Expert Tips on Treating Genitourinary Syndrome of Menopause

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We recently spoke with Dr. David Portman, Founder and Director Emeritus of the Columbus Center for Women’s Health Research, while onsite at ReachMD’s Innovation Theater in Chicago, Illinois.

Here’s his take on treating patients with genitourinary syndrome of menopause, or GSM, who have either had or have breast cancer.

Dr. Portman:
I think there are 250,000 women every year in the US diagnosed with breast cancer. There are 3 million breast cancer survivors, many of those with very early disease and essentially cured, who look at estrogen as the culprit. Just because you had an estrogen-positive cancer doesn’t mean that estrogen gave you the cancer. It meant that some of its growth was driven by the estrogen at that time. Once it’s gone, there’s really good reason to believe that that patient shouldn’t be at greater risk simply by being on local vaginal estrogen, but that’s a very hard conversation to get past because they really do see... If you think that the general population has fears about estrogen, the breast cancer survivor population is petrified, so that conversation doesn’t go very far. Although, if you look at ASCO’s recommendations, they do say that if you have tried lubricants, moisturizers, sometimes you might think about vaginal dilators—and again, this is something that you need to get comfortable with—that can really help quite a bit for these patients. There have been some decent studies with hyaluronic acid, which is available now. It’s a little expensive. The thing that I... I actually read an editorial about this. What I was really disturbed by is that one of the recommendations for these poor women was topical lidocaine. And even though it allowed for penetration, the thought there is that: Is that really any way to treat the problem, is to mask the pain?—because it’s certainly not going to correct all the underlying tissue changes.

I truly believe what would probably be the best solution, although I’d love to see more data, is intravaginal DHEA, and it’s partly because of what I mentioned about the endometrium not expressing aromatase so we didn’t see any activity. If you have a woman on an aromatase inhibitor, we should assume that the DHEA is not going to be converted in significant amounts into available estrogens. You will have androgens, and as I showed you, the androgens play a big role in urogenital health, particularly the labia, the clitoral tissue, the vestibular tissue, which is where you get all of your insertional dyspareunia. So, if, in fact, the androgen effect is enough, even in the presence of aromatase inhibitors… There’s been some studies that have looked at intravaginal testosterone, and that has looked beneficial, so there’s no reason to believe it won’t be. There are some ongoing studies. I think that a conversation with the oncologist about why you’re choosing your treatment modality for those patients I think makes a lot of sense. Those are some of the things that I think about when I think about a breast cancer survivor. And then there’s always potential use of laser technology, in that particular population I think would probably be the most useful. I don’t like the idea of that as a first-line for general populations with GSM given how prevalent it is and how little we know about potential long-term damage to tissue from laser energy. So, I think that if I was prioritizing, I would probably say intravaginal DHEA makes the most sense in women on aromatase inhibitors, although it deserves further study, or very low-dose vaginal estrogens if I’m going to use things. And this is obviously after you have really exhausted counseling with lubricants, moisturizers, and some of the nonhormonal methods.

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