Abstract ES4-1: Navigating the Obstacles and Risks of Survivorship: Breast Cancer Sexuality: Issues and Answers

The sexual consequences of breast cancer and its treatments are well known. Sexual difficulties include alteration in hormonal levels, changes in sexual organs and anatomy, vaginal and vulvar dryness, changes in libido, increased latency to orgasm and decreased intensity of orgasmic response. Changes in body image, sexual self-esteem and relationship dynamic tension may present as survivorship challenges for the breast cancer patient and her partner. Severe vulvo vaginal and clitoral atrophy as a result of chemotherapy and/or adjuvant hormone therapy, and loss of libido secondary to dyspareunia are widespread. Cytostatic medications that are prescribed for long-term use (aromatase inhibitors) can impact bone health, sexual functioning/satisfaction and overall quality of life. Many women on aromatase inhibitors have severe complaints of vulvar and vaginal atrophy.

Sexual dysfunction is common for breast cancer population and limited acceptable treatments are available. Minimally absorbed local vaginal estrogen use in this population remains controversial and a hotly debated controversial topic. More data should be forthcoming. There are multiple new innovative treatments in the research pipeline for female sexual dysfunction. DHEA intravaginal suppositories, Flibanserin and Bremelanotide (PT 141) remain promising although they have not been adequately studied in the breast cancer population. Ospemifene a novel estrogen agonist/ antagonist has demonstrated a strong estrogenic effect on the vaginal epithelium during a three month trial period and did not stimulate the endometrium; however, the medication did mildly aggravate hot flashes (this did not lead to drug discontinuation). Although not studied in breast cancer patients, pivotal Phase 3 data confirmed effectiveness of ospemifene as effective treatment for vulvovaginal atrophy. In a recent article in Menopause, Ospemifene and 4-hydroxyospemifene effectively prevented and treat breast cancer in Mtag. TG Transgenic Mouse.

Testosterone use remains off label and is not FDA approved, yet it is widely used in the non cancer population. New emerging safety data will be presented. Vaginal moisturizers, lubricants and dilators in association with genito pelvic floor therapy and intravaginal valium suppositories can be considered front line treatment for atrophy, dyspareunia and hypertonic vaginismus. New innovative data on non hormonal management of hot flashes is and important initial step in the overall management of the breast cancer patient who is suffering from sexual dysfunction.

A multi model treatment paradigm will be presented which will include pharmacologic, nonpharmacologic, and psychosocial interventions.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr ES4-1.

Treating dyspareunia caused by vaginal atrophy: a review of treatment options using vaginal estrogen therapy

Vulvovaginal atrophy (VVA) and dryness are common symptoms of the decline in endogenous production of estrogen at menopause and often result in dyspareunia. Yet while 10% to 40% of women experience discomfort due to VVA, it is estimated that only 25% seek medical help. The main goals of treatment for vaginal atrophy are to improve symptoms and to restore vaginal and vulvar anatomic changes. Treatment choices for postmenopausal dyspareunia resulting from vulvovaginal atrophy will depend on the underlying etiology and might include individualized treatment. A number of forms of vaginal estrogen and manner of delivery are currently available to treat moderate to severe dyspareunia caused by VVA. They all have been shown to be effective and are often the preferred treatment due to the targeted efficacy for urogenital tissues while resulting in only minimal systemic absorption. Both healthcare professionals and patients often find it difficult to broach the subject of sexual problems associated with VVA. However, with minimal effort to initiate a conversation about these problems, healthcare providers can provide useful information to their postmenopausal patients in order to help them each choose the optimal treatment for their needs and symptoms.

Usage trends of minimally absorbed vaginal estrogens in breast cancer patients versus patients with non-breast malignancies

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Background: To determine if differences exist in the use of minimally absorbed vaginal estrogens in a breast cancer population versus one with non-breast malignancies. Methods: A retrospective review of all patients with documented malignancy who were prescribed vaginal 17-β-estradiol tablets (Vagifem, Novo-Disc, Princeton, New Jersey) through the General Gynecology Service from July 1, 2003 to June 30, 2004. Data were accessed from the pharmacy health information computerized system. All patients complained of dyspareunia, and examination was consistent with vaginal atrophy. Comparison between groups was performed using the Fisher Exact Test and t-test. Results: 152 patients were identified_81 patients with breast cancer diagnoses and 71 with non-breast malignancies. There was no difference in the mean age of patients in either group, 56.9 vs. 55.1 years. (p = 0.30). Overall, 60 of the 152 patients refilled their prescriptions through the time of last follow-up. There was no difference in the proportion of breast versus non-breast cancer patients who continued vaginal estradiol, 39.5% (32/81) versus 39.4% (28/71) respectively. When the cohorts were stratified by age ≤ 50 or >50 at the time of initial consultation, 79% (11/14) of breast cancer patients age ≤ 50 years refilled their prescriptions at follow-up compared to 31.3% (21/67) of patients >50 (p = 0.002). In women with non-breast malignancies there was no age-related difference in the proportion who obtained refills: 35% (7/20) ≤ 50 years versus 41.2 % (21/51) >50 years (p = 0.79). Conclusions: Minimally absorbed vaginal estrogens appear to be viewed favorably amongst the younger breast cancer patient population. The older breast cancer population does not appear to continue vaginal estradiol use long-term. This may be due to differences in relationship status, interval from menopause to diagnosis, prior exposure to estrogen, or relief of symptoms with alternative therapies. These findings are different than those observed for similar patients with non-breast malignancies. Further studies looking at the use of minimally absorbed vaginal estrogens are needed to further evaluate the usage trends in differing patient populations.

No significant financial relationships to disclose.

Treatment of menorrhagia in women undergoing hematopoietic stem cell transplantation

The management of uterine bleeding in female transplant patients over a 3-year period at our institution was reviewed. A total of 33 females who had undergone allogeneic hematopoietic stem cell transplant were identified as having received gynecologic consultation for the diagnosis of menorrhagia. Hormone therapy achieved a resolution of symptoms in 32 (97%) of the patients, and 26 (79%) required only one hormone regimen. Following resolution of symptoms, transition to standard-dose oral contraceptive pills as maintenance therapy prevented recurrent menorrhagia due to high circulating estrogen levels. Alternatives for patients who are unable to tolerate oral administration and those with hepatotoxicity are also discussed.

Variation in vaginal breech delivery rates by hospital type

OBJECTIVE

To relate vaginal breech delivery rates to the following hospital types: public, health maintenance organization, private teaching, or private nonteaching.

METHODS

In a retrospective study using administrative discharge data from Los Angeles County, California, we calculated the vaginal breech delivery rates of singleton breech deliveries during calendar years 1988 and 1991.

RESULTS

Ten thousand four hundred breech deliveries were identified, 8988 (86.4%) term and 1412 (13.6%) preterm. Twelve percent (1252 of 10,400) were vaginal deliveries (10.1% term and 24.5% preterm). Term vaginal breech deliveries varied by hospital type and were more frequent in public hospitals (28.4%, 95% confidence interval [CI] 26.1%, 30.7%) and less frequent in private nonteaching hospitals (5.4%, 95% CI 4.8%, 5.9%). Term vaginal deliveries were 2.4 to 11.3 times more likely among black women and 1.3 to 6.3 times more likely for Hispanic women across all hospital types, compared with white women in private nonteaching hospitals. There was no difference in the proportion of preterm vaginal breech deliveries by hospital type (mean 24.5%). However, with the exception of public hospitals, the proportion of vaginal breech deliveries for both term and preterm deliveries varied significantly by ethnicity.

CONCLUSION

The use of vaginal breech delivery varied by hospital type and patient ethnicity. Within private teaching and nonteaching hospitals, vaginal breech delivery was more likely for black women than for women of other ethnic groups. Further study is needed to understand the hospital policies or organizational factors, as well as the patient-related sociocultural and clinical factors, that contribute to those differences.