Ob/gyns are increasingly being called upon to care for women with side effects from treatment of breast cancer because more patients are surviving the disease. Tips and tools for addressing quality-of-life issues such as vasomotor symptoms and vaginal atrophy were the focus of a presentation at the 2018 Annual ACOG Meeting in Austin by an ob/gyn with a unique perspective: She herself is a breast cancer survivor.
In 2016, the outcomes of the Suppression of Ovarian Function Trial (SOFT) and the Tamoxifen and Exemestane Trial (TEXT) were released, “which changed the management of breast cancer treatment in premenopausal patients,” says Erin Keyser, MD, the Associate Program Director for the Department of OB/GYN and Assistant Professor of Obstetrics and Gynecology at San Antonio Military Medical Center in Texas. “Prior to this, if you had estrogen-receptor (ER)-positive cancer and were premenopausal, you were placed on tamoxifen, and if postmenopausal, you were placed on an aromatase inhibitor (AI).”
However, SOFT and TEXT concluded that premenopausal women actually have a survival benefit if they are on ovarian suppression with an aromatase inhibitor (AI). “Therefore, we are seeing more women needing ovarian suppression in order to receive aromatase inhibitors,” said Dr. Keyser.
Ovarian suppression can be accomplished either by injecting a gonadotropin-releasing hormone (GnRH) agonist or removing the ovaries. “There is ongoing debate whether a woman should have her ovaries removed to avoid a monthly injection or whether she should schedule temporary medical suppression for 5 to 10 years in hopes of return of ovarian function,” Dr. Keyser told Contemporary OB/GYN.
Two factors to consider when deciding are the patient’s age at time of cancer diagnosis and her willingness to commit to monthly injections.
“I feel if the patient is under the age of 35 and there is the potential to achieve return of ovarian function, injections can be advantageous in the long run,” Dr. Keyser said. “But I completely understand when a patient tells me she does not want to visit the office monthly for 10 years to receive a painful injection.”
The most common side effects of AIs for ovarian suppression are hot flashes, musculoskeletal symptoms, vaginal dryness, decreased libido and dyspareunia. “You can argue most of these adverse events are in the purview of a gynecologist,” Dr. Keyser said.
To prevent vaginal dryness, Dr. Keyser recommended a daily, over-the-counter vaginal moisturizer, started upon initiation of chemotherapy. “A moisturizer will make the patient pay attention to her vagina during treatment and it will help alleviate the atrophy that occurs,” she says.
If a vaginal moisturizer fails, however, hormone therapy options can be discussed with the patient, ranging from vaginal estrogen to intravaginal dehydroepiandrosterone (DHEA) to laser therapy. Lubrication with intercourse is also advised. Similarly, low-dose vaginal estrogen, even for patients who are ER positive, is safe and can help.
Once a patient has completed 5 to 10 years of adjuvant therapy with an AI, it's reasonable to consider ospemifene.
Lifestyle modifications for vasomotor symptoms include layering of clothes and avoiding hot beverages and red wine. “These things will trigger hot flashes,” said Dr. Keyser.
A nonhormonal option for vasomotor symptoms is low-dose paroxetine if the patient is not on tamoxifen or venlafaxine or gabapentin.
For patients whose hot flashes mostly occur at night, Dr. Keyser prescribes a higher dose of gabapentin because it has the dual benefit of helping the patient sleep and potentially reducing hot flashes. Clonidine can also be used at night.
Four years ago, at age 34, Dr. Keyser was diagnosed with breast cancer. “As both a patient and a gynecologist, I was ill-equipped to deal with the gynecologic issues that a breast cancer survivor faces,” she said. “So, as the patient and gynecologist, I hope to empower ob/gyns to address sexual issues in cancer survivors.”
Dr. Keyser suspects that sexual concerns of men are discussed during their initial visit for prostate cancer. “Think of all the cancers that affect women’s sexual organs, yet we do not always address sexual dysfunction,” she says. “I think we assume it is not important to them, when really they are too embarrassed to ask.”
Hematologist and oncologists are also uneasy about addressing sexual concerns, “so as gynecologists, we need to feel comfortable managing this side effect of cancer treatment,” Dr. Keyser says. “Ask your cancer survivor patients about sexual dysfunction. Cancer survivors do care about their sexual identity and want help.”
Dr. Keyser reports no relevant financial disclosures.