Genitourinary syndrome of menopause in breast cancer survivors: Treatments are available

Anna Camille Moreno; Sabrina K. Sikka; Holly L. Thacker

doi:10.3949/ccjm.85a.17108

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TABLE 1

Systemic breast cancer treatments that cause genitourinary syndrome of menopause (GSM)

Treatments	Breast cancer effects	GSM effects	Notes
Endocrine therapy
Aromatase inhibitors	Effective in suppressing serum estrogen Indicated for treatment of estrogen receptor-positive breast cancers in postmenopausal women	Vaginal dryness, atrophic vaginitis	Third-generation aromatase inhibitors—anastrozole, exemestane, and letrozole—have largely replaced tamoxifen as the preferred treatment for hormone receptor-positive breast cancer in postmenopausal women
Tamoxifen	Indicated for metastatic breast cancer, adjuvant treatment of breast cancer, and to reduce breast cancer incidence in women at high risk	Vasomotor symptoms, vaginal dryness, and low libido	Lower rates of vaginal dryness than with aromatase inhibitors; may actually inhibit or improve vaginal dryness induced by chemotherapy or menopause
Chemotherapy
Chemotherapy, biologic therapy, hormonal therapy	Decrease levels of estrogen and progesterone, which improves clinical outcomes for breast cancer	Vaginal dryness, atrophic vaginitis, other symptoms of estrogen loss	Effective therapies but can induce symptoms of estrogen loss that negatively affect long-term vaginal health and quality of life; increase risk of ovarian failure in premenopausal women

Based on information in reference 1.

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TABLE 2

FDA-approved labeling notes for treatments for genitourinary syndrome of menopause

Products	GSM indications	Breast cancer effects
Estrogen products
17-beta estradiol vaginal cream (Estrace)	Moderate to severe vulvar and vaginal atrophy due to menopause	All estrogen products have the following labeling notes: WHI: Estrogen alone was not associated with increased risk of breast cancer; estrogen plus progestin increased the risk Contraindication: known, suspected, or history of breast cancer Warning: Estrogens with or without progestins should be prescribed at the lowest effective doses and for the shortest duration
Conjugated estrogen vaginal cream (Premarin^a)	Moderate to severe dyspareunia due to menopause Atrophic vaginitis and kraurosis vulvae
17-beta estradiol vaginal ring (Estring)	Moderate to severe vulvar and vaginal atrophy due to menopause
Estradiol hemihydrate vaginal tablets (Vagifem, Yuvafem^b)	Atrophic vaginitis due to menopause
Estradiol vaginal inserts (Imvexxy)	GSM, dyspareunia
Combination estrogen product
Conjugated estrogens/bazedoxifene (Duavee)	Moderate to severe vasomotor symptoms associated with menopause
Nonestrogen products
Prasterone vaginal tablet (Intrarosa; contains dehydroepiandrosterone)	Moderate to severe dyspareunia due to menopause	Warning: Prasterone is contraindicated in women with known or suspected breast cancer; prasterone has not been studied in women with a history of breast cancer
Ospemifene (Osphena) oral tablet	Moderate to severe dyspareunia due to menopause	Warning: Ospemifene has not been adequately studied in women with breast cancer; therefore, it should not be used in women with known or suspected breast cancer or with a history of breast cancer

↵a Premarin vaginal cream is the only locally applied preparation with FDA approval for dyspareunia due to GSM.
↵b Yuvafem is an FDA-approved generic equivalent to Vagifem.
FDA = US Food and Drug Administration; GSM = genitourinary syndrome of menopause; WHI = Women’s Health Initiative study