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

Abstract

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

摘要

许多乳腺癌幸存者(BCS)遭受抗肿瘤治疗的后果, 这些治疗引起雌激素水平低下, 导致诸如绝经生殖泌尿综合征(GSM)等慢性更年期症状, 显著影响生活质量。非激素疗法(NHT)是一线疗法, 安全但疗效欠佳。对中重度GSM时, BCS的选择有限：局部雌激素治疗被认为是‘金标准’, 但安全性方面仍有担忧；阴道雄激素和普拉睾酮似乎诱发了阴道上皮的雌激素和雄激素受体的活化, 而不激活其他组织上的雌激素受体, 潜在认为是安全的, 但仍然没有支持用于BCS的有力证据；阴道激光, 似乎通过刺激阴道基底层结缔组织的重塑来改善阴道黏膜的血管形成, 但在最近的随机临床试验中, 其疗效结果不一致；奥培米芬是一种口服选择性雌激素受体调节剂, 在子宫内膜和乳房表现出抗雌激素效应, 但在阴道表现为弱的雌激素样作用, 但根据最近的北美绝经学会指南, 仍不推荐用于BCS。有必要进行进一步的研究, 客观地评估这些有前景的治疗方案的有效性和安全性。另一方面, 性必须被视为一个多因素的问题, GSM只是问题的一部分；有证据表明, 性咨询改善了BCS的生活质量。最后, 有必要限制BCS中GSM的诊断不足和治疗不足；治疗BCS的医生在这个问题上的主要目标必须是向BCS提供有关生殖和性症状的信息, 并就可能有助于防止更严重的GSM的早期一线治疗提供咨询。

Keywords:

• Genitourinary syndrome of menopause
• atrophic vaginitis
• vulvovaginal atrophy
• breast cancer
• sexual dysfunction

Potential conflict of interest

No potential conflict of interest was reported by the authors.

Source of funding

Nil.