Advances in the Management of Menopausal Symptoms, Fertility Preservation, and Bone Health for Women With Breast Cancer on Endocrine Therapy

Abstract

In patients with hormone receptor–positive early-stage breast cancer, adjuvant endocrine treatment administered for up to 5-10 years after diagnosis significantly reduces the risk of recurrence and death. However, this benefit comes with the cost of short- and long-term side effects that may negatively affect patients' quality of life (QoL) and treatment adherence. Among them, the prolonged estrogen suppression associated with the use of adjuvant endocrine therapy in both premenopausal and postmenopausal women can induce life-altering menopausal symptoms, including sexual dysfunction. Moreover, a decrease in bone mineral density and an increased risk of fractures should be carefully considered and prevented whenever indicated. For young women diagnosed with hormone receptor–positive breast cancer with unfulfilled childbearing plans, several challenges should be addressed to manage their fertility and pregnancy-related concerns. Proper counseling and proactive management of these issues are critical components of survivorship and should be pursued from diagnosis through the breast cancer care continuum. This study aims to provide an updated overview of the available approaches for improving the QoL of patients with breast cancer receiving estrogen deprivation therapy, focusing on advances in the management of menopausal symptoms, including sexual dysfunction, fertility preservation, and bone health.

Ovarian Suppression: Early Menopause and Late Effects

“…The toxicity profile of this treatment depends also on the oral endocrine agent combined with GnRHa. Arthralgia and sexual dysfunction are more frequent in patients treated with an AI, while night sweats and hot flashes are more frequent in those receiving tamoxifen [ 67 , 68 ].…”

“…Early menopause induced by OFS may anticipate and accelerate the development of events associated with estrogen levels drop, including bone loss [ 68 ]. In the SOFT study, the addition of OFS to endocrine monotherapy was associated with an increased risk of osteoporosis (defined as T score < − 2.5) from 3.5 to 5.8% [ 45 ].…”

“…Sexual dysfunction includes different manifestations such as vaginal dryness, dyspareunia, decreased libido, low self-esteem, barriers on intimacy and difficulties in communicating with the partner. A comprehensive assessment and a multidisciplinary approach are needed, as well as a close collaboration with gynaecologists and psychologists [ 68 ]. Pharmacological strategies to treat sexual dysfunction include intravaginal estradiol-releasing tablets, estrogen-based vaginal creams, estradiol-releasing vaginal rings, vaginal testosterone and vaginal DHEA.…”

Letter to the Editor

“…3 For women with breast cancer on endocrine therapy with persistent symptoms of genitourinary syndrome of menopause after nonhormone treatment, the American Society of Clinical Oncology recommends the use of low-dose vaginal estrogen and recommends against energy-based vaginal treatments. 4 Energy-based devices such as CO 2 lasers are being marketed specifically to patients with breast cancer, but the lack of quality research demonstrating the benefits and an ongoing concern for patient harm should dissuade clinicians from directing patients toward these therapies. 4 This practice received strong criticism from the Food and Drug Administration.…”

“…4 Energy-based devices such as CO 2 lasers are being marketed specifically to patients with breast cancer, but the lack of quality research demonstrating the benefits and an ongoing concern for patient harm should dissuade clinicians from directing patients toward these therapies. 4 This practice received strong criticism from the Food and Drug Administration. 5 Additional randomized, prospective, sham-controlled trials of adequate size and scope are recommended before these therapies can be routinely used for genitourinary syndrome of menopause treatment.…”