Genitourinary Syndrome of Menopause and Breast Cancer Survivors
By: Dr. Anna Camille Moreno • Posted on August 02, 2017
What is Genitourinary Syndrome of Menopause?
Genitourinary Syndrome of Menopause (GSM), commonly known to us as “Vulvovaginal Atrophy (VVA),” is a very common and underreported issue during perimenopause, menopause and especially, postmenopause.
What is a breast cancer survivor to do about GSM?
GSM has nearly unanimously impacted the life of breast cancer survivors, especially those who have undergone chemotherapy, radiation and adjuvant endocrine hormonal ablative therapies such as aromatase inhibitors (AIs) and tamoxifen (TAM) an Estrogen Receptor Agonist Antagonist (ERAA).
The common adverse effects of breast cancer therapy involve decreasing levels of estrogen, causing the tissues of the vulva and the lining of the bladder and vagina to become thinner, drier and less elastic. These physiological changes lead to injury, tearing and pain during sexual intercourse called dyspareunia. They can even cause unbearable symptoms such as:
- vaginal burning
- recurrent urinary tract infections (UTIs)
- arousal difficulties
The GOOD NEWS is these symptoms can be prevented and/or treated, and the sooner the better.
What is the controversy about management of GSM in breast cancer survivors?
Local estrogen therapy is the most common approach to management of GSM. GSM is usually reversible with hormone therapy - locally in the vagina alone and systemically, if needed. Furthermore, there are emerging therapies to treat urogenital symptoms including:
- Vaginal precursor steroids (DHEA)
- Designer estrogens
Even in women with estrogen receptor positive breast cancer there are treatment options.
Based on a published study that surveyed oncologists’ attitude toward the diagnosis and treatment of GSM, the main reasons not to prescribe vaginal estrogen therapy in breast cancer survivors are:
- The fear of increased cancer recurrence.
- The possible interference with tamoxifen and aromatase inhibitors.
- Fear of medical litigation.
VVA is a relevant problem many postmenopausal women and virtually all breast cancer survivors who have lost their sex hormones.
Effective Treatments for GSM
Below I have created an overview of clinical approaches to inform you and your health provider about GSM/VVA problems and on the different possible available treatments.
Lubricants-for symptoms only
- Just Like Me
- K-Y Jelly
- Slippery Stuff
- Summer’s Eve
- ID Millennium
- Pure Pleasure
- Avoid Mineral oil
- It is OK to use olive oil and vitamin E oil
- Fresh Start
- K-Y Silk-E
- Moist Again
- K-Y Liquibeads
Vaginal Estrogen Products
- Vagifem (estradiol)or the generic Yuvafem (vaginal tablet)
- Estrace (estradiol vaginal cream)
- Premarin (vaginal cream)
- Estring (low-dose vaginal ring)
- Intrarosa 0.5% DHEA nightly vaginal suppository contains NO estrogen and is safe to use in women who have to avoid estrogen.
- Ospemifene (Osphena) is a non-estrogen oral daily medicine taken daily with food (for better absorption) and is an option to treat vaginal atrophy/genital syndrome of menopause (GMS) although not specifically studied in breast cancer.
- Conjugated estrogen/bazedoxifene (Duavee) is an oral estrogen combined with a ERAA BZD bazedoxifene, which can treat menopausal symptoms and GSM. Some women who are breast cancer survivors and have had a pregnancy after breast cancer and then find themselves menopausal, may want to consider this if other options do not work.
In addition women with stage 0 breast cancer (DCIS) and/or women at high risk for breast cancer but who do NOT have active breast cancer who are interested in taking menopausal hormone therapy, can benefit from Duavee.
This needs to be monitored by a menopause specialist in conjunction with your breast oncologist.
Choosing the Right GSM Treatment For you
When selecting which GSM therapy is right for you, the following factors should be taken into consideration:
- Hormone exposure
- Lack of any postmenopausal vaginal bleeding
- History of hysterectomy
- History of osteoporosis, osteopenia, and fractures
- History of receptor-positive or receptor negative breast cancer
There are investigational therapies as well. Talk to your women’s health care physician about your preferences, goals and desires for future childbearing to find out what might be the best option for you!
Be Strong. Be Healthy. Be in Charge!
Anna Camille Moreno, DO NCMP
Department of Obstetrics & Gynecology
Duke Women's Health Associates
Duke University Medical Center
Anna Camille Moreno, DO is a Family Medicine Doctor at Duke Women's Health Associates. Dr. Moreno is dedicated to an interdisciplinary women’s health practice focusing on the care of midlife women as it relates to menopause, perimenopause, hormone therapy, and their associated medical problems. Dr. Moreno is a graduate of the Specialized Women's Health Fellowship Program at Cleveland Clinic.