Breast cancer is the most frequent cancer in women. In our environment, mortality rates have been considerably reduced, so the life expectancy of these women has been prolonged. The effects of chemotherapy and hormone therapy enhance postmenopausal symptoms.
Estrogen loss causes vaginal dryness and pain during sexual intercourse (dyspareunia), which in many cases hinders the quality of life of these women. We know that 90% of women undergoing chemotherapy develop ovarian failure and that 23.4% present vaginal dryness. In addition, 70 % of breast cancers require treatment with tamoxifen or aromatase inhibitors, which cause 32 % and 58 % respectively of vaginal dryness in these patients.
We refer to a large group of women, many of them premenopausal, who present a deterioration that conditions their relationship with their partner and their quality of life. It is described that these women present higher rates of sexual dysfunction that affects the frequency, pleasure and discomfort in relationships.
What does the treatment consist of?
Treatment of atrophy is determined by hormone replacement and supportive measures to improve vaginal health. Menopausal hormone therapy restores the vaginal pH, regenerates the epithelium and also acts on the rest of the climacteric symptomatology at other levels. Similarly, local estrogen therapy improves the vaginal hormonal environment. Although treatment with local estrogens could be used in some cases, the contraindication to hormone treatment in women with breast cancer and hormonophobia conditions professionals and breast cancer patients when prescribing local estrogens in women with a history of breast cancer and moderate or severe vulvo-vaginal atrophy.
Faced with this scenario many women with breast cancer and vaginal dryness ask us. “If I should not use estrogens can I do anything else to improve my quality of life and my relationship with my partner?”
Sexual activity and mechanical measures can also improve elasticity and lubrication, however, deterioration of the vaginal mucosa hinders and limits relationships, thus perpetuating a cycle that leads to further atrophy and worsening symptomatology.
Ospemifene, prasterone and laser
The use of moisturizers and lubricants can partially alleviate these effects, however, they are generally not sufficient to reverse the symptoms, especially in younger women who have had breast cancer and require the absence of ovarian function. Moreover, from experience and from the results of the Spanish REVIVE study, we know that follow-up treatment is low and therefore the results are poor.
Ospemifene, prasterone and laser are presented as appropriate treatment options for these patients with poor response to moisturizers and who cannot or do not want to use estrogen therapy.
The scientific literature increasingly supports the use of these alternatives for the treatment of postmenopausal vulvo-vaginal atrophy, reporting positive results in symptomatology, vaginal parameters and sexual function, although with different methodologies and number of patients included.
The results of treatment with ospemifene in patients with breast cancer come from retrospective studies. After a one-year follow-up, there was no evidence of a greater appearance of breast cancer in the treated patients and the 12-week follow-up revealed an improvement, at least superimposable to that of patients without a history of breast cancer, in the most bothersome symptom and in the parameters of vaginal improvement.
Prasterone provides a randomized study in women with a history of breast cancer comparing this treatment with the use of vaginal moisturizers, evaluating the results at 12 weeks. Patients treated with prasterone presented significantly better results in dryness, dyspareunia and vaginal maturation parameters. Also in all parameters of sexual function.
The local action of laser treatment, favoring the development of collagen in vaginal regeneration, has no hormonal effect that could limit its use in women treated with breast cancer.
In all the works published with the use of laser in women with breast cancer, significant improvements in symptomatology, vaginal maturation and sexual function have been described, superimposable to that evidenced in the general postmenopausal population and to that reflected with ospemifene and prasterone. It is concluded that this treatment could offer improvement within one year.
Significant improvement in the regeneration of the vaginal microbiome has also been described, an added value in the treatment of vulvovaginal atrophy and its symptomatology.
Can side effects occur?
Breast safety is a primary objective when implementing or recommending treatment in women with a history of breast cancer.
No greater side effects were found in women with a history of breast cancer treated with ospemifene than in untreated women or in women without a history of neoplastic disease; it should even be noted that in these studies the patients with breast cancer did not report the appearance of hot flushes.
Assessing breast safety in clinical trials of prasterone, hormone levels in women with breast cancer were compared. In the study group, estradiol and testosterone levels were slightly increased, superimposable to those of postmenopausal women.
No serious side effects have been reported with the use of the laser that would contraindicate its use in women with breast cancer.
Could we choose a treatment for the patient with symptomatic vulvo-vaginal atrophy who has been treated for breast cancer?
At the present time we have to recommend moisturizers and lubricants as the first step of treatment. It is suggested that in most cases these preparations are used inconsistently and should be used on a daily basis.
Based on experience and time of use, ospemifene is indicated for the treatment of women free of disease and who have already completed antiestrogenic treatment. Because of its oral administration, the positive effect on bone mass and the breast profile, we could say that this drug provides an integral treatment for the symptomatic postmenopausal woman who has suffered from breast cancer.
Treatment with daily prasterone ovules brings a new concept by allowing estrogenic action at the local level without the potential general effect.
A similar situation arises with the use of vaginal lasers. Treatment with CO2 laser is showing symptomatic improvement in many patients and its use is becoming more and more widespread, offering new data on efficacy and safety, supported by the large number of studies with an increasing number of patients. Other types of laser are also offering promising results.
We cannot conclude on a specific recommendation, which will undoubtedly be specified with the forthcoming results, although there is no doubt that the combined use of laser with one of these preparations may offer a new treatment step for patients with therapeutic limitations, such as women treated for breast cancer, who do not respond to the different guidelines currently indicated.
Improving the quality of life of this large group of women who have already suffered from cancer should be a priority objective and opening up treatment possibilities represents an important advance in gynecological and health care. We must evaluate the characteristics of each patient in terms of age, pathology, comorbidities, possibilities of accessibility to each treatment and acceptability.
New treatment perspectives are opening up for these patients with a greater possibility of moderate-severe vulvovaginal atrophy by means of therapeutic options without systemic estrogenic effect. Ospemifene, prasterone and laser offer many possibilities to improve the quality of life of these women.