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ACOG Pub Review > Clinical Consensus #2: Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer > Flashcards

Clinical Consensus #2: Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer Flashcards

1
Q
A
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2
Q

Percentage of breast cancers that are ER+, percentage of breast cancers that are PR+

A

80%, 65%

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3
Q

Median age at breast cancer dx

A

62 y/o

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4
Q

Percentage of breast cancers diagnosed in pts <50 y/o, percentage of breast cancers diagnosed in pts <40 y/o

A

30%, 7%

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5
Q

Likelihood of having hormone receptor-neg breast cancer is higher in which age group of pts?

A

Premenopausal

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6
Q

Are majority of breast cancers in premenopausal pts hormone receptor-pos or -neg?

A

Hormone receptor-pos

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7
Q

Common adjuvant med therapy for premenopausal pts w/ breast cancer

A

Tamoxifen (typically 5+ years)

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8
Q

Class of common adjuvant med therapy for postmenopausal pts w/ breast cancer

A

AI (for up to 10 years)

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9
Q

Class of med of tamoxifen, MoA of tamoxifen re breast cancer

A

SERM, antagonist activity in breast (blocking E2 at receptor level)

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10
Q

MoA of AIs

A

Block peripheral E2 conversion from androstenedione and testosterone

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11
Q

Between tamoxifen and AIs, which meds are associated w/ GUSM

A

Both (2/2 low E2 levels), though sxs from tamoxifen ten to be more pronounced 2/2 pt age when used

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12
Q

How would exogenous estrogen affect breast tissue in pts taking tamoxifen, in pts taking AIs?

A

Effects would be blocked in pts taking tamoxifen, effects would not be blocked in pts taking AIs

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13
Q

Common indications for PO/transdermal estrogen (4)

A

Vasomotor sxs, night sweats, adjunct tx of GUSM, prevention of postmenopausal osteoporosis

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14
Q

First-line tx of GUSM alone

A

Vaginal estrogen

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15
Q

Therapy that is contraindicated in pts w/ a hx of hormone receptor-pos breast cancer, and why

A

Systemic estrogen, 2/2 potential for systemic estrogen to increase risk of recurrence

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16
Q

Hormonal tx options for GUSM (6)

A

CEE vaginal cream, 17β-estradiol vaginal cream, 17β-estradiol vaginal ring, estradiol hemihydrate vaginal tablet/insert, prasterone vaginal insert, testosterone vaginal cream

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17
Q

Dosing for CEE vaginal cream (and alternative dosing)

A

0.5g 2x/week (1g qHS x2 weeks > 0.5-1g 2x/week thereafter)

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18
Q

Dosing for 17β-estradiol vaginal cream

A

1-4g daily x1-2 weeks > reduced to half initial dosage x1-2 weeks > maintenance dose of 1g 1-3x/week

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19
Q

Dosing for 17β-estradiol vaginal ring

A

7.5mcg/day x90 days

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20
Q

Dosing for estradiol hemihydrate vaginal tablet/insert (and alternative dosing)

A

10mcg/day x2 weeks > 10mcg/day 2x/week (4mcg/day dosing also available)

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21
Q

Dosing for prasterone vaginal insert

A

6.5mg daily

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22
Q

For which pts should caution be exercised when using prasterone vaginal insert for GUSM, and why?

A

Pts w/ current/past hx of breast cancer, because E2 is active metabolite of prasterone

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23
Q

Dosing for testosterone vaginal cream (and alternative dosing)

A

300mcg/150mcg daily x28 weeks (300mcg/150mcg daily x2 weeks > 3x/week thereafter)

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24
Q

Nonhormonal tx categories for GUSM (4)

A

Lubricants, moisturizers, vaginal suppositories, aqueous lidocaine

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25
Q

Common composition options for lubricant products (3)

A

Water-based, silicone-based, polycarbophil-based

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26
Q

Common composition options for moisturizer products (3)

A

Hyaluronic acid, polyacrylic acid, polycarbophil-based

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27
Q

Dosing for hyaluronic acid vaginal moisturizer

A

5mg daily x2 weeks > 3-5x/week thereafter

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28
Q

Dosing for polyacrylic acid vaginal moisturizer

A

3g daily

29
Q

Dosing for polycarbophil-based vaginal moisturizer

A

2.5g 3x/week

30
Q

Common composition options for vaginal suppositories (2)

A

Vit E, vit D

31
Q

Dosing for vit E vaginal suppository

A

30-200IU

32
Q

Dosing for vit D vaginal suppository

A

1000IU

33
Q

Application instructions for aqueous lidocaine

A

4% aqueous lidocaine applied via fully saturated cotton ball applied to vulvar vestibule x3 mins before intercourse

34
Q

Average age of dx of breast cancer in Black pts compared to white pts

A

Slightly younger at 56 y/o compared to 59 y/o

35
Q

Sequelae of Black pts having younger age at dx of breast cancer

A

Potential to experience more severe sxs 2/2 endocrine therapy

36
Q

Which demographics were found to have lower initiation and adherence rates to endocrine therapy?

A

Black, Hispanic, Asian pts

37
Q

General category of first-line txs for pts w/ hx of breast cancer w/ GUSM sxs

A

Nonhormonal approaches

38
Q

Which was superior in terms of tx of vaginal dryness between polycarbophil-based lubricants and water-based lubricants?

A

Similar results

39
Q

Which was superior in terms of reducing dyspareunia between polycarbophil-based lubricants and water-based lubricants?

A

Polycarbophil-based lubricants

40
Q

Which was superior in terms of sx relief between silicone-based lubricants and water-based lubricants?

A

Silicone-based lubricants

41
Q

Percentage improvement in sexual dysfunction in pts using lubricants containing polyacrylic acid

A

96% to 24%

42
Q

Percentage improvement in sexual dysfunction in pts using standard lubricants

A

88.9% to 55.6%

43
Q

Are lubricants that contain hyaluronic acid associated w/ sx relief of sexual dysfunction?

A

Yes

44
Q

Measures for which both vit D and vit E suppositories have been shown to improve in pts taking tamoxifen experiencing sxs of vaginal atrophy (2)

A

Improved vulvovaginal sxs, lower vaginal pH

45
Q

Counseling for pts who use oil-based lubricants

A

Should not be used w/ condoms

46
Q

Can water-based and silicone-based lubricants be used w/ condoms?

A

Yes, yes

47
Q

Percent reduction in dyspareunia in pts using 4% aqueous lidocaine applied to introitus, percent reduction in dyspareunia in pts using saline placebo

A

88%, 38%

48
Q

Additional condition that aqueous lidocaine has been shown to be helpful for

A

Reversing vestibular sensitivity

49
Q

Is use of local vaginal estrogen-based txs safe for pts w/ a hx of hormone receptor-pos breast cancer?

A

Yes

50
Q

Serum E2 levels in many formulations of local estrogen-based txs

A

<20pg/mL

51
Q

Are low-dose vaginal estrogens superior to relieving sxs of urogenital atrophy compared to placebo or water-based lubricants?

A

Yes

52
Q

Improved objective measures of vaginal health associated w/ low-dose vaginal estrogens (4)

A

Improved vaginal maturation index, pH, vaginal cytology, sexual function (using Female Sexual Functioning Index)

53
Q

Does a sexual partner absorb local estrogen-based products?

A

Data are lacking

54
Q

Are there increased rates of breast cancer seen in pts using vaginal estrogen products?

A

No

55
Q

Class of medication of prasterone, and indication for use

A

Vaginal DHEA, FDA-approved for tx of mod-severe dyspareunia 2/2 menopause

56
Q

Pathway via which dehydroepiandrosterone can be converted to E2

A

Aromatization (dehydroepiandrosterone > androstenedione > E2)

57
Q

Do pts receiving higher dose (6.5mg) prasterone report better sexual health outcomes compared to the lower dose (3.25mg); differences in adverse effects?

A

Yes; none

58
Q

Are there increases in serum E2 seen in pts using using prasterone?

A

Only in pts receiving higher dose (6.5mg) who were not on AI therapy

59
Q

How does testosterone help improve vaginal sxs?

A

Proliferation of vaginal epithelium

60
Q

Can local testosterone be used in pts on AIs, and why/why not?

A

Yes, because conversion of testosterone to E2 is blocked in pts using AIs, so testosterone may improve atrophy w/o interfering w/ benefits of AIs

61
Q

Measures that vaginal testosterone has been shown to improve in pts taking AIs (3)

A

VV atrophy, dyspareunia, sexual dysfunction

62
Q

Class of medication of ospemifene, and indication for use

A

SERM, tx of postmenopausal VV atrophy

63
Q

Typical duration of use of ospemifene; measures that ospemifene has been shown to improve (3)

A

12 weeks to 1 year; vaginal pH, vaginal tissue health, pt-reported dyspareunia

64
Q

Ospemifene effect on vaginal tissue, bone, breast tissue

A

E2-agonist, E2-agonist, E2-antagonist

65
Q

Can pts w/ a hx of breast cancer use ospemifene for postmenopausal VV atrophy?

A

Despite FDA warning against use in such pts, evidence has not demonstrated increased risk of breast cancer recurrence (but inform pt of theoretical concerns prior to initiation)

66
Q

How does vaginal laser therapy work to improve vaginal sxs?

A

Fractional beams of light create small wounds in vaginal epithelium and lamina propria that then lead to stimulation of collagen/remodeling/regeneration

67
Q

Improved objective characteristics of vaginal mucosa after vaginal laser therapy use (4)

A

Vaginal mucosa thickness, vaginal mucosa lubrication, vaginal mucosa elasticity, increased blood flow to targeted area (thereby improving tissue quality)

68
Q

Types of vaginal laser therapy available (2)

A

CO2, erbium

69
Q

Improved subjective measures associated w/ vaginal laser therapy use (3)

A

VV sxs (including improved Vaginal Health Index measurements), subjective GUSM sxs, sexual function

ACOG Pub Review (6 decks)

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