Table 5.
Treatment options for management of genitourinary syndrome of menopause in specific patient populations: Consensus recommendations of the The North American Menopause Society[65]
|
General guidelines
|
| Individualize 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 firstline treatments |
| Involve treating oncologist in decision making when considering the use of local hormone therapies1 |
| Ospemifene, an oral SERM, has not been studied in women at risk for breast cancer and is not FDAapproved for use in women with or at high risk for breast cancer |
| Offlabel use of compounded vaginal testosterone or estriol is not recommended |
| Laser therapy may be considered in women who prefer a nonhormonal approach; women must be counseled regarding lack of longterm safety and efficacy data |
| Women at high risk for breast cancer2 |
| Local hormone therapies are a reasonable option for women who have failed nonhormonal treatment |
| Observational data do not suggest increased risk of breast cancer with systemic or local estrogen therapies beyond baseline risk |
| Women with ERpositive 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 nonhormonal treatments and who have factors suggesting a low risk of recurrence may be candidates for local hormone therapy |
| Women with ERpositive breast cancers on AI |
| 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 nonhormonal treatments may still be candidates for local hormone therapies after review with the woman’s oncologist vs consider switching to tamoxifen |
| Women with triplenegative breast cancers |
| Theoretically, the use of local hormone therapy in women with a history of triplenegative 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 |
1
Local hormone therapies are vaginal estrogen and intravaginal DHEA (prasterone).
2
Lifetime risk > 20%, carriers of the BRCA mutation, atypical ductal hyperplasia, lobular carcinoma in situ, or ductal carcinoma in situ. AI: Aromatase inhibitor; ER: Estrogen receptor; GSM: Genitourinary syndrome of menopause; QoL: Quality of life; SERM: Selective estrogen-receptor modulator.