Management of sexual dysfunction in postmenopausal breast cancer patients taking adjuvant aromatase inhibitor therapy

C Derzko, S Elliott, W Lam, C Derzko, S Elliott, W Lam

Abstract

Treatment with aromatase inhibitors for postmenopausal women with breast cancer has been shown to reduce or obviate invasive procedures such as hysteroscopy or curettage associated with tamoxifen-induced endometrial abnormalities. The side effect of upfront aromatase inhibitors, diminished estrogen synthesis, is similar to that seen with the natural events of aging. The consequences often include vasomotor symptoms (hot flushes) and vaginal dryness and atrophy, which in turn may result in cystitis and vaginitis. Not surprisingly, painful intercourse (dyspareunia) and loss of sexual interest (decreased libido) frequently occur as well. Various interventions, both non-hormonal and hormonal, are currently available to manage these problems. The purpose of the present review is to provide the practitioner with a wide array of management options to assist in treating the sexual consequences of aromatase inhibitors. The suggestions in this review are based on recent literature and on the recommendations set forth both by the North American Menopause Association and in the clinical practice guidelines of the Society of Gynaecologists and Obstetricians of Canada. The complexity of female sexual dysfunction necessitates a biopsychosocial approach to assessment and management alike, with interventions ranging from education and lifestyle changes to sexual counselling, pelvic floor therapies, sexual aids, medications, and dietary supplements-all of which have been reported to have a variable, but often successful, effect on symptom amelioration. Although the use of specific hormone replacement-most commonly local estrogen, and less commonly, systemic estrogen with or without an androgen, progesterone, or the additional of an androgen in an estrogenized woman (or a combination)-may be highly effective, the concern remains that in patients with estrogen-dependent breast cancer, including those receiving anti-estrogenic adjuvant therapies, the use of these hormones may be attended with potential risk. Therefore, non-hormonal alternatives should in all cases be initially tried with the expectation that symptomatic relief can often be achieved.First-line therapy for urogenital symptoms, notably vaginal dryness and dyspareunia, should be the non-hormonal group of preparations such as moisturizers and precoital vaginal lubricants. In patients with estrogen-dependent breast cancer (notably those receiving anti-estrogenic adjuvant therapies) and severely symptomatic vaginal atrophy that fails to respond to non-hormonal options, menopausal hormone replacement or prescription vaginal estrogen therapy may considered. Systemic estrogen may be associated with risk and thus is best avoided. Judicious use of hormones may be appropriate in the well-informed patient who gives informed consent, but given the potential risk, these agents should be prescribed only after mutual agreement of the patient and her oncologist.

Keywords: Aromatase inhibitor therapy; breast cancer; gynecologic side effects; hormone therapy; sexual dysfunction; side effect management; side effect treatment.

Figures

FIGURE 1
FIGURE 1
Incidence of specific gynecologic adverse events having a lower recorded incidence with anastrozole use than with tamoxifen use (>3% total difference), by time of occurrence in patients with an intact uterus at baseline in the Arimidex, Tamoxifen, Alone or in Combination main trial (Distler D, on behalf of the atac Trialists’ Group. Fewer gynaecological adverse events, gynaecological intervention, endometrial changes and abnormalities with anastrozole than with tamoxifen: findings from the atac trial. Poster presented at the 10th International St. Gallen Oncology Conference; St. Gallen, Switzerland; March 14–17, 2007). *Patients can have an event more than once, but in different time categories.
FIGURE 2
FIGURE 2
Changes in double endometrial thickness (DET) from baseline to 3 months of treatment with tamoxifen and with aromatase inhibitors.
FIGURE 3
FIGURE 3
Association between lower estrogen levels and increased prevalence of sexual problems,.

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