2025 Urogynecology for the Advanced Practice Provider-Urogyn/GSM Considerations in Patients with History of Breast and GU Cancers

Video Transcription

Jessica Bell. We actually met quite a few years ago at this conference, so this could be you if you guys wanted to talk. And so, she's a board-certified physician assistant  specializing in urogyne and sexual medicine in Corvallis. She's a Menopause Society certified  practitioner and a fellow of the International Society for the Study of Women's Sexual Health.  She's also a Healthy at Every Size registered practitioner. In addition to urogyne, she manages sexual medicine, pelvic and sexual pain, and vulvar concerns. And her expertise  includes treating hormonal symptoms during the menopause transition. She is an LGBTQIA positive, King positive, and trauma-informed provider.  Thank you so much for having me. It is an honor to be here. Thank you for the invitation, Carissa. And what a perfect talk to follow. We are similar people. I have vulva pictures.  I'm so grateful that you laid the groundwork for the vestibule, retracting the clitoral hood, and fighting steroid phobia. Like, same, same. So, okay. Well, today I'm going  to chat with you about GSM considerations in patients with a history of breast and gynecological  cancers. I have no financial disclosures. So, first of all, what is genitourinary syndrome  of menopause? So, this is urinary urgency, frequency, incontinence, dryness, pain, itching,  groaning, decreased blood flow or vasoconstriction, decreased arousal, orgasm, sensation changes,  pH changes, vaginal infections, and urinary tract infections, often recurrent urinary tract infections. So, this is important to us. In fact, at my next talk, I'll talk more  about sexual dysfunction specifically. But sexual dysfunction is common in women with incontinence. Approximately 46% of people report bothersome symptoms. So, today's objectives  will understand better what is female sexual medicine, how does it apply to urogynecology  and cancer. We'll also talk about the biopsychosocial approach, and we'll learn how to evaluate  and treat genitourinary syndrome of menopause in patients with a history of cancer. Some of this I'll go into more detail at my 1 p.m. talk. So, this is important because providers  get little training in sexual health, but it is definitely a common concern. Half of medical schools report offering only 3 to 10 hours of sexual health curriculum, but  44% of women report distress. When they look for help, they're looking to you. So, they're  going to their gynecologist, their urogynecologist, or their primary care provider. And guess  what? Urinary and bladder symptoms involve the tissues, particularly the vestibule. Okay, so the big why. The WHO describes sexual health as fundamental to the overall health  and well-being of individuals, couples, and families, and to the social and economic development  of communities and countries. Sexual health, when viewed affirmatively, requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility  of having pleasurable and safe sexual experience, free of coercion, discrimination, and violence.  So, where did I get this training? At ISHWISH. I have to mention this because we need you. Women's urge incontinence is associated with increased rates of sexual dysfunction. Cancer  impacts urogyne patients, and they want their concerns addressed. Concurrent screening is definitely warranted in your patients. So, come get involved with us. Here's the real  why. So, when I got into this, it was out of patient need, right? It was people coming into my practice expecting me to have the answers, and I did not have them to start.  I'll talk about some specific patient experiences, particularly Nancy, who wanted me to use her  name, and she wanted me to tell you guys that vaginal estrogen and her oral medication for overactive bladder has saved her life. Her husband experienced prostate cancer, and during  that journey, there was a lot of focus on his sexual function, a lot of conversations and plans for that, and she was there for him for that. When she experienced breast  cancer, she did not get the same care, and that was very frustrating for her and to him.  Her story is throughout this. So, here's some statistics. Eighty-seven percent of patients in a radiation oncology clinic reported that cancer treatment impacted sexual function  or desire. Twenty-seven point nine percent reported ever formally being asked about sexual  health. Compared with men, women with cancer are less likely to be asked about sexual health by their medical teams. This is consistent across the board. Current data reflects the  lack of attention paid to sexuality after cancer and disparities between genders. Symptoms  related to genital urinary syndrome and menopause are very common in breast cancer survivors,  both pre- and post-menopausal, especially those that have been on tamoxifen or an aromatase  inhibitor. And I would say also right now with some of the cancer prevention recommendations for people with non-breast cancer lesions, they are being put on tamoxifen and aromatase  inhibitor, or tamoxifen, preemptively. So, this is also happening in people that don't have an actual history of breast cancer. So, it is estimated that more than two million  U.S. survivors of breast cancer are affected by GSM, with most of them not receiving any treatment or conversation around this. And that's like the timeout, right? We need to  change that. Here's some more of the why. This is Nancy's quote, actually. The pain and dryness led us to not holding hands anymore. Now, we could digress a lot on communication  and all sorts of things, right? But for her, holding hands led to something else, and she found herself kind of even shying away from that intimate connection. Here's some other  things that my patients have told me. I want to be comfortable. I want that connection, and I don't want him to be scared to touch me. Here's another one. I couldn't care less  about sex. I might want to someday, but right now, my skin is so uncomfortable. I feel like I'm tearing when I wipe. I'm getting UTIs, and I swear my vagina is closing shut. I'm  not sexually active with anyone. I never want to be again. In fact, I don't even want  a relationship, but I want a positive relationship with my body again. So these people, honestly,  they just want comfort. All right. And on Saturday, I'll talk more about this, but in places with limited resources, sometimes we need to create them. So I created a one-day  retreat to really provide a holistic approach to people that have experienced cancer. Okay. So where do we start with this? I mean, we start by asking, and I often ask the question,  are you sexually active with yourself or others? Again, when you ask a person if they're just sexually active, they're often going to say no, particularly somebody with a history of  genital urinary syndrome or menopause. They may not be sexually active because of the severe pain  that they've been experiencing, right? So here's a sexual symptom checklist on the left, and then  we also have some stepwise approaches for asking these questions. And again, I'll go into more  detail at the 1 p.m. talk, but there's a four-step model. So in the beginning, you just elicit the  patient's story, right? You know, what is their story? And identify the problem. Also, what are  their goals? I often say your goals are my goals. Witness them, listen to them, and then evaluate,  treat, or refer. So pain. Pain is often a primary concern. These tissue changes, again, they result  in pain at rest, not just pain with intimacy. Post-surgical changes can impact our patients with a history of cancer. They can have scar tissue lines that are painful. They can have  medication side effects. They might have a baseline of tissue issues, right? So they might be entering their treatment with a baseline of low estrogen effect or like in sclerosis  or you name it. So they might have a baseline of tissue issues, and then they get treatments  that worsen this. They can often have hypertonic pelvic floor, hypotonic pelvic floor. Pelvic  floor dysfunction in general is very common. The location of pain is important. So that's  that talk again about the anatomy, the difference between the vestibule, clitoris, vulva versus  urethra. And also the honoring that pain leads to more pain, right? This is a cycle, so it  persists and it gets worse. So when I address this, I address this from what we call a biopsychosocial  approach. This is Western medicine's whole person approach to sexual health. So I consider  biology, hormones, baseline, medical conditions, and then everything else, the psychosocial  approach, society, culture, religion, relationships, lack of education. And then I often tell my  patients that this can be complex, but it's not overly complicated. And again, your goals  are my goals. This is a pretty, lots of words on this slide, but here's some detailed information  about symptoms related to genitourinary syndrome of menopause, and then some options for treatment.  So vaginal estrogen is pretty much gold standard. It's safe to use. I'll share the safety data here in just a moment. But the predominant concern regarding genitourinary syndrome of  menopause for sexually active people are the reduction of lubrication and dyspareunia, loss of libido, arousal, bleeding, and again, just discomfort overall. And we do have great  safety data on this. Oncologists do support the use of local hormone treatment, local, that's to emphasize that, for treatment. And I would say that is, again, we'll share the  data here in a moment. Years and years ago, when I would go to conference and I knew about  the safety, I would come back to my institution, talk to the oncologist, and they were kind of like, okay, yeah, I think it's going to be okay. Now they all know it's okay because  we've got good data. So we already talked a little bit about anatomy, but yes, the vestibule is important. The vestibule is not the same as the vulva. The nose is on the face, but  it's not the same as the mouth, right? So again, location of discomfort is important. Here's a handful of clinical pearls when it comes to using the medication. I agree,  a pea-sized amount is not enough. I often, again, when I'm counseling patients, we kind of commiserate about, you know, your vulva's different than another person's, and you might  need to use more than another person's, right? So that can sometimes get tricky when we're  trying to write prescriptions to the pharmacist and they're having issues with early refills. But when it comes to location of application, I often just tell people, throw away the  plastic applicator. Make sure that you are applying the estrogen cream to the vulva, the vestibule, and the urethra. When a person uses the plastic applicator, they're often  just going, like, right past where they need the medication. Not always, but often in my clinic that's what I see. I also often see that tablets don't work as well at the urethra  or vestibule, right? So a lot of my people that use vaginal estrogen tablets, as if it just kind of gets plunked inside there, and you do the speculum exam, there's a bit of  estrogen effect, but that's not often realized at the clitoris, labia, vestibule, or vulva,  and that's often the place where they're having pain and discomfort at rest, as well as with sexual activity if they are intimate. And the benefit, I would say, of the cream, too,  is we do have a generic formulation that is economical, right? So if a person's insurance does not cover their localized hormones well, they can typically use a coupon or send it  to a coupon-type pharmacy. Another pearl is that systemic estrogen does not always penetrate the tissue level, right? So if your patients have a history  of estrogen receptor positive breast cancer, they're not gonna be on systemic hormone therapy. But we're not only talking about that, right?  We're talking about other cancers as well. So some of your people might be on systemic hormone therapy that may not be working at the clitoris, the labia, or the vestibule.  And you can add estrogen cream into somebody's regimen if they are on systemic hormone therapy. Again, we know that vaginal estrogen works very locally at the tissue level,  so it is not additive or cumulative to the systemic medication that they are on.  Another little clinical pearl is that if they're non-responsive to vaginal estrogen cream alone, you could consider a combined estrogen-testosterone cream.  The vestibule has a good amount of androgens in it, so for my people that are not responding to estrogen cream alone, and I think that there's a hormonal component,  I might try an estrogen-testosterone cream.  All right, so some other things that we might use in a person with a history of cancer would be non-hormonal moisturizers. I need Vaseline on here.  But these were taken actually from, I think it's the Memorial Sloan Kettering Institute Cancer Center. These are some of the non-hormonal moisturizers  and vulvar balms that they recommend.  Laslabia.com is an excellent resource for people that have a lichen sclerosis. People with lichen sclerosis geek out a lot on vulvar balms and non-hormonal moisturizers.  We often need to use dilators, right? So if a person has had radiation, again, sometimes the medications that they're using for cancer might actually contribute  to a shortening of the vaginal canal or stenosis of the opening. And so I always try to see patients on their cancer journey early so that we can talk about anticipatory guidance,  tissue changes, body integrity changes that might occur, and also discuss dilators as well in case they might need to use those. And it's also important to know  that the scarring and vaginal stenosis can occur up to at least a year after radiation. So it's not only, they're not out of the woods yet.  There's some other devices on here that are often helpful for our patients. So the O-Nut device is a bumper for the penis, so that prevents deep penetration.  And that can be an excellent toolbox for a person that has a shortened vaginal canal secondary to their surgical treatments.  We also discuss sexual aids. I often say these are teammates, not competitors, right? And so sometimes when a person has experienced cancer,  again, different things go on in the pelvis, they might not be able to be intimate the way that they were previously. And so we can talk about expanding sexual repertoire.  Sexual aids can be helpful for relaxing the pelvis as well, maybe helping with some insertional pain.  I'll let you guys read this slide on your own, but this, I also often say all the lube all the time. So no lube, shame. Even if a person has good estrogen effect  or good hormone effect and no tissue issues, all the lube all the time. It decreases friction, improves pleasure. And this is derived, Sarah is the vagina whisperer.  She's a pelvic floor physical therapist that's a rockstar.  Okay, so safety and vaginal estrogen. So I really geek out on this stuff. I geek out on the data, the mechanism, and how things are absorbed, right?  So sometimes I'll also use analogies with my patient,  which these analogies are an overgeneralization, but they can be helpful for understanding, right? So I often say, right, so oral estrogen, not the same as estrogen on the skin.  Similar to if you take a Benadryl, you might need to take a nap, but if you just put Benadryl on your mosquito bite, it's just going to improve the itch.  Or prednisone, a big systemic steroid, not the same as steroid on the skin, right? So that sometimes can help people understand why the vaginal estrogen that I'm recommending  is different and safe for them to use, particularly if they have a history of estrogen receptor-positive breast cancer.  So when people study this, they study also the different receptors. We see that estrogen receptors are highest in the vaginal canal and lower at the vulva and vestibule.  Also a reason why sometimes location of application is important if there's any caution.  And remember, we are using this not only to treat symptoms of discomfort, but we're also honoring the portion of urinary tract infections when it comes  to genitourinary syndrome and menopause, right? So GSM causes UTIs. This is a pretty recent article that Rachel Rubin was a part of.  This is actually regarding a cost-savings analysis of using estrogen to prevent UTIs in women.  So here's some of that data. I've got a few articles here for you.  So vaginal estrogen therapy and survival in females with breast cancer. We see in this cohort of 49,237 females with breast cancer, there is no evidence of an increase  in early breast cancer-specific mortality with the use of vaginal estrogen therapy compared with non-hormone replacement therapy after breast cancer diagnosis.  Okay, here's another study, a large-scale study, which again showed no increased risk of breast cancer recurrence within five years in women with a personal history of breast cancer  who were using vaginal estrogen for genitourinary syndrome and menopause.  And here's ACOG committee opinion.  This is going to be updated. This is from 2016.  So we know the data does not show an increased risk of cancer rates among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer  use vaginal estrogen to relieve urogenital symptoms. Among women with a history of estrogen-dependent breast cancer who are experiencing urogenital symptoms,  vaginal estrogen should be reserved for those patients who are unresponsive to non-hormonal remedies. That is the portion that we anticipate being updated.  It's no longer the case that we need to try non-hormonals  for a long period of time before going to estrogen.  So here are some interventions that the American Society of Clinical Oncology Clinical Practice recommends. Again, I hear that this is going to be updated as well.  This is from 2018. So always addressing it from this biopsychosocial approach. Honoring the psychosocial, psychosexual counseling should be offered to people.  Medical and treatable contributing factors should be identified and addressed. In women with symptoms of vaginal vulvar atrophy, lubricants in addition to moisturizers  should be tried as a first option. Low-dose vaginal estrogen, lidocaine, and DHEA may also be considered in some cases. Again, my oncologist friends say that that part is changing.  Only doing the vaginal moisturizers as the first, first option.  So again, I'll talk about I think this more at the 1 p.m. talk. But in general, again, when I'm addressing a full spectrum of sexual health concerns  in my patients with a history of cancer, of course I'm addressing the tissue issues, the discomfort at rest, the recurrent urinary tract infections,  vaginal infections, incontinence, urgency and frequency that comes up. But we also address their other concerns as well.  This is a summary that I will give to you in more detail at the 1 p.m. talk as well.  At 1 o'clock, we will go into more detail about what is arousal, desire,  and the biopsychosocial approach.  But in summary, we see a problem here, right? Symptoms related to genitourinary syndrome and menopause are common in breast cancer survivors, both pre and post-menopausal,  especially those treated with tamoxifen or an aromatase inhibitor. Estimates are that 60% of post-menopausal breast cancer survivors  and 40% of pre-menopausal breast cancer survivors have GSM. It's estimated that more than two million U.S. survivors of breast cancer are affected by GSM,  with most of them not receiving any treatment. And we also have a solution. We know that this is treatable. Vaginal estrogen is gold standard, it is safe to use.  Non-hormonal moisturizers are a tool. They can be considered first, but make sure that you have a conversation  about the safety of local hormone treatment as well, and arrange some follow-up.  Lubricants always, dilators for some people, pelvic floor physical therapy always, all the time. They are also my favorite people in the world.  A holistic approach always as well. When we talk about how this has impacted their intimacy with themselves or a partner, that's when I talk about things like sensate focus,  and non-goal-oriented intimacy. It's also good to validate their concerns. Let them know that this is common. They're not alone, right?  Ask, ask them. Ask them if they're uncomfortable, at rest, what their goals are. Also, consider their future goals. That's something that I think should be honored  and emphasized as well, right? When we are seeing a person, we're seeing them right there in that moment, but they've got a lot of life ahead of them, right?  And so we should both honor their issue right there, but also talk about the future as well, right? For example, I had somebody that was not sexually active.  Her clinician knew she wasn't sexually active, and so never offered any sort of treatment for her GSM and the vaginal stenosis that was occurring.  She then got in an intimate relationship that she was really excited about and very disappointed to find out that she had severe vaginal stenosis and atrophy,  and that it was going to take a lot of work for her to meet her goals of comfortable intimacy.  So now you are educated on this. You can prescribe with confidence, I hope. And another thing I wanted to mention is some future considerations.  So I was a part of a study considering broadening the term for genitourinary syndrome of menopause to be more accurate across diverse populations.  So we see that genitourinary syndrome happens in a lot of different populations, not just menopause, right? I also deal with hormonally mediated vestibulodynia, right?  Or yes, some of my transgender patients have these symptoms as well. And picking the diagnosis code of GSM or using the language genitourinary syndrome of menopause  is often confusing. So here's some of our recommendations for considering changing this language to be more conclusive or inclusive. So it may be in the future,  genitourinary syndrome of cancer treatment and prevention, honoring that hormone-blocking therapies for breast cancer and endocrine treatments  cause significant hypoestrogenic states resulting in GSM-like symptoms.  All right, and those are my references. Thank you.

Video Summary

Jessica Bell, a board-certified physician assistant specializing in urogynecology and sexual medicine, outlines critical aspects of genitourinary syndrome of menopause (GSM), particularly for patients with a history of breast and gynecological cancers. Bell emphasizes the need for addressing GSM's symptoms, which include urinary, vaginal, and sexual health issues. Many medical schools offer limited sexual health training, yet 44% of women report sexual health distress and seek help from gynecologists or primary care providers.<br /><br />Bell highlights the significant impact of GSM on cancer survivors, noting that many aren't receiving treatment despite being affected. Vaginal estrogen is presented as a safe and effective treatment, even for those with estrogen-receptive cancers. She stresses a biopsychosocial approach to treatment, including both hormonal and non-hormonal methods, dilators, and pelvic floor therapy. The talk underlines the importance of holistic care and future-oriented planning for sexual health in cancer survivors.

Asset Subtitle

Genitourinary Syndrome of Menopause or Genitourinary Syndrome of Cancer Treatment & Prevention? “Tissue issues” can worsen with cancer treatments and be uncomfortable personally and intimately.

New nomenclature proposed to reflect a more inclusive term to enhance diagnostic accuracy for providers and understanding for patients.
The biopsychosocial approach to cancer treatment includes honoring “tissue issues” and the constellation of symptoms that arise. Cancer treatments and genitourinary symptoms are almost inevitable. Many patients start with a baseline of post menopausal tissues worsening GSM. The symptoms can be intolerable personally and impossible intimately.
There are safe non-hormonal and hormonal treatments. In this lecture we will review the literature and individualized approach to caring for this patient population including nuances of dosing and the clinical exam. The role of dilators, sexual aides and pelvic relaxation tools.
Mind, Body, Sexual Health & Cancer Retreat; a multidisciplinary approach to empowered patient education. Coordinate with professionals you know to bring this one day event to your community.

Speaker - Jessica Bell PA-C, MSCP, IF

Keywords

genitourinary syndrome of menopause

sexual health

cancer survivors

vaginal estrogen

biopsychosocial approach

pelvic floor therapy