Clinic Institute of Gynecology, Obstetrics and Neonatology, Faculty of Medicine, University of Barcelona, Hospital Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
Climacteric. 2023 Aug;26(4):296-301. doi: 10.1080/13697137.2023.2184253. Epub 2023 Mar 22.
Many breast cancer survivors (BCS) suffer the consequences of antineoplastic treatments that induce a hypoestrogenic state, leading to chronic climacteric symptoms such as genitourinary syndrome of menopause (GSM), arousing significant alteration in their quality of life. Non-hormonal therapies (NHT) are first-line treatments, safe but with mild efficacy. When facing moderate-severe GSM, the options for BCS are limited: local estrogen therapy, considered the 'gold standard' but with concerns about safety; vaginal androgens and prasterone, which seem to trigger an activation of estrogen and androgen receptors of the vaginal epithelium layers, without activating estrogen receptors on other tissues, being potentially safe but still without strong evidence in favor of BCS; vaginal lasers, which appear to improve vascularization of vaginal mucosa by stimulating the remodeling of the underlying connective tissue, but with contradictory results of efficacy in recent randomized clinical trials; and ospemifene, an oral selective estrogen receptor modulator presenting mild vaginal estrogenic potency and anti-estrogenic effect at the endometrial and breast level, but still not recommended for use in BCS in recent North American Menopause Society guidelines. There is a need for further studies evaluating objectively the efficacy and safety of these promising therapeutic options. On the other hand, sexuality must be seen as a multifactorial issue, where GSM is only part of the problem; evidence shows that sexual counseling improves the quality of life of BCS. Finally, there is a need to limit the underdiagnosis and undertreatment of GSM in BCS; the primary goal of physicians treating BCS regarding this issue has to be the provision of information of what to expect regarding genital and sexual symptoms to BCS and to counsel on early first-line treatments that may help prevent more severe GSM.
许多乳腺癌幸存者（BCS）遭受抗肿瘤治疗的后果，导致雌激素缺乏状态，引起慢性绝经后生殖泌尿系统综合征（GSM）等症状，显著改变其生活质量。非激素治疗（NHT）是一线治疗方法，安全但疗效温和。当面临中重度 GSM 时，BCS 的选择有限：局部雌激素治疗，被认为是“金标准”，但存在安全性担忧；阴道雄激素和普拉睾酮，似乎可以激活阴道上皮层的雌激素和雄激素受体，而不会激活其他组织的雌激素受体，具有潜在的安全性，但仍然缺乏支持 BCS 的有力证据；阴道激光，通过刺激底层结缔组织的重塑似乎可以改善阴道黏膜的血管化，但最近随机临床试验的疗效结果存在争议；以及 ospemifene，一种口服选择性雌激素受体调节剂，在阴道水平具有轻微的雌激素效力和抗雌激素作用，但在最近的北美绝经学会指南中仍不建议用于 BCS。需要进一步研究来客观评估这些有前途的治疗选择的疗效和安全性。另一方面，必须将性行为视为一个多因素问题，GSM 只是问题的一部分；有证据表明，性咨询可以提高 BCS 的生活质量。最后，需要限制 BCS 中 GSM 的漏诊和治疗不足；治疗 BCS 的医生在处理这个问题时的首要目标是向 BCS 提供有关生殖器和性症状的预期信息，并提供早期一线治疗的咨询，以帮助预防更严重的 GSM。
