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Cucciniello L, Miglietta F, Guarneri V, Puglisi F. Managing sexual health challenges in breast cancer survivors: A comprehensive review. Breast 2024; 76:103754. [PMID: 38820922 PMCID: PMC11170478 DOI: 10.1016/j.breast.2024.103754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/12/2024] [Accepted: 05/23/2024] [Indexed: 06/02/2024] Open
Abstract
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.
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Affiliation(s)
- Linda Cucciniello
- Department of Medicine, University of Udine, Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.
| | - Federica Miglietta
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy; Istituto Oncologico Veneto - IOV IRCCS, Padova, Italy.
| | - Valentina Guarneri
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy; Istituto Oncologico Veneto - IOV IRCCS, Padova, Italy.
| | - Fabio Puglisi
- Department of Medicine, University of Udine, Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.
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Whitton K, Baber R. Androgen-based therapies in women. Best Pract Res Clin Endocrinol Metab 2024; 38:101783. [PMID: 37246051 DOI: 10.1016/j.beem.2023.101783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Androgens play a key biological role in libido and sexual arousal in women, and knowledge about their complex role in other systems remains ambiguous and incomplete. This narrative review examines the role of endogenous androgens in women's health throughout the life span before focusing on evidence surrounding the use of androgen-based therapies to treat postmenopausal women. The role of testosterone as a therapeutic agent in women continues to attract controversy as approved preparations are rare, and use of off-label and compounded formulations is widespread. Despite this androgen therapy has been used for decades in oral, injectable, and transdermal formulations. Responses to androgen therapy have been demonstrated to improve aspects of female sexual dysfunction, notably hypoactive sexual desire disorder, in a dose related manner. Substantial research has also been conducted into the role of androgens in treating aspects of the genitourinary syndrome of menopause (GSM). Evidence for benefits beyond these is mixed and more research is required regarding long-term safety. However, It remains biologically plausible that androgens will be effective in treating hypoestrogenic symptoms related to menopause, either through direct physiological effects or following aromatization to estradiol throughout the body.
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Affiliation(s)
- Kath Whitton
- North Shore Private Hospital, Level 3, Suite 7, 3 Westbourne Street, St Leonards, NSW 2065, Australia
| | - Rodney Baber
- Obstetrics, Gynaecology and Neonatology, Northern Clinical School, The University of Sydney, Australia.
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Goldstein SW, Goldstein I, Kim NN. Vestibular tissue changes following administration of intravaginal prasterone: a vulvoscopic open-label pilot study in menopausal women with dyspareunia. Sex Med 2023; 11:qfad028. [PMID: 37351544 PMCID: PMC10281961 DOI: 10.1093/sexmed/qfad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/07/2023] [Accepted: 05/20/2023] [Indexed: 06/24/2023] Open
Abstract
Background Prasterone, an intravaginal dyspareunia treatment in menopausal women, improves vaginal health through intracellular conversion of dehydroepiandrosterone into androgens and estrogens. Phase 3 trials for prasterone showed significant improvement in vaginal tissue health and reduction of pain. Aim To assess vestibular changes with daily use of intravaginal prasterone in menopausal women with moderate to severe dyspareunia. Methods This open-label prospective pilot study was conducted over 20 weeks. It included 11 menopausal women (median age, 56 years) who were treated daily with intravaginal inserts of 6.5-mg prasterone and assessed monthly. During vulvoscopy, vestibular pain was assessed by cotton-tipped swab testing, and vestibular and vaginal health was independently assessed with the Visual Scale (VS). In addition, vulvoscopic photographs were obtained and assessed via the Vulvoscopic Genital Tissue Appearance (VGTA) scale to evaluate overall genital tissue health. Mean changes from baseline for genital tissue health and pain assessments were analyzed by repeated measures 1-way analysis of variance, followed by a Dunnett post hoc test. Sexual event diaries were completed and adverse events recorded. Outcomes Outcomes included indices of genital tissue health: pain assessment by cotton-tipped swab testing, VS of the vestibule and vagina, VGTA, and sexual event diary. Results Aggregate scores from the cotton-tipped swab test progressively improved, reaching statistical significance at week 16, which was maintained through week 20 (-7.27, P = .019). VS scores significantly improved from baseline by week 4 and were maintained through week 20 for the vestibule (-3.00, P = .004) and vagina (-4.00, P = .002). An overall 1607 vulvoscopic photographs were examined; all showed reduction in vestibular erythema and pallor at the end of the study. The mean change from baseline at week 20 for the VGTA score was -7.9 (P = .0016). Intercourse associated with pain was reduced from 81.3% of initiated events during the first month of the study to 8.3% during the last month. Sexual activities that were discontinued due to discomfort were reduced from 45.8% to 6.3%. No prasterone-related serious adverse events were reported. Clinical Implications Prasterone, a safe and effective intravaginal hormone treatment, significantly improves vestibular health parameters. Strengths and Limitations Strengths are the prospective study design and the use of multiple outcome measures to assess vestibular tissue health and pain associated with sexual activity. Limitations are the small study cohort and use of nonvalidated outcome measures. Conclusion Our findings suggest that intravaginal prasterone exerts biologic activity on the androgenic endodermal vestibule, as the medication passes from vagina to vestibule, resulting in amelioration of pain associated with sexual activity.
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Affiliation(s)
- Sue W Goldstein
- Corresponding author: San Diego Sexual Medicine, 5555 Reservoir Dr, Suite 300, San Diego, CA 92120, United States.
| | - Irwin Goldstein
- San Diego Sexual Medicine, San Diego, CA 92120, United States
- Sexual Medicine, Alvarado Hospital, San Diego, CA 92120, United States
| | - Noel N Kim
- Institute for Sexual Medicine, San Diego, CA 92121, United States
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Vizza R, Capomolla EM, Tosetto L, Corrado G, Bruno V, Chiofalo B, Di Lisa FS, Filomeno L, Pizzuti L, Krasniqi E, Sanguineti G, Villa A, Giannini A, Kayal R, Stranges V, Tomao S, Botti C, Tomao F, Barba M, Vizza E, Ciliberto G, Vici P. Sexual dysfunctions in breast cancer patients: evidence in context. Sex Med Rev 2023:7128131. [PMID: 37076125 DOI: 10.1093/sxmrev/qead006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION In breast cancer patients, endocrine therapy may exert a negative impact on sexual functioning in both genders, with potentially relevant consequences concerning quality of life and treatment adherence. The availability of effective interventions to maintain and/or restore sexual health in breast cancer patients is a key issue to a research agenda. OBJECTIVES To summarize and critically discuss the most updated and qualitatively relevant literature on the therapeutic approach to sexual impairment in breast cancer patients, with a focus on patients treated with endocrine therapy. METHODS We searched PubMed from its inception to February 2022 for observational and intervention trials including participants with sexual dysfunctions. We were particularly interested in studies of breast cancer patients with sexual dysfunctions while undergoing endocrine therapy. We developed a search strategy with the aim of maximizing the number of articles considered for screening and potential inclusion. RESULTS Forty-five studies were selected: 3 observational and 42 intervention studies. Thirty-five studies were exclusively focused on female breast cancer populations. We could not identify studies exclusively focused on or also including male breast cancer patients. Overall, in female patients, the available armamentarium encompasses vaginal lubricants, moisturizers, estrogens, dehydroepiandrosterone, CO2 laser, ospemifene, and counseling. None of these interventions has been demonstrated to completely solve sexual dysfunctions when singularly considered. More favorable outcomes have come from the combination of different therapies. CONCLUSION In female breast cancer, future research is oriented toward the gain of evidence on combined therapies and long-term data on safety issues on the most promising interventions. The lack of evidence on sexual disturbances in male breast cancer patients remains a major concern.
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Affiliation(s)
| | | | - Livia Tosetto
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Giacomo Corrado
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bruno
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Francesca Sofia Di Lisa
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Lorena Filomeno
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Laura Pizzuti
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Eriseld Krasniqi
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Alice Villa
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome 00161, Italy
| | - Andrea Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome 00189, Italy
| | - Ramy Kayal
- Department of Radiology and Diagnostic Imaging, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | | | - Silverio Tomao
- Department of Radiological, Oncological and Anatomo-pathological Sciences, "Sapienza" University of Rome, Rome 00161, Italy
| | - Claudio Botti
- Department of Surgery, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Federica Tomao
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome 00161, Italy
| | - Maddalena Barba
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Gennaro Ciliberto
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Patrizia Vici
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
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Abstract
IMPORTANCE AND OBJECTIVES Evaluation and treatment of dyspareunia remains a significant unmet need despite the availability of safe and effective treatments. The objectives of this review are to consider evaluation techniques, the medical causes, and treatment options for dyspareunia in postmenopausal women. METHODS This narrative review used PubMed to search for English-language articles related to postmenopausal dyspareunia. Search terms included, but were not limited to, dyspareunia, genitourinary syndrome of menopause, sexual dysfunction, postmenopausal dyspareunia, posthysterectomy dyspareunia, and postcancer dyspareunia. FINDINGS Many postmenopausal women with dyspareunia do not discuss their symptoms with their physicians. Healthcare clinicians should broach the topic of dyspareunia with their patients using oral or written questionnaires. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening, and vaginitis testing. Although dyspareunia in postmenopausal women is often due to the genitourinary syndrome of menopause, other conditions can also cause dyspareunia, including hypertonic pelvic floor, hysterectomy, cancer treatment, lichen conditions, vulvar cancer, vestibulodynia, and pelvic organ prolapse. Some of the treatments discussed include lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol, and fractional CO2 laser treatments. In some cases, dyspareunia may need to be specifically addressed by pelvic floor physical or sex therapists. CONCLUSIONS Dyspareunia is a common issue in postmenopausal women, which remains largely untreated. Women with dyspareunia require a thorough history, targeted physical examination, and coordination of multiple disciplines including medical clinicians, pelvic floor physical therapists, and sex therapists.
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Affiliation(s)
- Lauren F Streicher
- From the Northwestern Medicine Center for Sexual Medicine and Menopause, Northwestern Medicine, Chicago, IL
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Abstract
IMPORTANCE Menopause, due to loss of ovarian follicular activity without another pathological or physiological cause, typically occurs between the ages of 45 years and 56 years. During the menopausal transition, approximately 50% to 75% of women have hot flashes, night sweats, or both (vasomotor symptoms) and more than 50% have genitourinary symptoms (genitourinary syndrome of menopause [GSM]). OBSERVATIONS Vasomotor symptoms typically last more than 7 years and GSM is often chronic. Efficacious treatments for women with bothersome vasomotor symptoms or GSM symptoms include hormonal and nonhormonal options. Systemic estrogen alone or combined with a progestogen reduces the frequency of vasomotor symptoms by approximately 75%. Oral and transdermal estrogen have similar efficacy. Conjugated equine estrogens (CEE) with or without medroxyprogesterone acetate (MPA) were the only hormonal treatments for which clinical trials were designed to examine cardiovascular events, venous thromboembolism, and breast cancer risk. Compared with placebo, the increased risk of stroke and venous thromboembolism associated with CEE (with or without MPA) and breast cancer (with use of CEE plus MPA) is approximately 1 excess event/1000 person-years. Low-dose CEE plus bazedoxifene is not associated with increased risk of breast cancer (0.25%/year vs 0.23%/year with placebo). Bioidentical estrogens approved by the US Food and Drug Administration (with identical chemical structure to naturally produced estrogens, and often administered transdermally) also are available to treat vasomotor symptoms. For women who are not candidates for hormonal treatments, nonhormonal approaches such as citalopram, desvenlafaxine, escitalopram, gabapentin, paroxetine, and venlafaxine are available and are associated with a reduction in frequency of vasomotor symptoms by approximately 40% to 65%. Low-dose vaginal estrogen is associated with subjective improvement in GSM symptom severity by approximately 60% to 80%, with improvement in severity by 40% to 80% for vaginal prasterone, and with improvement in severity by 30% to 50% for oral ospemifene. CONCLUSIONS AND RELEVANCE During the menopausal transition, approximately 50% to 75% of women have vasomotor symptoms and GSM symptoms. Hormonal therapy with estrogen is the first-line therapy for bothersome vasomotor symptoms and GSM symptoms, but nonhormonal medications (such as paroxetine and venlafaxine) also can be effective. Hormone therapy is not indicated for the prevention of cardiovascular disease.
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Affiliation(s)
- Carolyn J Crandall
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Jaya M Mehta
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
- Primary Care Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
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Ye L, Knox B, Hickey M. Management of Menopause Symptoms and Quality of Life during the Menopause Transition. Endocrinol Metab Clin North Am 2022; 51:817-836. [PMID: 36244695 DOI: 10.1016/j.ecl.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Some women experience bothersome symptoms around the time of menopause that may have a negative impact on their quality of life and prompt them to seek treatments. Menopausal hormone therapy was historically the treatment of choice. However, medical contraindications and personal preference for nonhormonal therapy have prompted the evaluation of a range of nonhormonal pharmacologic and non-pharmacologic therapies. This review provides an update focusing on the latest evidence-based approach for the management of bothersome symptoms of menopause.
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Affiliation(s)
- Louie Ye
- The Royal Women's Hospital, 20 Flemington Road, Melbourne, Victoria 3052, Australia; The Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women's Hospital, Lv 7 20 Flemington Road, Melbourne, Victoria 3052, Australia
| | - Benita Knox
- The Royal Women's Hospital, 20 Flemington Road, Melbourne, Victoria 3052, Australia
| | - Martha Hickey
- The Royal Women's Hospital, 20 Flemington Road, Melbourne, Victoria 3052, Australia; The Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women's Hospital, Lv 7 20 Flemington Road, Melbourne, Victoria 3052, Australia.
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8
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Kearley-Shiers K, Holloway D, Bruce D. Intravaginal dehydroepiandrosterone for genitourinary symptoms of the menopause: Is the evidence sufficient? Post Reprod Health 2022; 28:237-243. [PMID: 36300276 DOI: 10.1177/20533691221135906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Intravaginal dehydroepiandrosterone (DHEA) is a locally metabolised estrogen and androgen precursor, licensed in 2018 in the EU for moderate to severe vulvovaginal atrophy in postmenopausal women. A literature search revealed four original trials suitable for appraisal, three evaluating change in dyspareunia or dryness as a primary outcome, one evaluated safety as a primary outcome. In two trials of 255 and 558 women without cancer, the benefit of placebo (nightly vaginal suppositories with a lipophilic base) was a 0.9 and 1 point reduction in dyspareunia as measured on a 3 point scale, an unvalidated outcome measure. With nightly DHEA, dyspareunia was reduced by an additional 0.4 points compared to placebo. When 464 women with gynaecological cancer were randomised, those using nightly plain moisturiser gel reported a reduction of 'most bothersome symptom' (either dyspareunia or dryness) of 1.5 points on a 3 point scale. Those using nightly DHEA reported an additional symptom reduction of 0.3 points. This is also an unvalidated outcome measure. Data evaluating the efficacy of DHEA over placebo is unconvincing and based on unvalidated primary outcome measures that also do not reflect the complex psycho-sexual and socio-cultural components of genitourinary menopausal symptoms. The efficacy and safety data excluded women taking systemic HRT, applies to postmenopausal, not perimenopausal, women and had relatively short follow up. It is important further independent trials use sophisticated and validated assessment tools to better establish the efficacy, safety and cost effectiveness of intravaginal DHEA in clinically representative groups of women before being routinely prescribed.
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Affiliation(s)
| | | | - Deborah Bruce
- Guys and St Thomas' NHS Trust, London, UK
- GKT School of Medical Education Faculty of Life Sciences and Medicine, King's College, 4616London, UK
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Marsden J. The British menopause society consensus statement on the management of oestrogen deficiency symptoms, arthralgia and menopause diagnosis in women with treated for early breast cancer. Post Reprod Health 2022; 28:199-210. [PMID: 36050892 DOI: 10.1177/20533691221122358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This guidance document by the British Menopause Society provides an overview of the management of women experiencing oestrogen deficiency symptoms and arthralgia following a breast cancer diagnosis. It is now recommended breast cancer patients are referred to health care professionals with an expertise in menopause for management of such symptoms, which in turn often involves liaison with patients' breast cancer teams.1 However, as many women initially present to primary health care professionals for advice, this statement is aimed to support the latter in such consultations by providing information about symptom aetiology, current management strategies and controversies and identifying useful practice points. This is an updated version of the 2018 consensus statement prepared by Miss Jo Marsden Consultant Breast Surgeon, King's College Hospital, London, (retired), Mr Mike Marsh, Consultant Gynae-endocrinologist, King's College Hospital, London, Dr Anne Rigg, Consultant Medical Oncologist, Guy's and St Thomas' Hospital, London.
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Affiliation(s)
- Jo Marsden
- 8948King's College Hospital NHS Foundation Trust, London, UK
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Alvisi S, Lami A, Baldassarre M, Lenzi J, Mancini I, Seracchioli R, Meriggiola MC. Short-Term Efficacy and Safety of Non-Ablative Laser Treatment Alone or with Estriol or Moisturizers in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med 2022; 19:761-770. [PMID: 35370104 DOI: 10.1016/j.jsxm.2022.02.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/27/2022] [Accepted: 02/26/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Among treatments for vulvo-vaginal atrophy (VVA), there is a new kind of energy-based device, the non-ablative CO2 laser. AIM This study aimed to assess the efficacy and safety of the non-ablative CO2 laser in menopausal women with VVA as a monotherapy or in association with vaginal estriol or moisturizer. METHODS Seventy-five women with VVA received laser treatment (Laser group), laser plus estriol gel (Laser+E) or laser plus moisturizers (Laser+M). The study protocol consisted of 3 monthly laser sessions (t0, t1, t2) and a gynecological examination at baseline and 1 month after last laser treatment (t3). Objective measures included VHI (Vaginal Health Index) and VuHI (Vulvar Health Index); subjective symptoms of VVA (Dryness, Burning, Itching, Dysuria) evaluated via visual analog scales, sexual function evaluated by FSFI (Female Sexual Function Index), FSDS (Female Sexual Distress Score) and MENQOL (Mopause-specific Quality Of Life). Adverse events and discomfort encountered during the procedure were also assessed. OUTCOMES Primary outcomes were the evaluation of VHI and VuHI and secondary outcomes were changes in VVA symptoms (VAS), sexual function (MENQOL, FSFI, FSDS) and discomfort during the procedure. RESULTS Seventy-five women (25 in Laser, 25 in Laser+E and 25 in Laser+M group) completed the study. At t3, mean VHI, VuHI, dryness, burning and itching VAS scores improved significantly with no differences between the groups. The lubrication domain of FSFI improved significantly only in the Laser+M group, while the pain domain improved significantly in all women with no differences between the groups. FSFI and FSDS overall scores and MENQOL sexual domain improved in all women with no significant difference between the groups. The mean score of the pain during the procedure was low at t0 and did not change throughout the study. CLINICAL IMPLICATIONS This study extends knowledge concerning the effectiveness of a new non-ablative CO2 laser in post-menopausal women with VVA. STRENGTHS & LIMITATIONS This is one of the first studies on this kind of laser and is the first to compare the effectiveness of laser treatment alone or in combination with vaginal estriol or moisturizers. Parameters of VVA and sexual function were evaluated using validated tools. Study limitations include short follow-up time, the limited number of participants and the absence of a sham-controlled group. CONCLUSION Non-ablative CO2 laser seems to be an effective treatment for VVA in menopausal women. Our preliminary data shows that it can be effective as monotherapy or with adjuvant treatments. Alvisi S, Lami A, Baldassarre M, et al. Short-Term Efficacy and Safety of Non-Ablative Laser Treatment Alone or with Estriol or Moisturizers in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med 2022;19:761-770.
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Affiliation(s)
- Stefania Alvisi
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Alessandra Lami
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Center for Applied Biomedical Research, Department of Surgical and Medical Sciences, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Ilaria Mancini
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maria Cristina Meriggiola
- Gynecology and Physiopathology of Human Reproduction, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Center for Applied Biomedical Research, Department of Surgical and Medical Sciences, S. Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy.
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Lubián López DM. Management of genitourinary syndrome of menopause in breast cancer survivors: An update. World J Clin Oncol 2022; 13:71-100. [PMID: 35316932 PMCID: PMC8894268 DOI: 10.5306/wjco.v13.i2.71] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/19/2021] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
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.
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Affiliation(s)
- Daniel María Lubián López
- Department of Mother and Child Health and Radiology, Faculty of Medicine, University of Cadiz, Cádiz 11100, Spain
- Department of Obstetrics and Gynecology Service, University Hospital of Jerez de la Frontera, Jerez de la Frontera 11407, Spain
- Department of Obstetrics and Gynecology, Hospital Viamed Bahía de Cádiz, Chiclana de la Frontera 11130, Cádiz, a Spain
- Department of Obstetrics and Gynecology, Hospital Quirónsalud Campo de Gibraltar, Los Barrios 11379, Cádiz, Spain
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Nácul AP, Rezende GP, Gomes DAY, Maranhão T, Costa LOBF, Reis FMD, Maciel GAR, Damásio LCVDC, Rosa E Silva ACJDS, Lopes VM, Baracat MC, Soares GM, Soares JM, Benetti-Pinto CL. Use of androgens at different stages of life: climacterium. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:83-88. [PMID: 35092963 PMCID: PMC9948071 DOI: 10.1055/s-0041-1740936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Andrea Prestes Nácul
- Unidade de Reprodução Humana, Hospital Fêmina, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | | | | | - Técia Maranhão
- Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | | | | | | | | | | | | | | | - José Maria Soares
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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13
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Stute P, Bertschy S, Birkhaeuser M, Bitzer J, Ging A, Raggi A, Steimann S, Stute V. Swiss consensus on the role of DHEA in the management of genitourinary syndrome of menopause. Climacteric 2021; 25:246-256. [PMID: 34907824 DOI: 10.1080/13697137.2021.2008894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Genitourinary syndrome of menopause (GSM) has a significantly negative impact on affected women's lives. However, despite the increasing number of GSM treatment options (e.g. non-hormonal vaginal products, vaginal hormones [estrogens], dehydroepiandrosterone [DHEA; prasterone], vaginal laser therapy, oral ospemifene), many women remain untreated. The goal of the Swiss interdisciplinary GSM consensus meeting was to develop tools for GSM management in daily practice: a GSM management algorithm (personalized medicine); a communication tool for vaginal DHEA (drug facts box); and a communication tool for understanding regulatory authorities and the discrepancy between scientific data and package inserts. The acceptance and applicability of such tools will be further investigated.
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Affiliation(s)
- P Stute
- Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - S Bertschy
- Swiss Paraplegic Research, Nottwil, Switzerland
| | - M Birkhaeuser
- Faculty of Medicine, University of Berne, Basel, Switzerland
| | - J Bitzer
- Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland
| | - A Ging
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - A Raggi
- Fertisuisse, Zentrum für Kinderwunschbehandlung, Frauen- und Männermedizin, Olten, Switzerland
| | - S Steimann
- Department of Obstetrics and Gynecology, Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - V Stute
- Private business, Frankfurt am Main, Germany
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Non-oestrogenic modalities to reverse urogenital aging. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2021; 20:140-147. [PMID: 34703415 PMCID: PMC8525256 DOI: 10.5114/pm.2021.109772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023]
Abstract
Urogenital aging is a common process affecting all women in the post-menopausal period of their life, and it is substantially due to oestrogen deprivation after ovarian function cessation. These changes can lead to a progressive, chronic, and complex association of symptoms identified as the genitourinary syndrome of menopause, which has a significant impact on quality of life. Genitourinary syndrome and urogenital aging do not resolve spontaneously and usually recur when treatment is stopped. Therefore, appropriate long-term management is of paramount importance, and local oestrogen is the most effective treatment to reverse urogenital aging and to improve symptoms of genitourinary syndrome as replacement therapy. In some women, topical oestrogen may be inconvenient, it may not achieve complete response, or it may be contra-indicated. Several non-hormonal therapies have been investigated, but few treatments have been reported as potentially able to reverse the urogenital aging process similarly to exogenous oestrogens. Laser seems the most promising, although further studies to define its safety and efficacy are mandatory. Vitamin D and E, and phytotherapy have returned conflicting results and require further confirmation. Lifestyle modifications, physiotherapy, and electrical stimulation represent inexpensive and applicable treatments that might slow urogenital aging. Among the hormonal non-oestrogenic therapies, the use of vaginal oxytocin and dehydroepiandrosterone have been found to be effective compared to placebo, as well as the use of oral ospemifene, which partially relieves vulvovaginal atrophy.
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Matarazzo MG, Sarpietro G, Fiorito D, Di Pasqua S, Ingrassano S, Panella MM, Cianci A, Caruso S. Intravaginal 6.5 mg prasterone administration in postmenopausal women with overactive bladder syndrome: A pilot study. Eur J Obstet Gynecol Reprod Biol 2021; 263:67-71. [PMID: 34167036 DOI: 10.1016/j.ejogrb.2021.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/25/2021] [Accepted: 06/09/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of vaginally prasterone administration on postmenopausal women with genitourinary syndrome of menopause (GSM) affected by overactive bladder syndrome (OAB). A secondary aim of this study was to assess the efficacy of prasterone on VVA and quality of life (QoL). STUDY DESIGN Thirty-two postmenopausal women with GSM and referred OAB symptoms received treatment with daily intravaginal prasterone 6.5 mg. We assessed urinary symptoms through approved ICIQ-OAB and ICIQ-UI questionnaires on incontinence. Women were also screened by the Vaginal Health Index (VHI) to investigate the vulvovaginal atrophy (VVA). Quality of life (QoL) was assessed by the SF-12 Health Survey. Each questionnaire was administrated at baseline (T0) and after a 12-week treatment (T1). RESULTS Incontinence questionnaires showed improvement at T1 (from 7.8 ± 2.7 to 2.7 ± 2.2, p < 0.001). Even if women referred an improvement of daily urine although the women reported improvement in daily urine leaks, their urine leak amount did not improve statistically significant [T0 (28.6%) Vs T1 (14.3%), p < 0.16]. Prasterone therapy improved significantly the VHI [T1(21 ± 3.7) Vs T0 (10.8 ± 4.1), p < 0.001]. Finally, women had a statistically significant improvement both in Mental [T1(49.9 ± 11.2) Vs T0 (42 ± 9.2), p < 0.009],) and Physical Health [T1(47.1 ± 9.1) Vs T0 (38.6 ± 8.4), p < 0.006], domains of the SF-12 questionnaire. No women referred side effects. CONCLUSION Prasterone is an inactive precursor converted into estrogens and androgens into vaginal tissue. It leads to positive effects on VVA through the activation of the vaginal androgen and estrogen receptors. Empirical evidence in this study suggests that intravaginal 6.5 mg prasterone administration could be an effective treatment for postmenopausal women with GMS affected by OAB.
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Affiliation(s)
- Maria Grazia Matarazzo
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy.
| | - Giuseppe Sarpietro
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Debora Fiorito
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Salvatore Di Pasqua
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Simona Ingrassano
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Marco Marzio Panella
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
| | - Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy
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16
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The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. ACTA ACUST UNITED AC 2021; 27:976-992. [PMID: 32852449 DOI: 10.1097/gme.0000000000001609] [Citation(s) in RCA: 198] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To update and expand the 2013 position statement of The North American Menopause Society (NAMS) on the management of the genitourinary syndrome of menopause (GSM), of which symptomatic vulvovaginal atrophy (VVA) is a component. METHODS A Panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on vaginal hormone therapies as well as on other management options available or in development for GSM. A search of PubMed was conducted identifying medical literature on VVA and GSM published since the 2013 position statement on the role of pharmacologic and nonpharmacologic treatments for VVA in postmenopausal women. The Panel revised and added recommendations on the basis of current evidence. The Panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees. RESULTS Genitourinary syndrome of menopause affects approximately 27% to 84% of postmenopausal women and can significantly impair health, sexual function, and quality of life. Genitourinary syndrome of menopause is likely underdiagnosed and undertreated. In most cases, symptoms can be effectively managed. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of symptoms. These include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hormone therapy, and the estrogen agonist/antagonist ospemifene. Long-term studies on the endometrial safety of vaginal estrogen, vaginal DHEA, and ospemifene are lacking. There are insufficient placebo-controlled trials of energy-based therapies, including laser, to draw conclusions on efficacy and safety or to make treatment recommendations. CONCLUSIONS Clinicians can resolve many distressing genitourinary symptoms and improve sexual health and the quality of life of postmenopausal women by educating women about, diagnosing, and appropriately managing GSM. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of treatments for the individual patient, and patient preference. Nonhormone therapies available without a prescription provide sufficient relief for most women with mild symptoms. Low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are effective treatments for moderate to severe GSM. When low-dose vaginal estrogen or DHEA or ospemifene is administered, a progestogen is not indicated; however, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data at present to confirm the safety of vaginal estrogen or DHEA or ospemifene in women with breast cancer; management of GSM should consider the woman's needs and the recommendations of her oncologist.
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Pinkerton JV, Blackman I, Conner EA, Kaunitz AM. Risks of Testosterone for Postmenopausal Women. Endocrinol Metab Clin North Am 2021; 50:139-150. [PMID: 33518182 DOI: 10.1016/j.ecl.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Transdermal testosterone therapy, dosed within premenopausal physiologic testosterone ranges, used alone or with menopausal hormone therapy for postmenopausal hypoactive sexual desire disorder, has shown short-term efficacy, with few androgenic side effects. After natural or surgical menopause, meaningful improvements include an additional satisfying sexual episode per month; improvement in desire, arousal, orgasm, pleasure, and responsiveness; and a reduction in distress. Long-term data on cardiovascular, cancer, and cognitive safety are lacking. No approved testosterone preparation is available for women. Compounded testosterone creams or reduced dosing of male-approved therapies represent off-label use. Injections or pellets cause supraphysiological testosterone levels and are not recommended.
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Affiliation(s)
- JoAnn V Pinkerton
- Department of Obstetrics and Gynecology, Division of Midlife Health, University of Virginia Health System, Midlife Health Center University of Virginia Health System, PO Box 801104, Charlottesville, VA 22908, USA.
| | - Isabella Blackman
- Department of Obstetrics and Gynecology, Division of Midlife Health, University of Virginia Health System, Midlife Health Center University of Virginia Health System, PO Box 801104, Charlottesville, VA 22908, USA
| | - Edward Alexander Conner
- Department of Obstetrics and Gynecology, Division of Midlife Health, University of Virginia Health System, Midlife Health Center University of Virginia Health System, PO Box 801104, Charlottesville, VA 22908, USA
| | - Andrew M Kaunitz
- University of Florida College of Medicine Jacksonville, UF Health Women's Specialists, Building 2, Suite 20, 4549 Emerson Street, Jacksonville, FL 32207, USA
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18
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Buck ES, Lukas VA, Rubin RS. Effective Prevention of Recurrent UTIs With Vaginal Estrogen: Pearls for a Urological Approach to Genitourinary Syndrome of Menopause. Urology 2020; 151:31-36. [PMID: 32533967 DOI: 10.1016/j.urology.2020.05.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/10/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To review the available data related to the prevention of recurrent urinary tract infection (rUTI) in postmenopausal women with vaginal estrogen preparations and provide the urologic community with the confidence to identify and treat genitourinary syndrome of menopause (GSM). MATERIALS AND METHODS A literature search of MEDLINE and the Cochrane Central Register of Controlled Trials databases was performed to identify studies utilizing vaginal estrogen in the treatment of urological conditions related to rUTI and GSM. RESULTS In the setting of untreated GSM, the etiology of rUTIs (at least 3 episodes of UTIs in 12 months or at least 2 episodes in 6 months) is not fully elucidated, but estrogen deficiency is a contributing factor. The diagnosis of GSM is primarily a clinical diagnosis supported by other objective findings including: a vaginal pH >5, decreased content of superficial cells, and/or increased proportion of parabasal cells on vaginal maturation index. Local vaginal estrogen, dehydroepiandrosterone (prasterone), and ospemifene are commonly used GSM treatments. Thirty-one trials were identified utilizing estrogen preparations for rUTI in postmenopausal women. CONCLUSION Overall, multiple randomized clinical trials have successfully been completed to show the efficacy of local estrogen preparations for the treatment of rUTIs. This high yield review provides a framework for assessing GSM, prescribing recommendations for local vaginal hormone preparations, and a summary of the substantial evidence supporting the new 2019 American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Guidance for local vaginal estrogen use for rUTI.
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Affiliation(s)
| | | | - Rachel S Rubin
- IntimMedicine Specialists, Washington, DC; Department of Urology, Georgetown University Hospital, Washington, DC.
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Escobar C, Rosenblum N. Vaginal Estrogen-What a Urologist Should Know. Urology 2020; 151:37-43. [PMID: 32504683 DOI: 10.1016/j.urology.2020.05.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/28/2020] [Accepted: 05/17/2020] [Indexed: 11/17/2022]
Abstract
The implications of estrogen depletion on the lower urinary tract and vagina are relevant to the urologist treating women with genitourinary symptoms. The main symptoms of vaginal estrogen depletion that affect women are dyspareunia and vaginal dryness, recurrent urinary tract infection, and lower urinary tract symptoms. Vaginal estrogen can be used to effectively treat these conditions. Vaginal estrogen is available in a variety of formulations. Each formulation has different considerations regarding its use and patients should be actively involved in choosing the right product for them. Contrary to concerns over the risks of oral estrogen, vaginal estrogen has a low-risk profile. In terms of contra-indications for use, there are relatively few absolute contraindications for vaginal estrogen. A thorough understanding of vaginal estrogen's safety, efficacy and correct use is essential to the urologist treating the post-menopausal female.
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20
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Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus 2020; 12:e7586. [PMID: 32399320 PMCID: PMC7212735 DOI: 10.7759/cureus.7586] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The genitourinary syndrome of menopause (GSM) is a relatively new term for the condition previously known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. The term was first introduced in 2014. GSM is a chronic, progressive, vulvovaginal, sexual, and lower urinary tract condition characterized by a broad spectrum of signs and symptoms. Most of these symptoms can be attributed to the lack of estrogen that characterizes menopause. Even though the condition mainly affects postmenopausal women, it is seen in many premenopausal women as well. The hypoestrogenic state results in hormonal and anatomical changes in the genitourinary tract, with vaginal dryness, dyspareunia, and reduced lubrication being the most prevalent and bothersome symptoms. These can have a great impact on the quality of life (QOL) of the affected women, especially those who are sexually active. The primary goal of the treatment of GSM is to achieve the relief of symptoms. First-line treatment consists of non-hormonal therapies such as lubricants and moisturizers, while hormonal therapy with local estrogen products is generally considered the “gold standard’’. Newer therapeutic approaches with selective estrogen receptor modulators (SERMs) or laser technologies can be employed as alternative options, but further research is required to investigate the viability and scope of their implementation in day-to-day clinical practice.
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Affiliation(s)
- Kyveli Angelou
- Urogynecology Unit, Alexandra Hospital-National and Kapodistrian University of Athens, Athens, GRC
| | - Themos Grigoriadis
- Urogynecology Unit, Alexandra Hospital-National and Kapodistrian University of Athens, Athens, GRC
| | - Michail Diakosavvas
- Urogynecology Unit, Alexandra Hospital-National and Kapodistrian University of Athens, Athens, GRC
| | - Dimitris Zacharakis
- Urogynecology Unit, Alexandra Hospital-National and Kapodistrian University of Athens, Athens, GRC
| | - Stavros Athanasiou
- Urogynecology Unit, Alexandra Hospital-National and Kapodistrian University of Athens, Athens, GRC
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Labrie F. Intracrinology and menopause: the science describing the cell-specific intracellular formation of estrogens and androgens from DHEA and their strictly local action and inactivation in peripheral tissues. Menopause 2020; 26:220-224. [PMID: 30130283 DOI: 10.1097/gme.0000000000001177] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The secretion of estrogens by the ovaries stops at menopause. Afterward, dehydroepiandrosterone (DHEA) becomes the only source of both estrogens and androgens during all the postmenopausal years. To maintain very low and biologically inactive concentrations of estrogens and androgens in the circulation, DHEA is transformed intracellularly into cell-specific small amounts of estrogens and androgens (except in the endometrium) which then act and are inactivated locally in the same cells, thus avoiding biologically significant systemic exposure to active sex steroids. The secretion of DHEA, however, mainly of adrenal origin, has already decreased by an average of 60% at the time of menopause and it continues to decrease thereafter with a parallel lowering in available intracellular estrogens and androgens. Consequently, after the arrest of estrogen secretion by the ovaries, the loss of DHEA becomes practically responsible for the symptoms and signs of menopause. Replacing what is missing, namely DHEA, at the right place, at the right time, and in the right amount, seems to be the logical and physiological approach for the treatment of menopausal symptoms and signs, as recently demonstrated for pain at sexual activity (dyspareunia), the most bothersome symptom of vulvovaginal atrophy due to menopause.
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Affiliation(s)
- Fernand Labrie
- Laval University, Quebec City, Quebec, Canada.,Endoceutics Inc., Quebec City, Quebec, Canada
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22
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Santen RJ, Mirkin S, Bernick B, Constantine GD. Systemic estradiol levels with low-dose vaginal estrogens. Menopause 2020; 27:361-370. [PMID: 31794498 PMCID: PMC7050796 DOI: 10.1097/gme.0000000000001463] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To critically evaluate published systemic estradiol levels during use of low-dose vaginal estrogens considering detection method and estrogen dose; describe challenges with accurately measuring estradiol; and determine the normal estradiol level range in postmenopausal women. METHODS PubMed was searched for studies reporting systemic estradiol levels with lower-dose vaginal estrogens (≤25 μg estradiol or 0.3 mg conjugated equine estrogens). Estradiol levels at baseline and during treatment, area under the curve, and maximum estradiol concentrations were summarized by dose within assay type. A proposed range of systemic estradiol in normal, untreated, postmenopausal women was estimated by conservatively pooling means and standard deviations from published studies. RESULTS Mean basal estradiol levels were 3.1 to 4.9 pg/mL using liquid or gas chromatography/mass spectroscopy (LC or GC/MS/MS) with a range of undetectable to 10.5 pg/mL using radioimmunoassay. Systemic estradiol levels with vaginal estrogens reflected their doses as measured with LC or GC/MS/MS in different studies: 7.1 to 9.1 pg/mL and 16.7 to 22.7 pg/mL with a 25-μg softgel capsule insert and a tablet insert, respectively; 4.6 to 7.4 pg/mL and 6.6 to 14.8 pg/mL with a 10-μg softgel capsule and a tablet insert, respectively; and 3.6 to 3.9 pg/mL with a 4-μg softgel capsule insert. A mean systemic estradiol concentration ranging from undetectable to 10.7 pg/mL is proposed as an estimate for basal estradiol levels in normal, untreated, postmenopausal women. Systemic estradiol absorption may be influenced by the placement of estradiol higher (as with an applicator) versus lower (as without an applicator) in the vagina, as estradiol transport to the uterus would be more likely further away than closer to the introitus. CONCLUSION Serum estradiol concentrations were generally lower when measured with more specific and sensitive assays. Estradiol absorption was dose-dependent, and may be influenced by dose, formulation, and positioning in the vagina. Very low systemic estradiol absorption with low/ultralow-dose vaginal estrogens may potentially decrease any adverse events that may be associated with higher doses of vaginal estrogens used for treating moderate to severe VVA due to less estradiol exposure.
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Affiliation(s)
- Richard J. Santen
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, VA
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24
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Digesu GA, Vieira‐Baptista P, Tailor V, Stockdale C, Preti M. Response letter to comments related to “The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document”. Neurourol Urodyn 2020; 39:473-476. [DOI: 10.1002/nau.24229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 11/06/2022]
Affiliation(s)
| | - Pedro Vieira‐Baptista
- Department of Obstetrics and Gynecology Hospital Lusíadas Porto Porto Portugal
- Lower Genital Tract Unit Centro Hospitalar de São João Porto Portugal
| | - Visha Tailor
- Department of Urogynaecology Imperial College Healthcare London UK
| | - Colleen Stockdale
- Department of Obstetrics and Gynecology University of Iowa Iowa City Iowa
| | - Mario Preti
- Department of Obstetrics and Gynecology University of Torino Torino Italy
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Alvisi S, Gava G, Orsili I, Giacomelli G, Baldassarre M, Seracchioli R, Meriggiola MC. Vaginal Health in Menopausal Women. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E615. [PMID: 31547180 PMCID: PMC6843679 DOI: 10.3390/medicina55100615] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 09/05/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Stefania Alvisi
- Gynecology and Physiopathology of Human Reproduction Unit, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
- Department of Surgical and Medical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
| | - Giulia Gava
- Gynecology and Physiopathology of Human Reproduction Unit, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
- Department of Surgical and Medical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
| | - Isabella Orsili
- Gynecology and Physiopathology of Human Reproduction Unit, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
| | - Giulia Giacomelli
- Gynecology and Physiopathology of Human Reproduction Unit, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
| | - Maurizio Baldassarre
- Department of Surgical and Medical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
- Center for Applied Biomedical Research (CRBA), University of Bologna, 40126 Bologna, Italy.
| | - Renato Seracchioli
- Gynecology and Physiopathology of Human Reproduction Unit, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
- Department of Surgical and Medical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
| | - Maria Cristina Meriggiola
- Gynecology and Physiopathology of Human Reproduction Unit, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
- Department of Surgical and Medical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy.
- Center for Applied Biomedical Research (CRBA), University of Bologna, 40126 Bologna, Italy.
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Affiliation(s)
- P. Cox
- Department of Gynaecology, Queen Charlotte’s and Chelsea Hospital, London, UK
| | - N. Panay
- Department of Gynaecology, Queen Charlotte’s and Chelsea Hospital, London, UK
- Department of Gynaecology, Chelsea and Westminster Hospital, London, UK
- Department of Gynaecology, Imperial College London, London, UK
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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. Menopause 2019; 25:596-608. [PMID: 29762200 DOI: 10.1097/gme.0000000000001121] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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La Rosa VL, Ciebiera M, Lin LT, Fan S, Butticè S, Sathyapalan T, Jędra R, Lordelo P, Favilli A. Treatment of genitourinary syndrome of menopause: the potential effects of intravaginal ultralow-concentration oestriol and intravaginal dehydroepiandrosterone on quality of life and sexual function. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2019; 18:116-122. [PMID: 31488961 PMCID: PMC6719636 DOI: 10.5114/pm.2019.86836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 06/23/2019] [Indexed: 02/05/2023]
Abstract
The climacteric is considered a natural phase in a woman's aging process and is defined as the period starting from the decline in ovarian activity until after the end of ovarian function. Genitourinary syndrome of menopause (GSM) is commonly observed in menopausal women and is characterised by a collection of symptoms resulting from changes to the internal and external genitalia as well as the lower urinary tract. Several studies have demonstrated the close association between sexual dysfunction and symptoms related to GSM. Many medications, at different doses, have been studied over the years for the treatment of the symptoms of GSM. More specifically, ultralow-dose intravaginal oestriol and intravaginal dehydroepiandrosterone (DHEA) are reported to improve symptoms, signs, and quality of life of women with GSM, and they are safe owing to their specific local effect. While the dosage and the administration of intravaginal DHEA are well defined, the literature on intravaginal oestriol is less uniform: different doses and times of administration are proposed with different possible combinations with other non-pharmacological therapies, although a more standardised treatment may be necessary. The aim of this review is to summarise the available data about the effects of ultralow-concentration oestriol and intravaginal DHEA on the menopause-related symptoms, quality of life, and sexual function of women affected by GSM.
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Affiliation(s)
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynaecology, The Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Li-Te Lin
- Department of Obstetrics and Gynaecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Shangrong Fan
- Department of Obstetrics and Gynaecology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Salvatore Butticè
- Department of Urology, San Giovanni di Dio Hospital, Agrigento, Italy
| | - Thozhukat Sathyapalan
- Department of Academic Diabetes, Endocrinology and Metabolism, Hull York Medical School, University of Hull, Hull, UK
| | - Robert Jędra
- Second Department of Obstetrics and Gynaecology, The Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - Alessandro Favilli
- Section of Obstetrics and Gynaecology, Department of Surgical and Biomedical Sciences, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy
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Abstract
For women at elevated risk of thrombosis, clinicians are challenged to relieve menopausal symptoms without increasing the risk of thrombosis. Oral menopausal hormone therapy increases the risk of venous thromboembolism by 2-fold to 3-fold. Observational studies suggest less thrombotic risk with transdermal therapies and with progesterone over synthetic progestogens (progestins), but the data are limited. Beneficial nonpharmacologic therapies include cognitive behavioral therapy and clinical hypnosis, whereas beneficial nonhormonal pharmacologic therapies include selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. For treatment of the genitourinary syndrome of menopause, vaginal lubricants and moisturizers, low-dose vaginal estrogen, and intravaginal dehydroepiandrosterone are options.
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Rege J, Turcu AF, Kasa-Vubu JZ, Lerario AM, Auchus GC, Auchus RJ, Smith JM, White PC, Rainey WE. 11-Ketotestosterone Is the Dominant Circulating Bioactive Androgen During Normal and Premature Adrenarche. J Clin Endocrinol Metab 2018; 103:4589-4598. [PMID: 30137510 PMCID: PMC6226603 DOI: 10.1210/jc.2018-00736] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/14/2018] [Indexed: 01/18/2023]
Abstract
CONTEXT Adrenarche refers to the rise of dehydroepiandrosterone sulfate (DHEA-S) associated with the development of a functional adrenal zona reticularis. Clinical features of adrenarche include onset of body odor, axillary hair, and pubic hair, which reflect increased androgen action. An early rise in adrenal androgens, or premature adrenarche (PremA), is a risk factor for adverse metabolic profiles in adolescence and adulthood. The bioactive androgens associated with adrenarche and PremA remain poorly understood. The adrenal gland is a potential source of testosterone (T) and the 11-oxygenated derivatives 11β-hydroxytestosterone (11OHT) and 11-ketotestosterone (11KT). OBJECTIVE The objective of this study was to characterize the adrenal androgen biome contributing to adrenarche and PremA. PARTICIPANTS AND METHODS With the use of mass spectrometry, 19 steroids including the 11-oxygenated derivatives of T were measured in sera obtained from girls with PremA (n = 37; 4 to 7 years) and age-matched girls (n = 83; 4 to 10 years). RESULTS In reference population girls, dehydroepiandrosterone, DHEA-S, androstenediol-3-sulfate, T, and 11KT all increased at the onset of adrenarche (6 to 8 years) and beyond (9 to 10 years) (P < 0.05 vs younger subjects 4 to 5 years). T, 11OHT, and 11KT were further elevated in PremA vs age-matched girls (P < 0.001). Circulating concentrations of 11KT during adrenarche and PremA exceeded those of T and 11OHT (11KT > T ≥ 11OHT). Androgen receptor activity and nuclear translocation studies demonstrated that 11KT is a potent androgen similar to T. CONCLUSIONS Our findings suggest that 11KT is the dominant bioactive androgen in children during adrenarche and PremA. Its androgenic capacity suggests that it may be responsible for the phenotypic changes seen in these phenomena.
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Affiliation(s)
- Juilee Rege
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Antonio M Lerario
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gabriela C Auchus
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan
| | | | - Perrin C White
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William E Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Correspondence and Reprint Requests: William E. Rainey, PhD, Departments of Molecular and Integrative Physiology and Internal Medicine, University of Michigan, 1150 West Medical Center Drive, 2560C Medical Science Research Building II, Ann Arbor, Michigan 48109-5622. E-mail:
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Phua C, Baber R. The Management of Menopausal Symptoms in Women Following Breast Cancer: An Overview. Drugs Aging 2018; 35:699-705. [PMID: 30073604 DOI: 10.1007/s40266-018-0574-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The improved detection and successful treatment of breast cancer, resulting in better survival rates, has led to an increasing number of women living with the effects of treatment modalities and their long-term consequences. Menopausal symptoms following breast cancer can occur at an earlier age, be more severe and significantly influence a woman's overall wellbeing, in particular, sexual function, quality of life and adherence to treatment. There is a dearth of good quality evidence on the safest and most effective treatment options available for these women, and this article aims to summarize the current available treatments. Pertinent to these women is general advice, such as avoidance of triggers, and lifestyle modifications. Following which, non-pharmacological interventions, including cognitive behavior therapy (CBT), hypnosis, acupuncture, stellate ganglion nerve block and complementary agents, are discussed. Pharmacological therapies and their safety profile in these high-risk women are then examined; namely, menopausal hormone therapy, progestogens, antidepressants (selective serotonin reuptake inhibitors and selective noradrenaline reuptake inhibitors), gabapentin, clonidine and intra-vaginal dehydroepiandrosterone (DHEA). Finally, neurokinin 3 receptor antagonists, promising new agents for the treatment of troublesome menopausal vasomotor symptoms, are discussed.
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Affiliation(s)
- Cheryl Phua
- Royal Prince Alfred Hospital, Sydney, Australia
| | - Rodney Baber
- Obstetrics and Gynaecology, Sydney Medical School North, Royal North Shore Hospital, The University of Sydney, Sydney, Australia.
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Gibson DA, Simitsidellis I, Collins F, Saunders PTK. Endometrial Intracrinology: Oestrogens, Androgens and Endometrial Disorders. Int J Mol Sci 2018; 19:E3276. [PMID: 30360364 PMCID: PMC6214123 DOI: 10.3390/ijms19103276] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 12/26/2022] Open
Abstract
Peripheral tissue metabolism of steroids (intracrinology) is now accepted as a key way in which tissues, such as the endometrium, can utilise inactive steroids present in the blood to respond to local physiological demands and 'fine-tune' the activation or inhibition of steroid hormone receptor-dependent processes. Expression of enzymes that play a critical role in the activation and inactivation of bioactive oestrogens (E1, E2) and androgens (A4, T, DHT), as well as expression of steroid hormone receptors, has been detected in endometrial tissues and cells recovered during the menstrual cycle. There is robust evidence that increased expression of aromatase is important for creating a local microenvironment that can support a pregnancy. Measurement of intra-tissue concentrations of steroids using liquid chromatography⁻tandem mass spectrometry has been important in advancing our understanding of a role for androgens in the endometrium, acting both as active ligands for the androgen receptor and as substrates for oestrogen biosynthesis. The emergence of intracrinology, associated with disordered expression of key enzymes such as aromatase, in the aetiology of common women's health disorders such as endometriosis and endometrial cancer has prompted renewed interest in the development of drugs targeting these pathways, opening up new opportunities for targeted therapies and precision medicine.
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Affiliation(s)
- Douglas A Gibson
- Centre for Inflammation Research, The University of Edinburgh, EH16 4TJ Edinburgh, UK.
| | - Ioannis Simitsidellis
- Centre for Inflammation Research, The University of Edinburgh, EH16 4TJ Edinburgh, UK.
| | - Frances Collins
- Centre for Inflammation Research, The University of Edinburgh, EH16 4TJ Edinburgh, UK.
| | - Philippa T K Saunders
- Centre for Inflammation Research, The University of Edinburgh, EH16 4TJ Edinburgh, UK.
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Guennoun R, Zhu X, Fréchou M, Gaignard P, Slama A, Liere P, Schumacher M. Steroids in Stroke with Special Reference to Progesterone. Cell Mol Neurobiol 2018; 39:551-568. [DOI: 10.1007/s10571-018-0627-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022]
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Sauer U, Talaulikar V, Davies MC. Efficacy of intravaginal dehydroepiandrosterone (DHEA) for symptomatic women in the peri- or postmenopausal phase. Maturitas 2018; 116:79-82. [PMID: 30244783 DOI: 10.1016/j.maturitas.2018.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 07/16/2018] [Accepted: 07/30/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVE There is uncertainty whether treatment with dehydroepiandrosterone (DHEA) decreases menopausal symptoms for women in the peri- or postmenopausal phase. A previous systematic review considering this subject suggested that DHEA may slightly improve sexual function compared with placebo (CS. Scheffers, S. Armstrong, AEP. Cantineau, C. Farquhar, V. Jordan Dehydroepiandrosterone for women in the peri- or postmenopausal phase. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD011066. DOI: https://doi.org/10.1002/14651858.CD011066.pub2). The purpose of this article is to review recent research investigating whether the use of DHEA, and in particular intravaginal DHEA (Prasterone®), improves sexual function. METHODS We conducted an online search using Medline OVID for recent articles related to DHEA and menopause. We found 48 relevant publications, out of which 14 papers were original research, all related to the development and licensing of intravaginal DHEA. We critically analysed these 14 articles in relation to sexual function. RESULTS All the randomised controlled trials assessed the efficacy of vaginal DHEA in women with vulvovaginal atrophy and showed that sexual dysfunction improved with treatment regardless of the level of dyspareunia at baseline. Treatment with DHEA was found to be superior to placebo and at least as efficacious as vaginal oestrogens in improving symptoms. CONCLUSION Intravaginal DHEA appears to be a safe and effective treatment for menopausal vulvovaginal atrophy and dyspareunia in most women. Further studies are required before it can be recommended for women with a history of thrombosis, cardiovascular disease or hormone-sensitive neoplasms.
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Affiliation(s)
- Ulrike Sauer
- Market Street Health Centre, 16-20 Market Street, Woolwich, London SE18 6QR, United Kingdom.
| | - Vikram Talaulikar
- Reproductive Medicine Unit, EGA Wing, University College London Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom
| | - Melanie C Davies
- Reproductive Medicine Unit, EGA Wing, University College London Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom
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Abstract
OBJECTIVE Breast cancer survivors often take hormonal treatments to prevent the recurrence of breast cancer, particularly aromatase inhibitors that can worsen the symptoms of genitourinary syndrome of menopause (GSM) such as dyspareunia, dysuria, and urinary incontinence, all of which may adversely affect survivors' quality of life. Few breast cancer survivors experiencing GSM receive adequate assessment or treatment. METHODS In this descriptive study, we reviewed medical records for documented GSM and any treatments administered or referrals for treatment in 800 female patients who visited the Breast Cancer Survivorship Clinic at a comprehensive cancer center between July 1, 2010 and June 30, 2011, either at least 5 years after completion of treatment for invasive breast cancer or at least 6 months after completion of treatment for ductal carcinoma in situ. RESULTS Of the 279 patients with documented symptoms of vaginal atrophy, only 111 (39.8%) had documentation of having received any form of treatment or referral. Of the 71 patients with documented symptoms of urinary tract atrophy, only 33.8% had documentation of having received treatment or referral for treatment. CONCLUSION Breast cancer survivors often experience GSM due to lack of estrogen. The worrisome lack of documentation of assessment or treatment for GSM in a large breast cancer survivorship practice reveals missed opportunities to improve quality of life. Dissemination of recent progress in the development of GSM assessment tools, patient handouts, and new treatments to providers who care for breast cancer survivors is needed to improve this process.
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Abstract
OBJECTIVE To analyze the effects of intravaginal prasterone obtained in the three randomized clinical studies performed in postmenopausal women suffering from moderate to severe (MS) dyspareunia due to vulvovaginal atrophy (VVA). METHODS In three independent 12-week prospective, randomized, double-blind, and placebo-controlled clinical studies, the effect of daily intravaginal 0.50% (6.5 mg) prasterone was examined on four co-primary objectives in women having MS pain during sexual activity (dyspareunia), identified as their most bothersome symptom (MBS) of VVA at baseline. RESULTS In 436 women treated with 0.50% prasterone and 260 women who received placebo, an average 35.1% decrease over placebo in the percentage of parabasal cells (P < 0.0001), an average 7.7% increase in the percentage of superficial cells (P < 0.0001), and a mean 0.72 pH unit decrease in vaginal pH (P < 0.0001) were observed. The severity score of most bothersome symptom dyspareunia was decreased by a 0.46 unit (49%) (P < 0.0001 over placebo), whereas the severity score of MS vaginal dryness decreased by 0.31 unit (P < 0.0001 over placebo). A very positive evaluation was obtained on the acceptability of the technique of administration of the insert, whereas the male partners reported a very positive evaluation of the changes observed in their sexual partner. CONCLUSION The efficacy data demonstrate highly positive effects on all the symptoms and signs of vulvovaginal atrophy with no significant drug-related side effects in line with the physiology of menopause and intracrinology.
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Abstract
OBJECTIVE To illustrate the marked differences between classical endocrinology that distributes hormones to all tissues of the body through the bloodstream and the science of intracrinology, whereby each cell of each peripheral tissue makes a small and appropriate amount of estrogens and androgens from the inactive precursor dehydroepiandrosterone (DHEA), DHEA being mainly of adrenal origin. Because only the inactivated sex steroids are released in the blood, influence in the other tissues is avoided. METHODS Molecular biology has been used for the identification/characterization of the steroid-forming and steroid-inactivating enzymes, whereas steroids have been measured by mass spectrometry-based assays validated according to the US Food and Drug Administration guidelines. RESULTS Evolution over 500 million years has engineered the expression of about 30 steroid-forming enzymes specific for each peripheral tissue. These tissue-specific enzymes transform DHEA into the appropriate small amounts of estrogens and androgens for a strictly intracellular and local action. Humans, contrary to species below primates, also possess intracellular steroid-inactivating enzymes, especially glucuronyl transferases and sulfotransferases, which inactivate the estrogens and androgens at their local site of formation, thus preventing the release of a biologically significant amount of estradiol (E2) and testosterone in the circulation. Since DHEA becomes the unique source of sex steroids after menopause, serum E2 and testosterone are thus maintained at low biologically inactive concentrations with no activity outside the cells of origin. DHEA secretion, unfortunately, starts decreasing at about the age of 30 at various rates in different women. Moreover, there is no feedback mechanism to increase DHEA secretion when the concentration of serum DHEA decreases. Considering this mechanism is unique to the human, it seems logical to replace DHEA locally in women suffering from vulvovaginal atrophy (genitourinary syndrome of menopause). The clinical data obtained using a small dose of intravaginal DHEA (prasterone) confirm the mechanisms of intracrinology mentioned above which avoid biologically significant changes in serum E2 and testosterone. CONCLUSIONS The symptoms and signs of vulvovaginal atrophy (genitourinary syndrome of menopause) can be successfully treated by the intravaginal administration of DHEA without safety concerns. This strategy exclusively replaces in the vagina the missing cell-specific intracellular estrogens and androgens. This approach avoids systemic exposure and the potential risks of estrogen exposure for the tissues other than the vagina.
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Concentration range of serum sex steroids in normal postmenopausal women and those with diagnosis of vulvovaginal atrophy. Menopause 2018; 25:293-300. [DOI: 10.1097/gme.0000000000000993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The consequences of estrogen deprivation and therapeutic interventions such as radiation, chemotherapy and surgery have a significant negative impact on libido, sexual arousal, orgasmic function and the ability to have pleasurable intercourse. Evaluation and treatment of female sexual dysfunction is a significant unmet need in the breast cancer survivor in spite of the availability of safe and effective treatments.
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Affiliation(s)
- Lauren Streicher
- The Northwestern Medicine Center for Sexual Medicine and Menopause, Feinberg School of Medicine, Chicago, USA.
| | - James A Simon
- The Northwestern Medicine Center for Sexual Medicine and Menopause, Feinberg School of Medicine, Chicago, USA
- George Washington University, Washington, USA
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Hetemäki N, Savolainen-Peltonen H, Tikkanen MJ, Wang F, Paatela H, Hämäläinen E, Turpeinen U, Haanpää M, Vihma V, Mikkola TS. Estrogen Metabolism in Abdominal Subcutaneous and Visceral Adipose Tissue in Postmenopausal Women. J Clin Endocrinol Metab 2017; 102:4588-4595. [PMID: 29029113 DOI: 10.1210/jc.2017-01474] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/21/2017] [Indexed: 02/13/2023]
Abstract
CONTEXT In postmenopausal women, adipose tissue (AT) levels of estrogens exceed circulating concentrations. Although increased visceral AT after menopause is related to metabolic diseases, little is known about differences in estrogen metabolism between different AT depots. OBJECTIVE We compared concentrations of and metabolic pathways producing estrone and estradiol in abdominal subcutaneous and visceral AT in postmenopausal women. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS AT and serum samples were obtained from 37 postmenopausal women undergoing surgery for nonmalignant gynecological reasons. Serum and AT estrone, estradiol, and serum estrone sulfate (E1S) concentrations were quantitated using liquid chromatography-tandem mass spectrometry. Activity of steroid sulfatase and reductive 17β-hydroxysteroid dehydrogenase enzymes was measured using radiolabeled precursors. Messenger RNA (mRNA) expression of estrogen-converting enzymes was analyzed by real-time reverse transcription quantitative polymerase chain reaction. RESULTS Estrone concentration was higher in visceral than subcutaneous AT (median, 928 vs 706 pmol/kg; P = 0.002) and correlated positively with body mass index (r = 0.46; P = 0.011). Both AT depots hydrolyzed E1S to estrone, and visceral AT estrone and estradiol concentrations correlated positively with serum E1S. Compared with visceral AT, subcutaneous AT produced more estradiol from estrone (median rate of estradiol production, 1.02 vs 0.57 nmol/kg AT/h; P = 0.004). In visceral AT, the conversion of estrone to estradiol increased with waist circumference (r = 0.65; P = 0.022), and estradiol concentration correlated positively with mRNA expression of HSD17B7 (r = 0.76; P = 0.005). CONCLUSIONS Both estrone and estradiol production in visceral AT increased with adiposity, but estradiol was produced more effectively in subcutaneous fat. Both AT depots produced estrone from E1S. Increasing visceral adiposity could increase overall estrogen exposure in postmenopausal women.
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Affiliation(s)
- Natalia Hetemäki
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Finland
- Folkhälsan Research Center, University of Helsinki, Finland
| | - Hanna Savolainen-Peltonen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Finland
- Folkhälsan Research Center, University of Helsinki, Finland
| | - Matti J Tikkanen
- Folkhälsan Research Center, University of Helsinki, Finland
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Feng Wang
- Folkhälsan Research Center, University of Helsinki, Finland
| | - Hanna Paatela
- Folkhälsan Research Center, University of Helsinki, Finland
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Finland
| | | | | | | | - Veera Vihma
- Folkhälsan Research Center, University of Helsinki, Finland
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Tomi S Mikkola
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Finland
- Folkhälsan Research Center, University of Helsinki, Finland
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Archer DF, Labrie F, Montesino M, Martel C. Comparison of intravaginal 6.5mg (0.50%) prasterone, 0.3mg conjugated estrogens and 10μg estradiol on symptoms of vulvovaginal atrophy. J Steroid Biochem Mol Biol 2017; 174:1-8. [PMID: 28323042 DOI: 10.1016/j.jsbmb.2017.03.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 03/14/2017] [Accepted: 03/17/2017] [Indexed: 11/26/2022]
Abstract
The objective is to compare the effect of intravaginal dehydroepiandrosterone (DHEA, prasterone), conjugated equine estrogens (CEE) and estradiol (E2) on moderate to severe dyspareunia and/or vaginal dryness. In a review of available data, independent prospective, randomized, double-blind and placebo-controlled Phase III 12-week clinical trials involved daily administration of 6.5mg (0.50%) prasterone, daily (21days on/7days off) 0.3mg CEE, twice weekly 0.3mg CEE or 10μg E2 daily for 2 weeks followed by twice weekly for 10 weeks. Vulvovaginal atrophy (VVA) symptoms were evaluated by questionnaires. The total severity score of dyspareunia decreased from baseline by 1.27 to 1.63 units with prasterone treatment, 1.4 with CEE and 1.23 in one statistically significant study with E2 (combined symptoms). Decreases over placebo ranged from 0.35 to 1.21 with prasterone, 0.7 to 1.0 with CEE and 0.33 for the E2 study. The total decreases in vaginal dryness severity ranged from 1.44 to 1.58 units for prasterone, 1.1 unit for CEE and 1.23 unit for E2. The decreases over placebo of vaginal dryness intensity ranged from 0.30 to 0.43 unit for prasterone, 0.40 unit for CEE and 0.33 for the E2 study with combined symptoms. Daily 6.5mg (0.50%) prasterone appears to be at least as efficacious as 0.3mg CEE or 10μg E2 for treatment of the VVA symptoms. In summary, the beneficial effects on the VVA symptomatology can be obtained by the addition of a small amount of intravaginal prasterone to compensate for the low serum concentration of prasterone observed in the majority of women after menopause without concerns about systemic effects.
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Affiliation(s)
- David F Archer
- CONRAD Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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Santen RJ, Stuenkel CA, Davis SR, Pinkerton JV, Gompel A, Lumsden MA. Managing Menopausal Symptoms and Associated Clinical Issues in Breast Cancer Survivors. J Clin Endocrinol Metab 2017; 102:3647-3661. [PMID: 28934376 DOI: 10.1210/jc.2017-01138] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/28/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Review evidence to guide management of menopausal signs and symptoms in women after breast cancer and make recommendations accordingly. EVIDENCE Randomized controlled clinical trials, observational studies, evidence-based guidelines, and expert opinion from professional societies. BACKGROUND Symptoms and clinical problems associated with estrogen depletion-sleep disorders, vulvovaginal atrophy (VVA), vasomotor symptoms (VMS), mood changes, depressive symptoms, cardiovascular disease, osteopenia, and osteoporosis-confront the estimated 9.3 million breast cancer survivors globally. RECOMMENDATIONS Following breast cancer, women should not generally be treated with menopausal hormone therapy or tibolone but should optimize lifestyle. Women with moderate to severe symptoms may benefit from mind-brain behavior or nonhormone, pharmacologic therapy. The selective serotonin/noradrenaline reuptake inhibitors and gabapentenoid agents improve VMS and quality of life. For osteoporosis, nonhormonal agents are available. Treatment of VVA remains an area of unmet need. Low-dose vaginal estrogen is absorbed in small amounts with blood levels remaining within the normal postmenopausal range but could potentially stimulate occult breast cancer cells, and although poorly studied, is not generally advised, particularly for those on aromatase inhibitors. Intravaginal dehydroepiandrosterone and oral ospemiphene have been approved to treat dyspareunia, but safety after breast cancer has not been established. Vaginal laser therapy is being used for VVA but efficacy from sham-controlled studies is lacking. Therapies undergoing development include lasofoxifene, neurokinin B inhibitors, stellate ganglion blockade, vaginal testosterone, and estetrol. CONCLUSIONS Nonhormone options and therapies are available for treatment of estrogen depletion symptoms and clinical problems after a diagnosis of breast cancer. Individualization of treatment is essential.
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Affiliation(s)
- Richard J Santen
- Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22903
| | - Cynthia A Stuenkel
- Division of Endocrinology and Metabolism, University of California, San Diego, La Jolla, California 92093
| | - Susan R Davis
- School of Public Health and Preventative Medicine, Monash University, Melbourne 3004, Australia
| | - JoAnn V Pinkerton
- Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, Virginia 22903
| | - Anne Gompel
- Hopitaux Universitaires Port Royal-Cochin Unite de Gynecologie Endocrinienne, Paris Descartes University, Paris 75014, France
| | - Mary Ann Lumsden
- Department of Medicine, Dentistry and Nursing, University of Glasgow School of Medicine, Glasgow G31 2ER, Scotland
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To the Editor:. Menopause 2017; 24:988. [DOI: 10.1097/gme.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Archer DF, Constantine GD, Simon J, Kushner H, Mayer P, Bernick B, Graham S, Mirkin S. In Reply. Menopause 2017; 24:988-989. [PMID: 28719419 DOI: 10.1097/gme.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology Eastern Virginia Medical School, Norfolk, VA EndoRheum Consultants, LLC, Malvern, PA The George Washington University School of Medicine, Washington, DC BioMedical Computer Research Institute, Inc, Philadelphia, PA Independent Consultant, West Chester, PA TherapeuticsMD, Boca Raton, FL. TherapeuticsMD, Boca Raton, FL. TherapeuticsMD, Boca Raton, FL
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Abstract
OBJECTIVE Women with gynecologic malignancies will be cured or may become long-term survivors. Management of menopausal symptoms is important in addressing their quality of life. We review the benefit and safety of hormone therapy use in these patients. METHODS MEDLINE was searched for studies on menopause management published in English through December of 2016. RESULTS Available data suggest that short-term use of hormone therapy in gynecologic cancer patients who do not have an estrogen-dependent malignancy do not adversely impact oncologic outcome and results in improvement of menopausal vasomotor and genitourinary symptoms. Evidence regarding safety of hormone therapy use in women with estrogen-dependent gynecologic malignances is currently lacking. CONCLUSIONS Candidates for hormone therapy in gynecologic oncology include women with menopausal symptoms diagnosed with low-grade, early-stage endometrial cancer, cervical, vulvar and vaginal cancer, and ovarian cancer.
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Affiliation(s)
- Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Laurel W Rice
- Department of Obstetrics and Gynecology, University of Wisconsin Hospital and Clinics, Madison, WI, United States
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Labrie F, Martel C, Bélanger A, Pelletier G. Androgens in women are essentially made from DHEA in each peripheral tissue according to intracrinology. J Steroid Biochem Mol Biol 2017; 168:9-18. [PMID: 28153489 DOI: 10.1016/j.jsbmb.2016.12.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 12/14/2016] [Accepted: 12/16/2016] [Indexed: 11/22/2022]
Abstract
The objective is to review how the cell-specific amounts of intracellular androgens are all made in women from circulating dehydroepiandrosterone (DHEA) in each peripheral tissue, independently from the rest of the body. Following 500 million years of evolution, approximately three dozen cell-specific intracrine enzymes have been engineered in human peripheral tissues whereby the inactive sex steroid precursor DHEA mainly of adrenal origin is transformed into the appropriate minute intracellular amounts of androgens. These intracellular androgens are inactivated in the same cells, with no biologically significant release of active androgens in the circulation. The best estimate is that approximately 50% as much androgens are synthesized in women, compared to men of the same age. The problem with DHEA, however, the exclusive source of androgens in women of all ages, is that DHEA secretion has already decreased by an average of 60% at time of menopause and continues to decrease thereafter. The human-specific and highly sophisticated mechanisms of intracrinology permit each cell to control androgen availability according to its own needs independently from the remaining of the body. Such a mechanism is completely different from classical endocrinology well understood in men where testosterone of testicular origin is transported through the blood and has indiscriminate access to the androgen receptor (AR) in all AR-containing cells of the body. In men, both the endocrine and intracrine mechanisms are in operation while, in women, only the intracrine mechanisms responsible for intracellular formation from DHEA provide androgens.
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Affiliation(s)
- Fernand Labrie
- Professor Emeritus, Laval University, Quebec City, Canada; Endoceutics Inc, Quebec City, Canada.
| | | | - Alain Bélanger
- Professor Emeritus, Laval University, Quebec City, Canada; Consultant, Endoceutics Inc, Quebec City, Canada
| | - Georges Pelletier
- Professor Emeritus, Laval University, Quebec City, Canada; Consultant, Endoceutics Inc, Quebec City, Canada
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Labrie F, Martel C. A low dose (6.5 mg) of intravaginal DHEA permits a strictly local action while maintaining all serum estrogens or androgens as well as their metabolites within normal values. Horm Mol Biol Clin Investig 2017; 29:39-60. [PMID: 27997350 DOI: 10.1515/hmbci-2016-0042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 10/28/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Serum concentrations of estradiol (E2) and testosterone (testo) measured by mass spectrometry-based assays should remain below the 95th centile measured at 9.3 pg/mL for E2 and 0.26 ng/mL for testo in normal postmenopausal women in order to avoid the risk of non-physiological systemic exposure to elevated serum concentrations of these two sex steroids. METHODS Serum E2 and testo, as well as dehydroepiandrosterone (DHEA) and nine of its other metabolites, were measured at 10 time intervals over 24 h on the first and seventh days of daily intravaginal administration of 0.50% (6.5 mg) DHEA by validated mass spectrometry-based assays. RESULTS No biologically significant change in the individual serum concentrations of E2, testo or DHEA was observed. Most importantly, estrone sulfate (E1-S) and the glucuronidated androgen metabolites also remained within normal values, thus confirming the absence of biologically significant systemic exposure in line with intracrinology. Using data from the literature, comparison is made with serum E2 above normal postmenopausal values following administration of 10-μg E2 tablets. CONCLUSION While the clinical program on vulvovaginal atrophy has shown the efficacy and safety of intravaginal 6.5 mg of DHEA (prasterone), the present data illustrate in detail the serum levels of the individual sex steroids and their metabolites derived from DHEA. The data obtained are in line with the physiology of intracrinology and confirm an action limited to the vagina as the serum concentrations of all sex steroids are maintained within the normal values of menopause, thus protecting the uterus and most likely other tissues.
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Deconstructing the genitourinary syndrome of menopause. Int Urogynecol J 2017; 28:675-679. [DOI: 10.1007/s00192-017-3295-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/09/2017] [Indexed: 11/29/2022]
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