Summary
Urogenital atrophy affects more than half of women after breast cancer (BC) and in this population there is reluctance to use local estrogen. Therapies free of hormones such as intravaginal laser and hyaluronic acid suppositories have shown to produce symptom relief in women with BC and urogenital atrophy. However, they have not been tested against each other. In sense, recently, Gold et al. [1] have published data of randomized controlled trial aimed at comparing these non-hormonal modalities in women with urogenital atrophy after BC. They randomly assigned 43 women (aged 49-58 years, mean 54) with urogenital atrophy and a history of BC to receive intravaginal laser therapy (n=22, 2 courses within 1 month) or hyaluronic acid suppositories (n=21, 3 times/week continuously for three months). Their primary endpoint was the score of the Vaginal Health Index (VHI) after 3 months. Secondary endpoints were subjective bother on a numeric rating scale for all urogenital atrophy domains, quality of life, sexual health and pelvic organ prolapse symptoms using validated questionnaires. After 3 months VHI scores improved significantly in both groups, without significant differences observed between treatment groups. Significant improvement was also seen in both groups for subjective bother of urogenital atrophy, quality of life and sexual health, without significant differences seen between both groups. The authors conclude that both, intravaginal laser therapy and hyaluronic acid suppositories, were effective treatment options for women after BC suffering from urogenital atrophy.
Commentary
Vulvovaginal atrophy (VVA) is an involution of the mucous membranes and tissues of the vulva and vagina caused by the decrease of estrogen that occurs in women during the menopausal transition [2,3]. These modifications are commonly associated with the absence of sexual activity and/or with female sexual dysfunction [4,5]. Patients with VVA complain of vaginal burning and discharges, itching, dryness, irritation, dysuria and dyspareunia [6]. The management of vulvovaginal atrophy is a major issue for postmenopausal woman, and especially for women with co-morbid conditions like BC. Indeed, women who are treated for BC with chemotherapy or anti-hormonal therapy, symptoms have been reported to be worse [7]. Urogenital atrophy affects >50% of women after BC and there is reluctance to use local estrogen in all these patients. Despite different available treatments, the eradication of the problem is not feasible with the current available options. In the present commented study, Gold et al [1], reported data of 43 women (aged 49–58 – mean 54) with urogenital atrophy and a history of BC that received intravaginal laser therapy (2 courses within 1 month) or hyaluronic acid suppositories (3 times/week continuously for three months). The authors [1] found that after 3 months VHI scores improved significantly in both groups, without significant differences observed between treatment groups. Significant improvement was also seen in both groups for subjective bother of urogenital atrophy, quality of life and sexual health, without significant differences seen between both groups. The increased number of elastic fibers after laser treatment for skin rejuvenation has been previously reported. Studies have described the improvement in epithelial atrophy, enhanced cellularity, increase of spindle cells (fibroblasts and myofibroblasts) and neovascularization [8]. On the other hand, hyaluronic acid stimulates the synthesis of collagen and elastin, that would improve vaginal mucous dryness. The results of Gold et al. [1] seem to favor, hyaluronic acid as a similar option to laser treatment. Indeed, at 3 months the VHI score had improved significantly in both groups. Significant improvement was also seen in both groups for subjective bother of urogenital atrophy, quality of life and sexual health, without significant differences between laser or hyaluronic acid therapy. This study shows a significant improvement of any urogenital atrophy related symptom, both after treatment with intravaginal laser and hyaluronic acid suppository therapy with no differences observed between treatment groups.
Vaginal dryness and dyspareunia were found to be the most bothersome symptoms, which is in accordance with a recent systematic review [9]. In one study, Salvatore et al. [10], published one of the first papers regarding the treatment of urogenital atrophy with a CO2 laser with significant improvement after 12 weeks. CO2 laser has also been investigated for the treatment of urogenital atrophy in women with BC, and similar to the data of the present commented paper, showed a significant improvement of symptoms [11]. In this study, the conclusion was that in BC survivors with the genitourinary syndrome of menopause, female sexual function improved after fractional CO2 laser therapy. Regarding urinary incontinence, it might be necessary to better analyze data in detail to determine whether treatment was successful or just statistically meaningful. Further research will be needed in this regard.
A limitation of the present commented trial [1] is the relatively short follow-up. Further studies will be needed to evaluate long-term results. At least three laser sessions are needed for best results, and studies should demonstrate the utility of the long-term actions of the laser versus the local administration of hyaluronic acid, as well as side effects.
Iván Altamirano-Barcia, MD, MSc
Professor of Obstetrics & Gynecology
Facultad de Ciencias Médicas
Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
References
- Gold D, Nicolay L, Avian A, et al. Vaginal laser therapy versus hyaluronic acid suppositories for women with symptoms of urogenital atrophy after treatment for breast cancer: A randomized controlled trial. Maturitas. 2022;167:1-7.
https://pubmed.ncbi.nlm.nih.gov/36279690/ - Castelo-Branco C, Cancelo MJ, Villero J, Nohales F, Juliá MD. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas. 2005;52:S46-52. https://pubmed.ncbi.nlm.nih.gov/16139449/
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https://pubmed.ncbi.nlm.nih.gov/19602990/ - Simon JA. Identifying and treating sexual dysfunction in postmenopausal women: the role of estrogen. J Womens Health (Larchmt) 2011;20:1453–65.
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https://pubmed.ncbi.nlm.nih.gov/18378532/ - Zerbinati N, Serati M, Origoni M, et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci. 2015;30(1):429-36.
https://pubmed.ncbi.nlm.nih.gov/25410301/ - Knight C, Logan V, Fenlon D. A systematic review of laser therapy for vulvovaginal atrophy/genitourinary syndrome of menopause in breast cancer survivors. Ecancermedicalscience. 2019;13:988.
https://pubmed.ncbi.nlm.nih.gov/32010212/ - Salvatore S, Nappi RE, Zerbinati N, et al. A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study. Climacteric. 2014;17(4):363-9.
https://pubmed.ncbi.nlm.nih.gov/24605832/ - Quick AM, Zvinovski F, Hudson C, et al. Patient-reported sexual function of breast cancer survivors with genitourinary syndrome of menopause after fractional CO2 laser therapy. Menopause. 2021;28(6):642-649.
https://pubmed.ncbi.nlm.nih.gov/33534429/
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