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World J Clin Oncol. Feb 24, 2022; 13(2): 71-100
Published online Feb 24, 2022. doi: 10.5306/wjco.v13.i2.71
Management of genitourinary syndrome of menopause in breast cancer survivors: An update
Daniel María Lubián López
Daniel María Lubián López, Department of Mother and Child Health and Radiology, Faculty of Medicine, University of Cadiz, Cádiz 11100, Spain
Daniel María Lubián López, Department of Obstetrics and Gynecology Service, University Hospital of Jerez de la Frontera, Jerez de la Frontera 11407, Spain
Daniel María Lubián López, Department of Obstetrics and Gynecology, Hospital Viamed Bahía de Cádiz, Chiclana de la Frontera 11130, Cádiz, a Spain
Daniel María Lubián López, Department of Obstetrics and Gynecology, Hospital Quirónsalud Campo de Gibraltar, Los Barrios 11379, Cádiz, Spain
Author contributions: Lubián López DM contributed to conceptualization, bibliographic search, design, writing and correction of the article.
Conflict-of-interest statement: The author reports no conflicts of interest in this work. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Non-financial competing interests.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Daniel María Lubián López, MD, PhD, Full Professor, Department of Mother and Child Health and Radiology, Faculty of Medicine, University of Cadiz, Service of Obstetrics and Gynecology, University Hospital of Jerez de la Frontera, Jerez de la Frontera 11407, Spain.
Received: March 1, 2021
Peer-review started: March 1, 2021
First decision: September 2, 2021
Revised: September 19, 2021
Accepted: January 17, 2022
Article in press: January 17, 2022
Published online: February 24, 2022

There is increasing attention about managing the adverse effects of adjuvant therapy (Chemotherapy and anti-estrogen treatment) for breast cancer survivors (BCSs). Vulvovaginal atrophy (VVA), caused by decreased levels of circulating estrogen to urogenital receptors, is commonly experienced by this patients. Women receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM), that it can in turn lead to pain, discomfort, impairment of sexual function and negatively impact on multiple domains of quality of life (QoL). The worsening of QoL in these patients due to GSM symptoms can lead to discontinuation of hormone adjuvant therapies and therefore must be addressed properly. The diagnosis of VVA is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Systemic estrogen treatment is contraindicated in BCSs. In these patients, GSM may be prevented, reduced and managed in most cases but this requires early recognition and appropriate treatment, but it is normally undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy (VET) because of unknown levels of systemic absorption of estradiol. Lifestyle modifications and nonhormonal treatments (vaginal moisturizers, lubricants, and gels) are the first-line treatment for GSM both in healthy women as BCSs, but when these are not effective for symptom relief, other options can be considered, such as VET, ospemifene, local androgens, intravaginal dehydroepiandrosterone (prasterone), or laser therapy (erbium or CO2 Laser). The present data suggest that these therapies are effective for VVA in BCSs; however, safety remains controversial and a there is a major concern with all of these treatments. We review current evidence for various nonpharmacologic and pharmacologic therapeutic modalities for GSM in BCSs and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. We include recommendations for an approach to the management of GSM in women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

Keywords: Genitourinary syndrome of menopause, Breast cancer survivors, Aromatase inhibitors, Vaginal moisturizers and lubricants, Vaginal estrogens, Laser

Core Tip: Genitourinary syndrome of menopause (GSM) is commonly experienced by breast cancer survivors (BCSs) receiving antiestrogen therapy, specifically aromatase inhibitors. Vaginal dryness, itching, irritation and dyspareunia produce impairment of sexual function and negatively impact on the quality of life. Healthy women, and even more so BCSs, are reluctant to discuss this problem with their general practitioner or oncologist. Safety of vaginal estrogen therapy for management of GSM refractory to other nonhormonal treatment in BCSs has not been definitively established, and recommendations for use remain controversial. This review aims to summarize the clinical approach and emerging therapeutic alternatives, considering the efficacy and potencial adverse effects in this population.