Management Of Genitourinary Syndrome Of Menopause In Women With Or At High Risk For Breast Cancer

Publication Date: November 1, 2018
Last Updated: March 14, 2022

Treatment options for management of GSM in specific patient populations

General guidelines
  • Individual treatment, taking into account risk of recurrence, severity of symptoms, effect on QOL, and personal preferences
  • Moisturizers and lubricants, pelvic floor physical therapy, and dilator therapy are first-line treatments.
  • Involve treating oncologist in decision making when considering the use of local hormone therapies.a
  • Ospemifene, an oral SERM, has not been studied in women at risk for breast cancer and is not FDA-approved for use in women with or at high risk for breast cancer.
  • Off-label use of compounded vaginal testosterone or estriol is not recommended.
  • Laser therapy may be considered in women who prefer a nonhormone approach; women must be counseled regarding lack of long-term safety and efficacy data.
Women at high risk for breast cancerb.
  • Local hormone therapies are a reasonable option for women who have failed nonhormone treatment.
  • Observational data do not suggest increased risk of breast cancer with systemic or local estrogen therapies beyond baseline risk
Women with ER-positive breast cancers on tamoxifen.
  • Tamoxifen is a SERM that acts as an ER antagonist in breast tissue; small transient elevations in serum hormone levels noted with local hormone therapies in women on tamoxifen are less concerning than in women on AIs.
  • Women with persistent, severe symptoms who have failed nonhormone treatments and who have factors suggesting a low risk of recurrence may be candidates for local hormone therapy.
Women with ER-positive breast cancers on AIs.
  • AIs block conversion of androgen to estrogen, resulting in undetectable serum estradiol levels; transient elevations in estradiol levels may be of concern.
  • GSM symptoms are often more severe.
  • Women with severe symptoms who have failed nonhormone treatments may still be candidates for local hormone therapies after review with the woman’s oncologist vs consider switching to tamoxifen.
Women with triple-negative breast cancers.
  • Theoretically, the use of local hormone therapy in women with a history of triple-negative disease is reasonable, but data are lacking
Women with metastatic disease.
  • QOL, comfort, and intimacy may be a priority for many women with metastatic disease.
  • Use of local hormone therapy in women with metastatic disease and probable extended survival may be viewed differently than in women with limited survival when QOL may be a priority.
a Local hormone therapies are vaginal estrogen and intravaginal DHEA (prasterone).
b Lifetime risk > 20%, carriers of the BRCA mutation, atypical ductal hyperplasia, lobular carcinoma in situ, or ductal carcinoma in situ.

Overview

Title

Management Of Genitourinary Syndrome Of Menopause In Women With Or At High Risk For Breast Cancer

Authoring Organization

North American Menopause Society