Vaginal Estrogen ‘Underutilized’ in Women With GSM After Breast Cancer

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NEW ORLEANS — While vaginal estrogen therapy is safe and effective for genitourinary syndrome of menopause (GSM), few women who have had breast cancer use it, researchers reported here.

Breast cancer survivors with GSM were half as likely to be prescribed vaginal estrogen compared to women with GSM and no history of breast cancer (11% vs 22%), reported Taylor Kohn, MD, a resident at Johns Hopkins University School of Medicine in Baltimore, at the American Urological Association annual meeting.

“Vaginal estrogen therapy for GSM in breast cancer survivors remains underutilized,” he said at a press briefing. “We see no major changes in prescribing practices, despite more recent guidelines supporting its use.”

In 2018, the North American Menopause Society and the International Society for the Study of Women’s Sexual Health issued recommendations saying that vaginal estrogen could safely be used as a localized therapy for women either at high risk for or with a personal history of breast cancer.

Kohn noted that while treatment with vaginal estrogen has been shown to significantly improve GSM symptoms, since most breast cancers are hormone-receptor positive there has been “historic hesitancy” to prescribe estrogen for those cancers.

Urologists need to be more aggressive about “getting the message out” that vaginal estrogen is safe and effective for women who have had breast cancer, he urged.

Session moderator Rachel Rubin, MD, of Georgetown University Hospital in Washington, D.C., agreed, observing that oncologists “don’t look at vulvas routinely, and they don’t prescribe these products routinely, but 50% of women go off their endocrine therapy for breast cancer — which is life-saving therapy — because of genital and urinary complains that they have.”

“So, we can actually keep these women on these therapies longer if we adequately address the symptoms that these medications cause,” Rubin said. “And we actually have safety data showing no harm from these local vaginal products.”

In explaining the rationale behind the study, Kohn noted that systemic therapies for breast cancer — selective estrogen receptor (ER) modulators, aromatase inhibitors, and chemotherapies — can result in GSM for up to 70% of postmenopausal breast cancer survivors.

Signs and symptoms of GSM include vaginal dryness, burning, or discharge, along with genital itching, burning with urination, urgency with urination, frequent urination, and recurrent urinary tract infections.

For their analysis, Kohn and colleagues relied on the TriNetX Diamond network database to identify more than 2 million women with GSM from 2009 to 2021. Of those women, 4.8% had a personal history of breast cancer.

The rate of vaginal estrogen prescribing in patients with a history of breast cancer stayed relatively flat, at 10.3% in 2013-2015, 10.6% in 2015-2017, and 10.2% in 2018-2020.

In addition, the researchers found no significant difference in the rate of vaginal estrogen prescribing in patients with ER-positive (7.4%) or ER-negative (8.4%) breast cancer.

Rubin emphasized that GSM for these patients is a problem that must be addressed collectively by urologists, oncologists, and primary care physicians.

“We as urologists must explain that these are urologic symptoms,” she said. “We must get that messaging out so that people understand that there are safe and effective therapies out there. And we need to convince the primary care doctors and oncologists that it’s not that scary, it’s not that difficult to do, and it’s safe.”

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    Mike Bassett is a staff writer focusing on oncology and hematology. He is based in Massachusetts.

Disclosures

Kohn and Rubin had no disclosures.

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