Endocrine therapy has been a lifesaver for women with estrogen receptor–positive breast cancer, but decreases in recurrence and cancer-related mortality have come with substantial side effects, according to data presented at the 2019 Supportive Care in Oncology Symposium.¹ The results of a cross-sectional retrospective study have underscored genitourinary symptoms and sexual health concerns experienced by women with breast cancer, including vaginal discharge, dryness, and dyspareunia.

Jeanne Carter, PhD

“These data show that endocrine exposure and menopause can impact vaginal tissue quality,” said Jeanne Carter, PhD, Psychologist and Head of the Department of Sexual Health and Women’s Health at Memorial Sloan Kettering Cancer Center (MSK), New York. “Women exposed to aromatase inhibitors appeared to have the poorest self-reported and clinical outcomes. Proactive sexual health interventions, including early counseling, are warranted in these patients.”

As Dr. Carter reported, treatment of female breast cancer has been linked to side effects such as vulvovaginal dryness, dyspareunia, and sexual dysfunction. However, she noted, there are limited data on specific sexual changes in patients with varying endocrine therapies.

Retrospective Study Details

For this cross-sectional retrospective study, Dr. Carter and colleagues examined patient-reported outcomes and pelvic exam characteristics of women with a history of breast cancer. These women were seen as initial consultations at the Female Sexual Medicine and Women’s Health Program at MSK. The Female Sexual Medicine Clinic Assessment Forms completed by participants were composed of a pelvic exam checklist, sexual function measures (Female Sexual Function Index, Sexual Activity Questionnaire), and vulvovaginal health measures (Vaginal Assessment Scale, Vulvar Assessment Scale) as well as questions about other concerns.

The researchers categorized a total of 446 women with breast cancer into three categories: postmenopausal (77%), actively on ovarian suppression (7%), and pre/perimenopausal (16%). Subcohorts included postmenopausal with aromatase inhibitors alone (30%); tamoxifen followed by an aromatase inhibitor (22%), tamoxifen alone (16%), and no therapy (16%); and pre/perimenopausal with tamoxifen alone (9%) or no therapy (5%).

Postmenopausal women on tamoxifen and aromatase inhibitors were less sexually active, in comparison to other groups, Dr. Carter reported, and the average time since treatment was significantly longer (3.3 years posttreatment vs 1.8 years in pre/perimenopausal groups). Postmenopausal women were also, on average, 13.3 years older than women who had ovarian suppression and pre/perimenopausal women receiving tamoxifen. The average time since initial diagnosis was 6.3 years for the postmenopausal group vs 4.0 and 2.5 years for the ovarian suppression and pre/perimenopausal groups, respectively.

Vaginal and Vulvar Outcomes

Regarding vaginal outcomes, pH levels were highest in postmenopausal women treated with an aromatase inhibitor or tamoxifen followed by an aromatase inhibitor. Vaginal tissues were thin with endocrine use, regardless of age, which is concerning, noted Dr. Carter. Long-term endocrine therapy use may contribute to stenosis in some breast cancer survivors, she added.

“Women exposed to aromatase inhibitors appeared to have the poorest self-reported and clinical outcomes. Proactive sexual health interventions, including early counseling, are warranted in these patients.”

— Jeanne Carter, PhD

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“For patients with high pH levels, nonhormonal moisturizers could be applied intervaginally, or, if appropriate, low-dose estrogens can normalize pH levels. Nonhormonal vaginal moisturizers can also be used on the vulva and applied to the vestibular area (by the vaginal opening) to improve tissue quality,” said Dr. Carter. “For vaginal thickness and atrophy, vaginal moisturizers need to be used at a higher frequency than what is recommended for the general population. For vaginal stenosis, physical therapy and dilators should be considered along with low-dose estrogens.” 

With respect to vulvar outcomes, vulvar atrophy was highest in postmenopausal women on ovarian suppression, whereas vulvar irritation without atrophy was higher among pre/perimenopausal women with endocrine exposure; all groups experienced vestibular irritation. Despite differences in age, time since last menstrual period, and average endocrine use, all postmenopausal women or women with ovarian suppression reported vulvar symptoms, the study authors noted.

“The implication here is that we should be intervening early, since it’s necessary to address vulvar atrophy in postmenopausal women as well as women with ovarian suppression for vulvar irritation,” explained Dr. Carter.

“Vestibular irritation, which was present in all groups, from 53% to 70% of patients, is an issue that more people need to be aware of, because it can contribute to insertional pain or pain with exams,” Dr. Carter added. “Use of internal and external moisturizers is essential for both improvement of the quality of vaginal and vulvar tissue, as well as symptom relief.”

When patients were asked directly about concerns regarding sexual function and vulvovaginal health, the majority expressed a high degree of concern and a lack of confidence about future sexual activity. These concerns were reinforced by a validated measure of female sexual functioning, which showed that 99% of postmenopausal women had a score indicating sexual dysfunction.

“The average score was worse in postmenopausal women who were on tamoxifen and then transitioned to an aromatase inhibitor,” Dr. Carter concluded. “This speaks to the cumulative effect of these therapies. 

DISCLOSURE: Dr. Carter reported no conflicts of interest.

REFERENCE

1. Carter J, Saban S, Arkema A, et al: Breast cancer patients in a female sexual medicine and women’s health program: A cross-sectional retrospective study. 2019 Supportive Care in Oncology Symposium. Abstract 8. Presented October 26, 2019.