What does the data tell us about the effect of hormone therapy on the incidence of Alzheimer’s disease? Conflicting data has appeared in the literature for many years.
The WHI (Women’s Health Initiative) data demonstrated that women over 65 who were given oral Premarin and medroxyprogesterone acetate had cognitive decline, while the younger women did not. Perhaps, similar to cardiovascular disease, timing is important.
Data from a Finnish study which followed women for 25 years had different findings. Of the 8000 women who were followed, 227 eventually developed Alzheimer’s disease, with a mean age of 72. The analysis controlled for the following risk factors: age, alcohol use, smoking, exercise, occupation, and parity ( the number of children a women has had). The data demonstrated that if hormone therapy was taken for 5 years, there was no increased risk of developing Alzheimer’s. If hormones were taken 5-10 years, the risk ration was .89, or an 11% decrease in the incidence of Alzheimer’s, although this did not reach statistical significance.
What was significant was that women who took hormones for more than 10 years had an almost 50% reduction in Alzheimer’s disease.
Three other large randomized trials in which women took HRT for less than 7 years did not demonstrate a change in cognitive function. In contrast, the Cache County study from Utah did demonstrate a significant reduction in Alzheimer’s disease if HRT was started early in menopause and continued for at least 10 years.
Mortality date from the WHI calculated 18 years after the study was completed demonstrated a decreased risk of dementia in estrogen and progesterone uses, with a larger decrease in risk in those women who took estrogen alone.
Since the WHI, there have been changes in hormone prescribing, with more use of transdermal preparations and bio-identical progesterone. It is possible that these preparations would
provide improved results.
At this point, the North American Menopause Society does not recommend that HRT be given for the prevention of dementia until more definitive data is available. Hormones given soon after surgical menopause may improve cognitive function, and should be considered at least until the age of natural menopause.
It is not likely that long-term randomized clinical trials will be done to put this issue to rest.
What can be concluded from the data as provided is that hormone therapy started soon after menopause and continued for ten years or more may reduce the incidence of Alzheimer’s disease.
Update Menopause. OBG Management, Volume 30, Number 6, June 2018
What’s the impact of long-term use of systemic hormone therapy on Alzheimer disease risk?
Andrew Kaunitz, MD, JoAnn Pinkerton, MD, JoAnn Manson, MD
Imtiaz, et al., Post-menopausal hormone therapy and Alzheimer’s disease: a prospective cohort study, Neurology, 2017; 88 (11) pp 1062-1068
Women over the age of 40 know that it is unlikely that they will conceive spontaneously, however, gynecologists recommend that women use contraception until one year after the last menstrual period.
Although conception over 40 may be difficult, US census data demonstrated 26 births per 1000 women over the age of 40. Of these, one-third are unintended. Therefore, there is a need for contraception during this age group. Additionally, women over 40 experience a high risk of spontaneous miscarriage: 34% up to age 44, and 53% over the age of 45. Increased maternal complications include hypertension and diabetes, For the fetus, there is a high risk of chromosomal defects. Therefore, the need for effective contraception in this age group is an important consideration.
So what does the data tell us?
The CDC (Center for Disease Control) has important data regarding safety considerations and contraindications to contraceptive use.
IUD’s are considered in the top tier of recommended contraceptives. There are two types of IUD’s, those with progesterone, and those with no hormones. IUD’s are placed in the office and there are few contraindications. They are highly effective and remain in place for 5 or 10 years. They are easily reversible. Risk of infection and expulsion are quite small, and the continuation rate is higher than oral contraceptives.
The copper IUD is considered to be effective for 10-12 years. The failure rate is less than !%. It is the recommended IUD for women who have had breast cancer and should not be exposed to progesterone. Although in the first 6 months of use menstrual bleeding can be heavier, the bleeding tends to normalize in the first year of use.
Progesterone containing IUD’s have become very popular. They are effective for 3-5 years, depending the the type used. There are therapeutic benefits beside the contraceptive one. The progesterone in the IUD thins the lining of the uterus, therefore making menstrual bleeding less. The effectiveness of the decrease in bleeding is similar to an endometrial ablation, and therefore reduces the need for surgery in women with bothersome, heavy bleeding. The progesterone containing IUD can also be used in postmenopausal women on estrogen therapy to protect the endometrium.
Progesterone only contraceptive products can be used in women in whom estrogen is contraindicated. Contraindications to the use of estrogen would be tobacco use, obesity, migraines with aura, long-standing diabetes, hypertension, and a history of thromboembolism.
Options include the progesterone only oral contraceptive, the progesterone implant, and injections of depo-progesterone which are administered every 3 months. Contraindications to progesterone contraceptives are a recent history of breast cancer.
The progesterone implant is inserted in the office with local anesthesia. It is effective for at least three years, and the failure rate is less than !%. The shots of depo-progesterone are administered every three months. The longer the injections are given, the more likely that menses will stop. After stopping the injections, it can take more than 6 months for menses to resume. Users of this form of contraception were noted to have an 80% decreased risk of endometrial cancer, and a 40% deceased risk of ovarian cancer. Most studies have not demonstrated an increased risk of breast cancer.
What about combined estrogen and progesterone contraceptives? Oral contraceptives are safe in most patients, except for those with the medical problems mentioned previously. The failure rate for OC’s is stated to be 9%, but with close to perfect use, the risk is much lower. OC’s are often used in the peri-menopausal women to control irregular cycles and heavy bleeding. OC’s can also treat the symptoms or irregular hormone levels often found in the peri-menopause. These symptoms can include headaches, hot flashes, and mood changes. The risk of thromboembolism is increased with OC users, and the risk if about 8-10 per 10,000 women/years of use. The greatest risk is in the first 3 months of use.
When oral contraceptives are used in women over 40, careful considerations must be given to medical situations that might increase the risk of heart attack and stroke, since these are rare but significant side effects. OC’s should be avoided in smokers and hypertensives, and also in women who have migraines with aura.
Combined estrogen and progesterone can also be administered as a patch or intra-vaginal ring. The patch is considered to provide higher levels of estrogen and an increased risk of blood clots than a similar OC.
The benefit of reducing cancer risk is impressive and lasts for at least 15 years after discontinuation. The decreased risk of endometrial cancer is 56% after 4 years of use, and 72% after 12 years of use. Women who used OC’s more than 10 years reduced their risk of ovarian cancer by more than 50%, and the benefit lasted 20 years. A reduction of colon cancer was found to be 18%. The most reliable study done on OC effect on breast cancer risk was done by the NIH, which demonstrated no increased risk, although several other studies have demonstrated a small increased risk. Women who carry the BRCA gene did not have an increased risk of breast cancer if the formulation contained 35 mcg or less of estrogen, while the OC also decreases the risk of ovarian cancer in this high risk group.
As far as peri-menopausal symptom control, contraception has significant medical benefits.
The progesterone IUD controls heavy bleeding better than oral contraceptives, and can be used to decrease bleeding in women with fibroids, although the expulsion rate is higher. For vasomotor symptoms of hot flashes and night sweats, oral contraceptives are very effective, especially if giving continuously. Standard hormone replacement will not provide contraception.
Permanent sterilization is always an option for women after childbearing is complete. Traditional tubal ligation performed laparoscopically or after a vaginal delivery or at the time of C-section has been found to reduce the risk of ovarian cancer. Many doctors are now performing bilateral removal of the fallopian tubes, as many ovarian cancers are thought to begin the the tubes.
Another option is a metal coil placed through the uterus into the fallopian tubes.
Emergency contraception is an option after unprotected intercourse. Progesterone emergency contraceptive can be used within 72 hours of intercourse, and a copper IUD can be inserted within 5 days of intercourse. Inserting an IUD is 99% effective in preventing pregnancy if inserted within 5 days.
Use of contraception can be continued until age 55, or sooner if a blood test, FSH, demonstrates evidence of menopause. The FSH should be checked at least 14 days after discontinuation of oral contraceptives.
This article provides general considerations, but medical decisions regarding the best contraception options should be made with your personal physician who can consider your history, examination, family history, and your goals.
Menopause: The Journal of the North American Menopause Society, value 25, Number 7, July 2018. Contraception for midlife women: a review. Miller, et al.
A new video from the North American Menopause Society discussing current data regarding how hormones affect the cardiovascular system.
Dr. Marla Shapiro, Immediate Past President of NAMS interviews Dr. Maria Stuenkel, Clinical Professor of Medicine, University of California at San Diego
Treating vulvovaginal atrophy in postmenopausal breast cancer survivors: efficacy of the fractional carbon dioxide laser
Many women experience symptoms of vulvovaginal atrophy after the menopause transition.
The symptoms include vaginal dryness, painful intercourse, vaginal itching and burning, vaginal bleeding with intercourse, painful urination, and decreased sensitivity with intercourse. Women can be prone to more vaginal and urinary infections. The cause is lack of estrogen in the vaginal and vulvar tissues, which are very sensitive to estrogen. The result of lack of estrogen is decreased lubrication which comes from the blood vessels beneath the epithelium of the vaginal wall. There is also a decrease in the collagen and elastic fibers of the vaginal wall, which leads to decrease elasticity, and narrowing and shortening of the vagina.
In women being treated for breast cancer, chemotherapy can cause premature menopause and a decrease in estrogen levels. Anti-estrogen drugs such as tamoxifen and aromatase inhibitors also decrease estrogen levels. The vulvovaginal atrophy in breast cancer patients is often worse than in women who transition to menopause naturally. Quality of life is often severely impacted by inability to have a normal sexual relationship, as well as other bothersome symptoms. These symptoms can be so bothersome that some women might consider discontinuing anti-estrogen treatments early, which can affect survival.
Treatments for women who have not experienced breast cancer include lubricants, local and systemic hormone therapy. Vaginal testosterone and DHEA are metabolized in the body to estrogen, although the level is very low. Many women are concerned about any treatment that might increase the estrogen level in the body.
In women who have had breast cancer, the treatments include vaginal moisturizers, vaginal dilators, and pelvic floor physical therapy. Many women resort to non-penetrative sexual activity, and become resigned to not having intercourse again. In 2014, the fractional carbon dioxide laser was introduced in the US, and was approved by the FDA for the treatment of vaginal dryness and painful intercourse. In women who experienced natural menopause, studies demonstrated that the affect of the laser was to increase vascularity of the vaginal wall, which increased lubrication. It also increased collagen and elastic fibers, which restored the integrity of the vaginal wall. Data regarding the benefit to women who have experienced menopause because of breast cancer chemotherapy or hormonal treatments had not been studied in any large trials.
In the latest issue of Menopause, a study was published from the University of Naples in Italy.
The study looked at 82 women who were affected by breast cancer and vulvovaginal atrophy, made worse by chemotherapy or anti-estrogen treatments. Almost two-thirds of these patients were younger than age 50. All of the women studied had failed treatment with non-estrogenic lubricants or moisturizers.
Patients in the study were treated with the vaginal laser three times, 30-40 days apart. A number of symptoms were evaluated with each treatment, including pain, dryness, painful intercourse, vulvar itching, and reduced sensation.
The results of the study demonstrated that many of the symptoms (vaginal dryness, itching, vaginal sensitivity, bleeding, painful intercourse, and pain with penetration with the laser probe) were significantly improved, although not completely in many patients. It is possible that more than three cycles should be used in these patients. The study did not demonstrate any systemic adverse effects. Although patients do not experience pain with administration of the laser treatment, the initial discomfort with the insertion of the laser probe appears to improve with subsequent treatments. There was evidence that starting treatments before symptoms are more severe, produced a greater reduction in symptoms.
Further studies should look at whether additional treatments will benefit women who continue to have symptoms after the initial three treatments, and how long the benefits lasts. It is recommended that women have a touch-up yearly, but in this unique population, a different treatment schedule might be more effective. Stay tuned as more data is collected and reported.
Marilyn C. Jerome, MD
Fractional microablative CO2 laser in breast cancer survivors affected by iatrogenic vulvovaginal atrophy after failure of nonestorgenic local treatments: a retrospective study.
Pagano, et al. Menopause, alum 25, Number 6, June 2018
New data on breast cancer and chemotherapy: more women with early stage disease do not need chemotherapy
More than 300,000 women were diagnosed in the US with breast cancer in 2017. Of those, approximately 63,000 were diagnosed with ductal carcinoma in situ, DCIS, or non-invasive breast caner. The remaining 250,000 had breast cancer that was invasive. Of those, 60,000 were diagnosed with early stage breast cancer that had intermediate Oncotype DX score, and the decision about whether to recommend chemotherapy was unclear.
The Oncotype DX test analyzes the activity of a group of genes that describes the behavior of cancer and its response to treatment, and whether it is likely to grow and spread. This test is used in patients who have been diagnosed with Stage 1 or 2 breast cancer that is estrogen-receptor positive and lymph node negative for cancer cells. The test is used to determine if chemotherapy would be useful to prevent recurrence. It is also used to determine if DCIS is likely to be recurrent or progress to invasive cancer, and whether radiation would be helpful.
It is typical that tamoxifen or aromatase inhibitors (endocrine therapy) are used after surgical removal of the tumor to prevent recurrences, but some women are more at risk of having recurrences, and the Oncotype DX is used to determine who would benefit from chemotherapy.
The results of the Oncotype DX will provide a recurrence score, between 0 and 100. If the recurrence score is less that 18, the cancer’s risk of recurrence is low and the benefits of chemotherapy may not outweigh the risks of the treatment. If the score is 18-30, the risk of recurrence is considered intermediate, and it was not clear whether the benefits of chemotherapy would outweigh the risks. If the score is 31 or greater, it is felt that the benefits outweigh the risks, and chemo is offered to the patient.
Prior to the most recent data, patients who found themselves in the intermediate category found themselves in a conundrum. The decision on whether to offer chemotherapy was a shared decision between doctor and patient, taking into account many factors including age, other medical problems, and the patient’s wishes. Data were needed to further clarify the benefits in this group of patients.
The TailorRx was a prospective clinical trial that enrolled 10,000 women between 2010 and 2016. These women had estrogen-receptor positive, HER2 negative, lymph node negative breast cancer. If the recurrence score was less than 11, the women received only endocrine therapy. If the score was greater than 26, the women received chemotherapy and endocrine therapy. If the score was between 11 and 25, the women were randomized to receive either endocrine therapy only, or endocrine therapy plus chemo. These women were followed on average 8-9 years. The results were published last week in the New England Journal of Medicine.
There were 6711 women who were in the mid-range, and who were randomized. In that group, there were 836 events, which included recurrence, a new primary, or death. The study demonstrated that the women who had undergone chemotherapy and endocrine therapy did no better than those who had endocrine therapy alone. The exception to this were women who were diagnosed with breast cancer at age 50 or younger. If the recurrence score in this group was 16 or greater, they received substantial benefit from chemotherapy. This could be accounted for by the fact that chemotherapy induced early menopause.
In women with a score of 10 or less, the risk of recurrence at 9 years was 3%. In the intermediate score group (11-25) the nine year risk of recurrence was 5% for those who did and did not have chemotherapy.
There are other gene assays besides the Oncotype DX that can be used, and it is expected the further research will identify and analyze additional genes that will be useful.
All medical decisions, including those that regarding the treatment of cancer, must take into account an individual’s specific disease and medical situation. Medical oncologists should be consulted to get an accurate assessment of risks and benefits.
Marilyn C. Jerome, MD
Foxhall Ob-Gyn Associates
The Washington Post: Health and Science, June 3, 2018
Most women with a common type of early-stage breast cancer can skip chemo, a new report finds, by Laurie McGinley
The New England Journal of Medicine. June 3, 2018
Adjuvant Chemotherapy Guided by a 21-Gene Expression Assay in Breast Cancer, Sparano, et al.
Breast cancer.org. Oncotype DX
Gynecologists often prescribe oral contraceptives to manage the perimenopausal symptoms of irregular cycles, heavy and prolonged bleeding, and hormonal variations that can result in mood changes, irritability, headaches and hot flashes. The data regarding the risks of oral contraception increasing breast cancer incidence has been confusing.
An editorial published in the May, 2018, issue of the journal Menopause, addressed this controversy.
The New England Journal of Medicine published a Danish study recently that demonstrated a small but statistically significant increase in breast cancer in women who currently or recently used birth control pills. The relative risk was in the range of 1.2, and was similar to the increased risk of women who used the progesterone containing IUD. Because this was on observational study and looked at women only below the age of 50 (most breast cancers occur in women over the age of 50), the authors noted that the study did not control for other factors that also increase the risk of breast cancer such as age at first menses, alcohol intake, exercise. and a history of lactation. The study also did not take into account the surveillance for breast cancer such as clinical breast exams and mammograms. it is probable that women receiving regular exams and being prescribed medication would have greater surveillance than women not seeing a physician as regularly. Because the elevated risk was modest and this was an observational study, the study does not prove cause-and-effect, and the data should be interpreted within its limitations.
Several studies published prior to this one differed in conclusions. The NIH funded a population-based study looking at women ages 35 to 64, performed by the CDC and published in 2002. The study was felt be rigorously conducted and detailed regarding oral contraceptive use and breast cancer incidence. The results of this study did not demonstrate an increase in breast cancer in uses of birth control pills, progesterone only pills, and progesterone implants or injections. The doses of oral contraceptives were often higher prior to 2002 than they are now.
The follow-up analysis done in 2012 did not demonstrate a difference between the ten most commonly prescribed formulations of oral contraceptives. A different study did show in increase of breast cancer in formulations with higher doses of estrogen and the progestin ethynodial acetate which is rarely used today. Lower dose OC’s did not demonstrate an increased risk of breast cancer.
A study which came from the UK and published in 2017 was the longest-term study published to date. On average, they followed women for 40 years since 1968. Many of the women were in their 70’s, and the results were impressive. There was no increase in breast cancer for women who ever used oral contraceptives vs. never users, but the risks of colon, endometrial, and ovarian cancer were significantly decreased!! The risk of cervical cancer was increased but not statistically significant.
When multiple studies were analyzed, there was not found to be an increased all-cause mortality or breast cancer specific mortality for women who ever took OC’s, despite length of use or time since discontinuation.Women who ever took OC’s demonstrated a reduced mortality of ovarian cancer to RR 0.58.
Women at risk of breast cancer because of family history do not further increase their risk by taking oral contraceptives, when pooled data were evaluated.
What about carriers of the BRCA genes? The data varies, but multiple studies do demonstrate an increased incidence of breast cancer which is moderate, and not always statistically significant, but a very definite decrease in ovarian cancer which is significant.
The use of hormonal contraception to manage peri-menopause must take into account multiple variables. Women in this age group with untreated hypertension are at increased risk of stroke, heart attacks, and peripheral vascular disease. Healthy, normal weight, non-smokers can use oral contraceptives until menopause or the age of 55 to manage the menopausal transition. Available data demonstrated no increase in breast cancer or all-cause mortality of this intervention, while offering protection against endometrial, ovarian and colon cancer.
As will similar medical decisions, consult your gynecologist to choose the best intervention for your particular situation.
Marilyn C. Jerome, MD
Foxhall Ob-Gyn Associates
Editorial: Hormonal contraception and the risk of breast cancer: a closer look, Andrew M. Kunitz, MD, JoAnn V. Pinkerton, MD, JoAnn Manson, MD
Menopause: The Journal of the North American Menopause Society, Volume 25, Number 5, May 2018
Here is a lecture given in March at Sibley Hospital by Drs. Marilyn Jerome and Tara Abraham.
The video looks at the data regarding the risks and benefits of hormone replacement therapy. It discussed the options, and alternatives. Click on the link to view the lecture.
Should I have a hysterectomy, or are there other options?
Perhaps is was suggested that you consider a hysterectomy for heavy bleeding or fibroids. These problems are very common in women in their late 30’s and 40’s. You should know that there are non-surgical options that can control symptoms and avoid a major surgical procedure.
First of all, anyone with abnormal bleeding or a pelvic mass should be evaluated. Although uterine cancer is rare in women before the age of 50, a pelvic sonogram and/or an endometrial biopsy can evaluate the uterus and ovaries and decrease that concern.
Heavy menstrual cycles can be controlled often by using oral contraceptives. Birth control pills are very safe for women in their 40’s if they are not smokers or hypertensive. Birth control pills will manage the irregularity of the intervals between cycles that occurs in peri-menopause, and
markedly decrease the amount of flow. Additional benefits of oral contraceptives are that the pills can eliminate some of the hormonal irregularity of the peri-menopause which can cause hot flashes, mood changes, and insomnia.
If heavy bleeding is the issue, an IUD containing progesterone will often make the menstrual bleeding very light or absent, while also providing contraception. The progesterone IUD lasts for 5 years, and is inserted easily in the office.
Minor surgical procedures can also control heavy bleeding. A uterine ablation is a procedure that cauterizes the endometrial lining, so that bleeding is markedly reduced. Most often the procedure is performed in the hospital, but some doctors perform this in the office. A hysteroscopy and D&C (dilation and curettage) may be performed at the same time to evaluate the endometrial cavity. The results are permanent and should be performed after childbearing is completed.
If you have fibroids that are in the uterine cavity, a procedure can be done that resects these fibroids. There are several devices that shave off the portion of the fibroid which is in the cavity, and if most of the fibroid can be removed, bleeding can be markedly reduced. This procedure is most often done in the hospital as a same-day surgical procedure, and the recovery is minimal. Most patients would be able to go back to work in a day or two.
If you have large fibroids and they are causing symptoms of heavy bleeding or pressure on other organs, a minimally invasive procedure, a uterine artery embolization, can be done by a radiologist. The uterine artery is catheterized through a vessel in the groin, and the uterine artery is blocked by small pellets that block the vessels that supply blood to the fibroids. The result is that the blood supply to the fibroids is cut off, and the tissue undergoes necrosis or cell death. Most patients need pain killers for several days, but the size of the fibroids decrease over the next several months, and menstrual bleeding is often much decreased.
Although each case is individual and a physician who performs gynecologic procedures can help you decide which procedures are applicable to your situation, it is important to know your options so that you can make an informed decision.
Marilyn C. Jerome, MD
Foxhall OB-Gyn Associates
Genitourinary syndrome of menopause (GSM) is defined as symptoms of vaginal dryness, painful intercourse, vulvar discomfort, urinary frequency and urgency, incontinence, and increased frequency of bladder infections. These symptoms are caused by the thinning of the estrogen sensitive tissues of the vagina after menopause, due to the lack of estrogen in these tissues. The most effective treatments for these symptoms are topically applied vaginal estrogen products. Women who are at risk for breast cancer or who have had breast cancer are often very reluctant to use any products that contain estrogen, even if the dose is small.
The North American Menopause Society along with the International Society for the Study of Women’s Sexual Health have collaborated to review the literature in this area and have developed a consensus statement to guide physicians regarding the safety of prescribing vaginal estrogen for women who are at high risk for developing breast cancer, or who have already had breast cancer.
There are over 3 million breast cancer survivors in the US. Many survivors experience GSM symptoms, and often at a younger age because of treatments which decrease estrogen. It is important to discuss these symptoms with your health care provider and know your options. Some clinicians are reluctant to treat patients because of the lack of data that assures safety in particular populations.
In approaching the discussion with your physician, begin by noting your symptoms: vulvovaginal burning and dryness, painful intercourse, inability to have penetration, urinary frequency and urgency, incontinence, and increased frequency of urinary tract infections. Your physician should examine you to determine if there are any conditions such as a vaginal infection or inflammation that could lead to these symptoms.
Next, consider breast cancer risk which can be determined by several models that can be easily calculated. For women who are breast cancer survivors, consideration for risk of recurrence should take into consideration factors including the time since diagnosis, stage and grade of disease,
hormone receptor status, use of aromatase inhibitors, severity of GSM symptoms and their effect on quality of life. Consultation with your breast cancer oncologist should be included in decision making.
Here are the options for treatment:
1. Vaginal moisturizes are used for symptoms of dryness and must be used frequently and independently of intercourse.
2. Lubricants are used during intercourse to reduce pain from penetration and friction. The ideal lubricant has the same pH and osmolality of the vaginal tissue and should not include parabens, flavors or scents, glycerin and spermicides that can be irritating.
3. Vaginal dilators in graduated sizes can be used to maintain the caliber of the vagina and stretching of the tissues.
4. Vaginal vibrators can be used independently or with other sexual activity.
5. Pelvic floor physical therapy can relieve pain from pelvic floor muscle spasm and vaginismus (involuntary muscle spasm of the vagina which makes penetration difficult).
6. Vaginal estrogen can be inserted as a cream, pill or vaginal ring. Because of the difference in products, methods of administration, amount of cream administered and site of administration (lower vagina vs. upper vagina), and the quality of the vaginal tissue (thinner vaginal epithelium is more absorptive than thicker tissue), the amount of systemic absorption varies. Observational studies including data from the Women’s Health Initiative have not shown any evidence of an increased risk of breast cancer in women who used vaginal estrogens. One study did not find an increased risk of recurrent breast cancer in women who used vaginal estrogen products after the diagnosis of breast cancer. The message here is that the available evidence is reassuring, but in making a decision, risk should be considered.
7. Vaginal DHEA, prasterone, has shown evidence of improvement in sexual function. The suppositories are used daily, at least in the first month of use. The DHEA is converted to estrogen and testosterone in the body, although the levels are small and in the postmenopausal range, the difference is significant. It has not been tested in breast cancer survivors.
8. SERMs: Ospemifene if a selected estrogen receptor modulator which acts like estrogen on the vaginal tissue. It is an oral table taken daily. It is not approved in the US for use by women with breast cancer, and its effect on breast tissue has not been studies.
9. Topical lidocaine 4% applied to the vaginal opening prior to penetration can reduce pain, but it can also reduce sensation.
10. Vaginal testosterone can be compounded for use as a vaginal gel, but is not FDA approved. Testosterone is converted to estrogen in the body, and there is evidence that use of vaginal testosterone increases serum estrogen levels.
11. Estriol is considered a weaker estrogen produced in women during pregnancy. It can be compounded but is not FDA approved and there is not data to determine its safety in patients with breast cancer.
12. Vaginal lasers are now being used to improve the integrity of the vaginal epithelium.The effect of the vaginal laser is to increase vascularization of the vaginal epithelium which increases lubrication with sexual excitation. It also increases the thickness of the vaginal epithelium as well as increased collagen and elastic fibers in the submucosa.Studies in breast cancer survivors demonstrated significant improvement in GSM symptoms and improved sexual function.
As with other medical conditions, an evaluation with a gynecologist is the best way to evaluate risks and determine which treatment is appropriate for your individual situation.
Consensus Recommendations: Management of genitourinary syndrome of menopause in women with
or at high risk for breast cancer: consensus recommendations from the North American Menopause
Society and the International Society for the Study of Women's Sexual Health,
Menopause. The Journal of the American Menopause Society, Volume 25, No. 4, 2018
This lecture was given at Sibley Memorial Hospital in February by Dr. Shawn Davis-Wilensky and Dr. Shannon Green.