was not statistically significant. During the implementation period, a statistically significant difference in GSM diagnosis was observed for patients who completed the DIVA questionnaire when compared to those patients who did not complete the questionnaire (37.2% vs 9.7%, P < 0.001). When results were stratified by visit type, women presenting for an annual wellness visit who completed the DIVA questionnaire had a higher GSM diagnosis rate than those who did not complete the questionnaire (37.2% vs 10%, P < 0.001). When results were stratified by menopausal status, GSM diagnosis rates were also more likely for postmenopausal women who completed the DIVA questionnaire when compared to those who did not complete the questionnaire (44.2% vs 8.5%, P < 0.001).

CONCLUSIONS

The DIVA questionnaire is a brief, but comprehensive screening tool that can increase GSM identification and treatment, particularly for postmenopausal, and midlife women presenting for an annual wellness visit in a busy women's health practice setting. : Video Summary:http://links.lww.com/MENO/A655.

Fractional CO₂ vaginal laser for the genitourinary syndrome of menopause in breast cancer survivors

Adjuvant chemotherapy and endocrine therapy can induce early iatrogenic menopause or worsen pre-existing menopausal symptoms in breast cancer survivors (BCS). The second most frequent menopausal symptom after hot flushes is the genitourinary syndrome (GSM). Since hormone replacement therapy is contraindicated in BCS, vaginal laser might represent a new nonhormonal option for GSM. This study aims at evaluating the effectiveness of the fractional CO₂ vaginal laser for GSM in BCS compared with healthy women. This is a retrospective study on 135 postmenopausal women (45 BCS and 90 healthy women) who underwent fractional CO₂ laser for GSM. Objective (VHI and VVHI) and subjective outcomes (VAS for dyspareunia and vaginal dryness and a pain questionnaire) were evaluated at baseline visit and at every follow-up visit. Subjective and objective parameters improved significantly in both groups after laser therapy. The improvement was progressive and long-lasting up to 12 months after the end of the treatment. No severe adverse events were observed during the treatment. Fractional CO₂ vaginal laser induces a significant and long-lasting improvement on GSM symptoms in BCS. However, this improvement is slower than in healthy women undergoing the same treatment. Laser therapy turns out to be safe and well-tolerated.

Genitourinary Symptoms in Breast Cancer Survivors: Prevalence, Correlates, and Relationship With Sexual Functioning

OBJECTIVES

To evaluate (a) the prevalence of genitourinary symptoms, (b) which demographic and clinical factors predict genitourinary symptoms, and (c) the association between genitourinary symptoms and sexual functioning in breast cancer survivors.

SAMPLE & SETTING

A secondary analysis of cross-sectional, patient-reported outcomes data from 1,085 breast cancer survivors was conducted.

METHODS & VARIABLES

Prevalence and correlations with demographics, clinical factors, and sexual functioning were identified using descriptive analysis, multivariable logistic regression analysis, chi-square tests, t tests, and Pearson correlation coefficients.

RESULTS

Symptoms included vaginal/vulvar irritation, pelvic discomfort, problems with urinary control, vaginal infection, and vaginal bleeding. Younger age, more comorbidities, and taking treatment for menopausal symptoms were significantly related to reporting genitourinary symptoms. Experiencing more symptoms was associated with lower sexual functioning.

IMPLICATIONS FOR NURSING

The prevalence, correlates, and relationship of genitourinary symptoms with sexual functioning supports the assessment and treatment of these symptoms as part of routine care for breast cancer survivors.

The European Vulvovaginal Epidemiological Survey (EVES). Impact of history of breast cancer on prevalence, symptoms, sexual function and quality of life related to vulvovaginal atrophy

OBJECTIVE

Women with history of breast cancer (HBC) frequently suffer from vulvovaginal atrophy (VVA). European Vulvovaginal Epidemiology Survey (EVES) sub-analysis assesses the impact of HBC on VVA, sexual life and quality of life (QoL) in postmenopausal women.

MATERIALS AND METHODS

Women with at least one VVA symptom aged 45-75 years were included. EuroQol (EQ-5D-3L) and Day-to-Day Impact of Vaginal Aging (DIVA) questionnaires were filled to investigate QoL. VVA diagnosis was confirmed with objective gynecological examination. Comparison of postmenopausal women with and without HBC, and evaluation of treatment impact on VVA were performed.

RESULTS

1985 postmenopausal women without HBC and 175 with HBC were included. VVA was confirmed in 90.4% of women without HBC and 91.4% of women with HBC. There were no differences in VVA symptoms severity or vulvovaginal discomfort between groups. However, women with HBC who had completed treatment and had surgery 11-20 years previously versus those without HBC presented significantly worse Vaginal Health Index scores, as well as a higher prevalence of VVA objective diagnosis, although their overall symptom severity score was lower. Health status and QoL comparisons were similar.

CONCLUSIONS

Results support a similar burden in terms of VVA prevalence and symptoms, QoL and sexual function in postmenopausal women with and without HBC.

Pilot study of fractional CO2 laser therapy for genitourinary syndrome of menopause in gynecologic cancer survivors

PURPOSE

The objectives of this study were to evaluate the feasibility and efficacy of fractional CO₂ laser therapy in gynecologic cancer survivors.

METHODS

This was a pilot, multi-institutional randomized sham-controlled trial of women with gynecologic cancers with dyspareunia and/or vaginal dryness. Participants were randomized to fractional CO₂ laser treatment or sham laser treatment. The primary aim was to estimate the proportion of patients who had improvement in symptoms based on the Vaginal Assessment Scale (VAS). Secondary aims included changes in sexual function assessed using the Female Sexual Functioning Index (FSFI) and urinary symptoms assessed using the the Urinary Distress Inventory (UDI-6).

RESULTS

Eighteen women participated in the study, ten in the treatment arm and eight in the sham arm. The majority of participants had stage I (n = 11, 61.1 %) or II (n = 3, 16.7 %) endometrial cancer with adenocarcinoma histology (n = 9, 50 %). In total, 15 (83.3 %) of the participants completed all treatments and follow-up visit. There was no difference in the change in the median VAS score from baseline to follow-up. However, there was an improvement in change in the median total FSFI score with treatment compared with sham (Δ 6.5 vs -0.3, p = 0.02). The change in the median UDI-6 score was lower in the treatment arm (Δ -14.6 vs -2.1, p = 0.17), but this was not statistically significant. There were no reported serious adverse events.

CONCLUSIONS

Fractional CO₂ laser therapy is feasible in gynecologic cancer survivors, with preliminary evidence of safety. In addition, there was preliminary evidence of improvement in sexual function compared with sham treatment. Clinicaltrial.gov Identifier: NCT03372720 (OSU-17261; NCI-2017-02051).

Genitourinary Syndrome of Menopause: Current Treatment Options in Breast Cancer Survivors - Systematic Review

Breast cancer survivors (BCS) usually receive treatments which lead to persistent oestrogen suppression, which may cause atrophic vaginitis in a large proportion of these women. The most effective treatments for vulvovaginal atrophy (VVA) are based on local oestrogen therapy. However, these treatments are restricted in BCS due to the controversy over their use in women who had hormone-dependent tumours. Therefore, it is common to find untreated symptoms that affect sexual function and quality of life in BCS, thereby leading to the discontinuation of anti-oestrogenic treatments. This systematic review aims to discuss the current treatment options available for the genitourinary syndrome of menopause (GSM) in BCS. A comprehensive literature search was conducted electronically using Embase and PubMed to retrieve studies assessing treatment options for GSM or VVA in BCS up to April 2020. Studies evaluating treatments in different BCS cohorts were excluded. A total of 29 studies were finally included in the review. Non-hormonal treatments are the first-line treatment for VVA, but when these are not effective for symptom relief, other options can be considered, such as local oestrogen, erbium laser or CO2 laser and local androgens. The present data suggest that these therapies are effective for VVA in BCS; however, safety remains controversial and a major concern with all of these treatments.

No increase in incidence or risk of recurrence of breast cancer in ospemifene-treated patients with vulvovaginal atrophy (VVA)

OBJECTIVE

To estimate the incidence and recurrence of breast cancer (BC) in patients with vulvovaginal atrophy (VVA) treated with ospemifene and matched untreated VVA patients using real-world data.

STUDY DESIGN

Retrospective matched cohort study.

MAIN OUTCOME MEASURES

VVA patients were identified from the 2011-2018 US MarketScan® insurance claims database. For incidence, ospemifene-treated VVA patients without evidence of BC prior to index treatment were matched to two untreated VVA controls similarly without history of BC on age, index VVA year, geographic region, Charlson Comorbidity categories, and follow-up time. BC after the index treatment was identified by BC diagnosis codes, mastectomy, chemotherapy, or radiation procedure. Incidence rate, rate ratio (RR) and their 95 % confidence intervals (CI) were calculated. The process was repeated to estimate BC recurrence in patients with a history of BC in 1:1, 1:2 and 1:3 matches.

RESULTS

1728 ospemifene users and 3456 untreated patients met the inclusion and matching criteria for assessing incidence. The average number of days for which ospemifene was supplied was 314 (standard deviation [SD] = 340). Average follow-up time from index treatment was 937 days (SD = 392) for treated patients and 915 days (SD = 396) for controls. BC incidence rates per 1000 person-years was 2.03 (95 % CI: 1.06-3.91) for treated patients and 3.53 (95 % CI: 2.49-4.99) for controls (RR = 0.58, 95 % CI: 0.28-1.21). No difference in recurrence was observed between ospemifene-treated and matched untreated patients. Ten (32.3 %) treated vs. 25 (40.3 %) controls in the 1:2 matched analysis had a recurrence.

CONCLUSION

No differences were observed in the BC incidence and recurrence rates in ospemifene users compared with matched controls.

Carbon dioxide laser treatment for vulvovaginal atrophy in women treated for breast cancer: Preliminary results of the feasibility EPIONE trial

BACKGROUND AND OBJECTIVE

Quality of life preservation after anti-cancer therapy is a major challenge for breast cancer survivors. Approximately 42-70% of patients who receive systemic therapy for breast cancer, including endocrine therapy, will develop vulvovaginal atrophy (VVA). For these patients, the commonly proposed gel-based treatments for topical applications are restrictive. Recently, innovative, non-hormonal therapeutic approaches, such as laser therapy, have emerged. The purpose of this feasibility study is to investigate the safety and efficacy of CO₂ laser therapy in women with a history of breast cancer.

MATERIAL AND METHODS

This prospective monocentric study included 20 patients with vulvovaginal atrophy who were treated at Henri Mondor University Hospital between 2017 and 2018. We included patients with a vaginal health index (VHI) score<15 and a contraindication for hormone administration due to a history of breast cancer. Two carbon dioxide laser sessions were used. The treatment was delivered using the following settings: vaginal tightening, FinePulse (pulse width 0.9ms), and energy density of 11.5J/cm² that allows coverage of 70% of the targeted vaginal area to be treated. All patients had their follow-up visit at one (M1), three (M3), and six (M6) months after the first treatment to evaluate efficacy of the treatment on vulvovaginal atrophy. Vaginal health index score and female sexual distress (FSD) score were used to assess treatment efficacy and its impact on sexual quality of life. A score≥11 was associated with sexual dysfunction. The vaginal health index and female sexual distress scores were evaluated at baseline, M1, M3, and M6 of follow-up.

RESULTS

The mean age of the patients was 56.1±8.8 years (range, 27-69 years). Seventeen of the 20 patients had experienced menopause (mean menopausal age, 51.25±1.5 years). At inclusion, the mean vaginal health index and the female sexual distress scores were 10.58±1.71 and 21.36±15.10, respectively. Fourteen out of 20 patients (70%) had FSD scores≥11 at the baseline. At M1, the mean vaginal health index score increased significantly to 13.42±2.3 (P=0.03), which represented an improvement of 21% from the baseline. A persistent and significant improvement in the vaginal health index score was observed at M6, with the score increasing to 16.75±4.23 post-treatment (P<0.0001), representing a 34% improvement from the mean baseline score. The mean female sexual distress at M1 was 19.83±13.57, representing a 7% decrease compared to the baseline scores (P<0.01). At M3, the female sexual distress significantly decreased to 13.88±15.58, representing an improvement of 35% (P=0.006). It increased to 10.35±14.7 at M6, representing an improvement of 52% (P=0.001). At M3, 35% of the patients had a female sexual distress score>11, and at M6, only 15% had a female sexual distress score>11. No side effects were reported during follow-up.

CONCLUSION

This pilot feasibility study showed that carbon dioxide laser treatment appears to be an effective and safe method to improve the trophicity and decrease vaginal mucosal dryness in women with vulvovaginal atrophy that developed after systemic breast cancer therapy.

Fractional CO2 laser therapy for genitourinary syndrome of menopause for breast cancer survivors

PURPOSE

Fractional CO2 laser therapy is an emerging treatment for genitourinary syndrome of menopause (GSM). The objective of this study was to determine the feasibility and preliminary efficacy of fractional CO2 laser therapy in breast cancer survivors.

METHODS

This was a single arm feasibility study of breast cancer survivors with dyspareunia and/or vaginal dryness. Participants received three treatments of fractional CO2 laser therapy at 30-day intervals and returned for a 1-month follow-up. Feasibility was defined as treatment completion without serious adverse events (SAE) in 80% of patients. We collected data on the Vaginal Assessment Scale (VAS), the Female Sexual Function Index (FSFI), the Urinary Distress Index (UDI), and SAE.

RESULTS

A total of 64 patients participated in the study. The majority of women had Estrogen receptor/Progesterone receptor (ER/PR) positive/Her2neu negative (n = 37; 63%), stage I (n = 32, 54%) or II (n = 19, 32%) breast cancer. Most were receiving endocrine therapy (n = 54, 92%), most commonly aromatase inhibitors (AI; n = 40, 68%). Fifty-nine (88.1%) of those enrolled completed all treatments according to protocol with no reported SAE. No patient withdrew due to SAE. The scores of the VAS (mean Δ - 0.99; 95% CI [- 1.19, - 0.79], p < 0.001)), FSFI (mean Δ 9.67; 95% CI [7.27, 12.1], p < 0.001), and UDI (mean Δ - 8.85; 95% CI [- 12.75, - 4.75], p < 0.001)) improved from baseline to follow-up.

CONCLUSION

Fractional CO2 laser treatment for breast cancer survivors is feasible and appears to reduce GSM symptoms across treatment and follow-up.

Efficacy of injecting platelet concentrate combined with hyaluronic acid for the treatment of vulvovaginal atrophy in postmenopausal women with history of breast cancer: a phase 2 pilot study

OBJECTIVE

Approximately 50% to 70% of breast cancer survivors are affected by one or more symptoms of vulvovaginal atrophy (VVA). For those who cannot take hormone therapy, autologous platelet-rich plasma combined with hyaluronic acid (A-PRP-HA) may provide a new alternative therapy for the treatment of VVA in postmenopausal women with history of breast cancer.

METHODS

We enrolled 20 postmenopausal breast cancers survivors with VVA and a score of <15 on the Gloria Bachman Vaginal Health Index (VHI) comprised of five items including: vaginal pH, elasticity, fluid volume (secretions), epithelial integrity, and moisture.We administered intramucosal injections of A-PRP combined with HA (Regenkit) and performed clinical evaluations at 0, 1, 3, and 6 months. Primary endpoint: evaluation of vulvovaginal mucosa changes using the VHI; secondary endpoint: evaluation of dyspareunia and sexual dysfunction based on the Female Sexual Distress (FSD) score.

RESULTS

All participants (20 women) showed improvement in the clinical symptoms of vaginal dryness and dyspareunia. The VHI score showed a significant increase at 6 months, going from a total baseline score (pretreatment) of 10.7 ± 2.12 to 20.75 ± 4.8 (P < 0.0001) at 6 months. Improvement in hydration and vaginal epithelial integrity was reported. A VHI score of > 15 showed a successful treatment outcome. The FSD score decreased significantly during the study, from a baseline score of 36.35 ± 2.53 pretreatment to 30.15 ± 2.47 6 months after treatment, representing improvement of 17% (P < 0.0001, respectively). No adverse events were reported.

CONCLUSIONS

The injection of A-PRP-HA appeared to be a promising method to improve the trophicity and hydration of vaginal mucosa for the treatment of VVA in postmenopausal breast cancer survivors with contraindications to hormone therapy.

Vaginal Health in Menopausal Women

The aim of this review is to provide an overview of genitourinary health in peri- and postmenopause, particularly of vulvovaginal atrophy (VVA), which is part of genitourinary syndrome (GSM). This condition has a high prevalence among post-menopausal women and negatively affects a woman's quality of life. Epidemiology, signs, symptoms, diagnostic criteria of VVA and target treatments for restoring vaginal health are discussed in light of the most recent literature. Issues related to this condition in menopausal women are under-diagnosed, lack objective diagnostic criteria, and consequently under-treated. Over the years, many treatments have been developed but their long-term effectiveness and safety have yet to be clearly defined. Patients are often dissatisfied and stop treatment, suggesting the need for a more personalized and tailored approach to achieve better compliance and thereby effectiveness. The aim of this paper is to provide an overview of the most recent literature on VVA in order to help the gynecologist in the management of this condition.

The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review

OBJECTIVE

The objective of this consensus document is to broaden the perspective on clinical management of genitourinary syndrome of menopause to include androgens.

METHODS

A modified Delphi method was used to reach consensus among the 14 international panelists representing multiple disciplines and societies.

RESULTS

Menopause-related genitourinary symptoms affect over 50% of midlife and older women. These symptoms have a marked impact on sexual functioning, daily activities, emotional well-being, body image, and interpersonal relations. Tissues in the genitourinary system are both androgen and estrogen-dependent. The clitoris, vestibule, including minor and major vestibular glands, urethra, anterior vaginal wall, periurethral tissue, and pelvic floor are androgen-responsive. Historically, treatment of postmenopausal genitourinary symptoms involved both androgens and estrogens. This subsequently gave rise to predominantly estrogen-based therapies. More recently, double-blind, placebo-controlled clinical trials have demonstrated that local vaginal dehydroepiandrosterone improves symptoms in postmenopausal women, including moderate to severe dyspareunia. Limited data suggest that systemic testosterone treatment may improve vaginal epithelial health and blood flow. Open-label studies that have used high doses of intravaginal testosterone in the presence of aromatase inhibitor therapy for breast cancer have resulted in supraphysiological serum testosterone levels, and have been reported to lower vaginal pH, improve the vaginal maturation index, and reduce dyspareunia.

CONCLUSIONS

Vaginal dehydroepiandrosterone, hypothesized to enhance local production of both androgen and estrogen, is effective for the management of dyspareunia in menopause. Vaginal testosterone offers potential as a treatment for genitourinary syndrome of menopause, but more studies are needed.

The effect of vaginal erbium laser treatment on sexual function and vaginal health in women with a history of breast cancer and symptoms of the genitourinary syndrome of menopause: a prospective study

OBJECTIVES

To assess the effects of vaginal erbium laser treatment on the vaginal health and sexual function of postmenopausal women with a history of breast cancer.

METHODS

An open, prospective, therapeutic intervention study was conducted with 24 postmenopausal women with a history of breast cancer and vaginal dryness, and/or dyspareunia, who had not used vaginal hormone therapy for at least 6 months. The women were treated using a 2,940-nm Erbium: YAG laser (Etherea-MX, Athena, São Carlos, São Paulo, Brazil), with 90 and 360 scanning scopes, between August, 2017 and October, 2017 in a private clinic in a city of southeastern Brazil. Vaginal erbium laser treatment was performed at three sessions with a 30-day interval between each session. Sexual function was assessed before and 1 month after treatment using the Short Personal Experiences Questionnaire. Questions related to genitourinary symptoms were also applied. Vaginal health was assessed before each laser session using the Vaginal Health Index Score.

RESULTS

Mean age was 53.7 years. Vaginal health improved, as shown by an increased overall score (P < 0.001). The effect size was large between pretreatment and post-treatment scores for vaginal elasticity, fluid volume, epithelial integrity, and moisture. The effect size was also significant for the overall sexual function score and for the score in the dyspareunia domain between pretreatment and 1 month after the final treatment session.

CONCLUSION

Vaginal erbium laser may represent a novel therapeutic option for improving vaginal health and sexual function in postmenopausal women with a history of breast cancer.

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

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.

Fractional microablative CO2 laser in breast cancer survivors affected by iatrogenic vulvovaginal atrophy after failure of nonestrogenic local treatments: a retrospective study

OBJECTIVE

Vulvovaginal atrophy (VVA) is a condition frequently observed in menopause. Its symptoms can significantly affect the quality of life of patients. Since VVA is related to estrogen deficiency, chemotherapy and hormone therapy for breast cancer (BC) might cause VVA by inducing menopause. Given the lack of effective treatment for VVA in BC survivors, we retrospectively evaluated the efficacy and tolerability of fractional microablative CO2 laser therapy in these patients.

METHODS

We treated 82 BC survivors with three cycles of CO2 laser after failure of topical nonestrogenic therapy. The severity of symptoms was assessed with a visual analog scale (VAS) at baseline and after completion of laser therapy. Differences in mean VAS scores of each symptom before and after treatment were assessed with multiple t tests for pairwise comparisons. Multivariate analyses were used to adjust the final mean scores for the main confounding factors.

RESULTS

Pre versus post-treatment differences in mean VAS scores were significant for sensitivity during sexual intercourse, vaginal dryness, itching/stinging, dyspareunia and dysuria (P < 0.001 for all), bleeding (P = 0.001), probe insertion (P = 0.001), and movement-related pain (P = 0.011). Multivariate analyses confirmed that results were significant, irrespective of patients' age and type of adjuvant therapy.

CONCLUSION

This study shows that CO2 laser treatment is effective and safe in BC patients with iatrogenic menopause. However, the optimal number of cycles to administer and the need for retreatment remain to be defined. Prospective trials are needed to compare CO2 laser therapy with therapeutic alternatives.

Intravaginal energy-based devices and sexual health of female cancer survivors: a systematic review and meta-analysis

A systematic review and meta-analysis was undertaken to assess the efficacy and safety of intravaginal energy-based therapies (laser and radiofrequency) on sexual health of cancer survivors (CS) (breast cancer (BCS) and/or gynecological cancer (GCS)). PubMed, Scopus, Web of Science, and Cochrane Library were searched until 21/02/2019. Quality of reporting, methodology, and body of evidence were assessed using STROBE, MINORS, and GRADE. Primary outcomes were dyspareunia, dryness, and sexual health (FSFI, FSDS-R). Secondary outcomes were burning, itching, dysuria, incontinence, Vaginal Health Index Score (VHIS), microbiome-cytokine evaluation, and adverse events. Main analyses, subgroup analyses, and sensitivity analyses were performed. Eight observational studies (n = 274) were eligible for inclusion. None of the studies evaluated radiofrequency. BCS and BCS-GCS were included in 87% and 13% of studies, respectively. All primary outcomes improved significantly with the exception of FSDS-R (dyspareunia (5 studies (n = 233), standardized mean difference (StdMD) (- 1.17), 95%CI [- 1.59, - 0.75]; p < 0.001; I² = 55%), vaginal dryness (4 studies (n = 183), StdMD (- 1.98), 95%CI [- 3.31, - 0.65]; p = 0.003; I² = 91%), FSFI (2 studies, n = 28, MD (12.79), 95%CI [7.69, 17.89]; p < 0.001; I² = 0%). Itching, dysuria, and VHIS increased significantly, while burning was not improved. Serious adverse events were not observed by any of the studies. Intravaginal laser therapies appear to have a positive effect on dyspareunia, vaginal dryness, and FSFI of CS. However, the quality of evidence is "very low," with no data on intravaginal radiofrequency therapy. Further research with high-quality RCTs and long-term follow-up is needed to evaluate the value of energy-based devices as a therapeutic option for CS with sexual problems.

Laser treatment for the management of genitourinary syndrome of menopause after breast cancer. Hope or hype?

INTRODUCTION AND HYPOTHESIS

Fractional CO₂ and vaginal erbium lasers have emerged as potential treatment options for genitourinary syndrome of menopause (GSM) in breast cancer (BC) survivors.

METHODS

We conducted a systematic review of the literature to ascertain whether available evidence supports the efficacy and safety of laser treatment for GSM in BC patients. MEDLINE, Scopus and Cochrane Library databases were systematically searched from inception until March 2019 for studies on laser treatment for GSM in BC patients.

RESULTS

We yielded six observational studies meeting the inclusion criteria. The studies were of moderate quality. Taken together, the studies suggest that laser treatment may significantly alleviate or resolve the GSM-related symptoms and improve sexual function. Furthermore, a significant increase of the vaginal health index was reported. Positive effect was maintained up to 12 months. The safety and tolerability profile is encouraging, given that no adverse effects were reported, while only few patients discontinued laser treatment, owing to reported discomfort.

CONCLUSIONS

Our findings suggest that lasers appear to be effective and practical treatment options in BC survivors suffering from GSM. Evidence concerning long-term effects is lacking. The rationale for repeated treatment remains uncertain. Randomized controlled trials that collate different frequencies, intensities and durations are warranted to ascertain a dose-response relationship and adherence.

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

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.