Treating genitourinary syndrome of menopause in breast cancer survivors: main challenges and promising strategies.

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.

Safety of prasterone in breast cancer survivors treated with aromatase inhibitors: the VIBRA pilot study.

BACKGROUND: Due to safety concerns on estrogen-based treatments for genitourinary syndrome of menopause (GSM) in breast cancer survivors (BCS), new options are appearing, such as androgen-based treatments, which according to proprieties would not be transformed systemically to estrogens in patients receiving aromatase inhibitors (AIs). OBJECTIVE: The aim of this pilot study is to assess the security and efficacy of vaginal prasterone (dehydroepiandrostenedione [DHEA]) in BCS treated with AIs. METHODS: This open, prospective, pilot study included 10 BCS treated with AIs. All participants complained of severe GSM. DHEA was administrated as a vaginal ovule. Participants were instructed to use one ovule every night during the first month, and one ovule every two nights for the entire five remaining months. The patients were requested to attend seriated visits after the beginning of the prasterone treatment to evaluate symptoms, physical improvement and serum estradiol. RESULTS: Mean serum estradiol remained low from 3.4 pg/ml to 4.3 pg/ml (p = 0.9136) after 6 months of follow-up. The visual analog scale of dyspareunia improved from 8.5 to mean values after treatment of 0.4 (p = 0.0178). The Vaginal Health Index (VHI) scale and Female Sexual Function Index improved from 9.75 to 15.8 (p = 0.0277) and from an initial score of 11.2 to 20.6 (p = 0.0277), respectively. Vaginal pH changed from basal 8.1 to final 6.5 (p = 0.0330). CONCLUSION: Symptoms and physical examination regarding sexuality and vaginal health improved significantly, while serum estradiol remained at low levels. Prasterone seems a safe and effective option to treat GSM in BCS receiving AIs.

[Update of the care model in a urogynaecology unit of a tertiary hospital: impact of the COVID-19 pandemic on face-to-face care]. / Cambio del modelo asistencial en una unidad de uroginecología de un hospital de tercer nivel: impacto de la pandemia por COVID-19 en la presencialidad.

The COVID-19 pandemic caused a sudden change in the usual care practice of our urogynaecology unit. Therefore, we designed a new healthcare model to adapt our practice to the epidemiological situation. The central axis of the new model was reduced hospital attendance, offering the same healthcare quality through the introduction of telemedicine.To achieve this aim, we made the following changes: a first telematic medical visit was the first step, telematic monitoring visits for conservative and pharmacological treatments and pack visit. We created the following packs: LUTS, postpartum and post-discharge pack. All packs included visits and diagnostic tests performed on the same day.The LUTS pack is indicated in patients with lower urinary tract symptoms, associated or not with pelvic organ prolapse. It includes two visits (nursing and medical) and two tests (urodynamics and pelvic floor ultrasound).The postpartum pack is indicated in women with symptoms of urinary incontinence, anal incontinence, pelvic organ prolapse and sexual disfunctions after delivery, as well as asymptomatic patients with a history of obstetric perineal trauma. It includes a medical visit, a pelvic floor ultrasound and a visit with the physiotherapist.The post-discharge pack is scheduled a month after the surgery and includes two tests (pelvic floor ultrasound and uroflowmetry) and a medical visit.Some face-to-face visits were maintained, as were physiotherapy treatments and other visits following medical criteria.

[How did COVID-19 pandemic change the way we attend the patients in an urogynaecological unit]. / Cómo la pandemia por COVID-19 ha cambiado la forma de atender a las pacientes en una unidad de uroginecología.

The current SARS-coronavirus type 2 pandemic caused, in few weeks, important changes in the health system organization and in the way we attend the patients. Urogynaecological diseases affect quality of life, but without life risk in most cases, so it is possible to delay. Moreover, urogynaecological diseases affect mostly women over 65 years old (a high risk population for contracting COVID-19). In this manuscript we summarise the current evidence about telemedicine efectivity to manage to pelvic floor dysfunctions and, in addition, the recommendations of Urogynaecological scientific societies during state of alarm. We describe the management of the different pelvic floor dysfunctions during COVID-19 pandemic and a proposal to organize the urogynaecological services to diagnose (visits and diagnostic investigations) and to treat (conservative, pharmacological or surgery) in the interpandemic period and in the future.

Sexual activity and function of women with severe pelvic organ prolapse subjected to a classical vaginal surgery. A Multicentre study. / Actividad y función sexual en mujeres con prolapso de órganos pélvicos avanzado sometidas a cirugía vaginal clásica. Estudio multicéntrico.

INTRODUCTION AND OBJECTIVE: Pelvic organ prolapse (POP) is related with female sexual dysfunction. The present study aimed to determine the impact of POP corrective surgery on the sexual life of women with advanced POP. MATERIALS AND METHODS: A prospective, multicentre cohort study was designed, including patients with grade≥II, symptomatic POP, who underwent vaginal surgery with traditional procedures. Sexual activity and function were assessed by PISQ-IR before surgery and 12 months after. RESULTS: We included 355 women; 322 had data from the follow-up visit. The mean (SD) age was 64.8 (9.9) years. At baseline, 170 women were sexually active and 185 were not. After surgery, 29 women (16.8%) became sexually active and 20 (12.8%) ceased sexual activity. Before surgery, 42.3% reported not having sexual intercourse due to bladder, bowel or POP problems; and 11.4% after surgery. At baseline visit, 25.3% had no sexual activity due to pain, however, at follow-up visits, this percentage was 8.5%. A statistically significant improvement was observed in 5 out of 6 scales of the PISQ-IR in sexually active women. CONCLUSIONS: Symptomatic POP is associated with female sexual dysfunction. Surgical intervention seems to have a positive impact on sexual life among sexually inactive and active women.