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Physicians hesitant to prescribe vulvar atrophy treatment to breast cancer survivors

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September 4, 2018

OB-GYNs and primary care physicians reported similar attitudes toward treatment for vulvar and vaginal atrophy, or VVA, including a low comfort level when prescribing treatment for the condition to women with a history of breast cancer, according to survey data published in Menopause.

Sheryl A. Kingsberg

“These findings should be a wake-up call to clinicians,” Sheryl A. Kingsberg, PhD, chief in the division of behavioral medicine at University Hospitals Cleveland Medical Center and professor in the departments of reproductive biology and psychiatry at Case Western Reserve University School of Medicine in Cleveland, told Endocrine Today. “Every clinician should be asking women, particularly every breast cancer survivor, about these symptoms because VVA is so common, and the majority of women are going to be affected. If you don’t ask, women either are going to suffer in silence and get progressively worse, or they are going to take some untested, non-evidence-based treatment that may do them harm.”

Kingsberg and colleagues evaluated data from an internet survey conducted by a market research firm to assess physicians’ behaviors and attitudes toward VVA treatment. The WISDOM survey included 23 multipart questions and was conducted August through September 2016. A total of 2,424 physicians were invited to participate, and 27%, including 369 OB-GYNs and 275 PCPs, completed the survey. OB-GYNs saw an average of 111 menopausal women per month (55% with VVA symptoms and 58% with vasomotor symptoms). PCPs saw an average of 99 menopausal women per month (44% with VVA symptoms and 52% with vasomotor symptoms).

Physicians reported most commonly recommending prescription therapy alone or with other therapies for VVA treatment (49%), followed by over-the-counter products alone, no treatment, behavioral/lifestyle management and vaginal laser therapy. OB-GYNs and PCPs reported prescribing VVA treatments, including estrogen therapy, dehydroepiandrosterone and ospemifene (Osphena, Duchesnay), but not OTC products most commonly because of effectiveness (77% and 76% of OB-GYNs and PCPs, respectively), followed by patient out-of-pocket cost (33% and 34%), patient preference (28% and 30%) and ease of product use (29% and 28%).

More OB-GYNs than PCPs (72% vs. 47%) disagreed or strongly disagreed that VVA is best treated with OTC products rather than prescription products. Eighty-four percent of all physicians reported it was important to use the lowest effective dose of hormone therapy when treating women with VVA symptoms.

Approximately 40% of physicians agreed that their ability to treat women with VVA was limited by currently available choices and that VVA required treatment only if the symptoms negatively affected quality of life.

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Ninety-five percent of OB-GYNs and 80% of PCPs were comfortable prescribing existing VVA therapies to women with no personal history of or predisposition to breast cancer. However, only 49% of OB-GYNs and 23% of PCPs felt comfortable prescribing VVA therapies to women with a family history of breast cancer or BRCA gene mutation. Only 34% of OB-GYNs and 17% of PCPs were comfortable prescribing VVA therapies to women with a personal history of breast cancer.

Kingsberg and colleagues noted in their discussion that medical societies have supported the use of vaginal estrogen therapy in women with a history of breast cancer in consultation with an oncologist when symptoms do not to improve with nonhormonal therapies.

“Regardless of the subspecialty of women’s health care professionals, there is such a reluctance to treat women who are [breast cancer] survivors,” Kingsberg said. “Physicians really need to pay attention to and listen to their patients, because the vast majority of these breast cancer survivors are going to have genitourinary syndrome of menopause. Any postmenopausal woman is at high risk, but these breast cancer survivors are on chemotherapy and adjuvant therapy that exacerbate symptoms.”

Kingsberg suggested physicians consult the consensus recommendations from the North American Menopause Society and the International Society for the Study of Women’s Sexual Health on the management of genitourinary syndrome of menopause in women with or at high risk for breast cancer. – by Tina DiMarcantonio-Brown

For more information:

Sheryl A. Kingsberg, PhD, can be reached at MacDonald Women’s Hospital, Mailstop 5034, 11100 Euclid Ave., Cleveland, OH 44106; email: sheryl.kingsberg@uhhospitals.org.

Disclosures: Kingsberg reports that she is a paid consultant or on a scientific advisory board for AMAG, Dare, Duchesnay, Emotional Brain, Endoceutics, GTx, IVIX, Lupin, Palatin Technologies, Pfizer, Materna, Sprout, Strategic Science Solutions, TherapeuticsMD and Valeant. She also reports that she receives institutional grant support (clinical trial investigator) from Endoceutics and Palatin. Please see the study for all other authors’ relevant financial disclosures.

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Kingsberg and colleagues’ WISDOM trial complements her studies of women’s views on vulvovaginal atrophy, or VVA, to evaluate physicians’ perspectives on treatment of affected women. The investigators surveyed both primary care providers and gynecologists. Kingsberg’s previous studies have shown that most women with atrophy have never been questioned about their VVA symptoms, but that they really wished their providers had brought up these issues.

This current study showed that a significant number of providers felt that only symptomatic women required therapy. Of interest is that they did not really consider the expanded term for genitourinary syndrome of menopause, which includes the urinary tract issues attendant with vulvar and vaginal issues. So indeed, many providers may not be enquiring about urinary issues either.

The investigators also highlighted the responses on VVA treatment for breast cancer survivors. The majority of providers would not consider estrogen therapy for these women, with more gynecologists than primary care providers willing at least to consider therapy. Although this study was conducted before the North American Menopause Society issued their guidelines for VVA treatment for breast cancer survivors, the American College of Obstetricians and Gynecologists had already issued clear guidelines suggesting hormone therapy for breast cancer survivors who have failed over-the-counter non-estrogenic therapy. There are multiple studies showing that the systemic absorption of vaginal estrogen therapy is minute; however, there are no data that show long-term outcomes of survivors exposed to vaginal estrogen therapy. What surprised me was that the majority of all physicians felt uncomfortable prescribing vaginal estrogens to women with a family history of breast cancer — and we know from the Women’s Health Initiative that a family history of breast cancer does not confer even a fully additive risk for breast cancer development with full-dose systemic estrogen and progestin therapy. (And of course, the WHI showed no increased risk for estrogen-only therapy, and vaginal estrogen therapy is of course estrogen only.)

Studies like the WISDOM study will, hopefully, promote further recognition of this significant problem and lead to further dialogue between patients and their providers. There are a lot of options available for women — we just need to have providers and their patients communicating.

Mary Jane Minkin, MD, FACOG

Clinical professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale Medical School

Disclosure: Minkin reports consulting for AMAG pharmaceuticals, Duchesnay and Pfizer.