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Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women's Sexual Health

Faubion, Stephanie, S., MD, FACP, NCMP, IF1; Larkin, Lisa, C., MD, FACP, NCMP, IF2; Stuenkel, Cynthia, A., MD, NCMP3; Bachmann, Gloria, A., MD4; Chism, Lisa, A., DNP, APRN, BC, NCMP, CSC, FAANP5; Kagan, Risa, MD, FACOG, CCD, NCMP6; Kaunitz, Andrew, M., MD, FACOG, NCMP7; Krychman, Michael, L., MD, FACOG, MPH, IF8; Parish, Sharon, J., MD, IF, NCMP9; Partridge, Ann, H., MD, MPH10; Pinkerton, JoAnn, V., MD, FACOG, NCMP11; Rowen, Tami, S., MD, MS12; Shapiro, Marla, CM, MDCM, CCFP, MHSC, FRCPC, FCFP, NCMP13; Simon, James, A., MD, CCD, NCMP, IF, FACOG14; Goldfarb, Shari, B., MD15; Kingsberg, Sheryl, A., PhD16

doi: 10.1097/GME.0000000000001121
Consensus Recommendations

The objective of The North American Menopause Society (NAMS) and The International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel was to create a point of care algorithm for treating genitourinary syndrome of menopause (GSM) in women with or at high risk for breast cancer. The consensus recommendations will assist healthcare providers in managing GSM with a goal of improving the care and quality of life for these women. The Expert Consensus Panel is comprised of a diverse group of 16 multidisciplinary experts well respected in their fields. The panelists individually conducted an evidence-based review of the literature in their respective areas of expertise. They then met to discuss the latest treatment options for genitourinary syndrome of menopause (GSM) in survivors of breast cancer and review management strategies for GSM in women with or at high risk for breast cancer, using a modified Delphi method. This iterative process involved presentations summarizing the current literature, debate, and discussion of divergent opinions concerning GSM assessment and management, leading to the development of consensus recommendations for the clinician.

Genitourinary syndrome of menopause is more prevalent in survivors of breast cancer, is commonly undiagnosed and untreated, and may have early onset because of cancer treatments or risk-reducing strategies. The paucity of evidence regarding the safety of vaginal hormone therapies in women with or at high risk for breast cancer has resulted in avoidance of treatment, potentially adversely affecting quality of life and intimate relationships. Factors influencing decision-making regarding treatment for GSM include breast cancer recurrence risk, severity of symptoms, response to prior therapies, and personal preference.

We review current evidence for various pharmacologic and nonpharmacologic therapeutic modalities in women with a history of or at high risk for breast cancer and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. Treatment of GSM is individualized, with nonhormone treatments generally being first line in this population. The use of local hormone therapies may be an option for some women who fail nonpharmacologic and nonhormone treatments after a discussion of risks and benefits and review with a woman's oncologist. We provide consensus recommendations for an approach to the management of GSM in specific patient populations, including women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

1Division of General Internal Medicine, Mayo Clinic, Rochester, MN

2Lisa Larkin, MD, & Associates, Cincinnati, OH

3Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA

4Departments of Obstetrics, Gynecology, and Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

5Karmanos Cancer Institute, Detroit, MI

6Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Berkeley, CA

7Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL

8Southern California Center for Sexual Health and Survivorship Medicine, Irvine, CA

9Departments of Medicine and Psychiatry, Weill Cornell Medical College, New York, NY

10Department of Medicine, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA

11NAMS Executive Director, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA

12Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA

13Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

14George Washington University, Women's Health and Research Consultants, Washington, DC

15Departments of Medicine, Epidemiology, and Biostatistics, Memorial Sloan Kettering Cancer Center, Department of Medicine, Weill Cornell Medical College, New York, NY

16Departments of Reproductive Biology and Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH.

Address correspondence to: The North American Menopause Society; 30100 Chagrin Blvd., Suite 210; Pepper Pike, OH 44124. E-mail: info@menopause.org. Website: www.menopause.org.

Received 21 March, 2018

Revised 22 March, 2018

Accepted 22 March, 2018

This CME activity is supported through unrestricted educational grants from Amag Pharmaceuticals, Aytu BioScience, Inc., and Cynosure. Funding was also provided by The International Society for the Study of Women's Sexual Health.

© 2018 by The North American Menopause Society.