Efficacy of injecting platelet concentrate combined with hyaluronic acid for the treatment of vulvovaginal atrophy in postmenopausal women with history of breast cancer: a phase 2 pilot study

Hyaluronic acid injection to treat symptoms of vulvovaginal atrophy in postmenopausal women: A 12-week randomised, placebo-controlled, multicentric study

OBJECTIVE

To evaluate the efficacy and safety of a single injection session of cross-linked hyaluronic acid gel for vulvovaginal atrophy, versus placebo.

DESIGN

Two-step study comprising a 12-week randomised, placebo-controlled, single-blind phase, followed by an open-label phase. Eligible postmenopausal women with vulvovaginal atrophy were randomised (2:1) to a single injection session of either hyaluronic acid or placebo. This is the report of the single-blind phase.

MAIN OUTCOME MEASURES

The primary outcome was the mean change in the severity score for the most bothersome symptom at 12 weeks compared with baseline. Secondary outcomes included differences in scores for individual vulvovaginal atrophy symptoms, score on the Female Sexual Function Index and vaginal pH.

RESULTS

A total of 116 of the 117 patients in the randomised population contributed outcome data to the study (79 receiving hyaluronic acid and 37 placebo). Compared with baseline, the mean score for the severity of the most bothersome symptom was significantly reduced in the hyaluronic acid arm at 12 weeks (between-group difference [95 % confidence interval]: -0.58 [-1.01; -0.16], p = 0.008). Similarly, there were significant reductions in mean scores for dryness (-0.87 [-1.27; -0.47]; p < 0.001) and dyspareunia (-0.65 [-1.09; -0.21]; p = 0.004) and improvement in score on the Female Sexual Function Index (3.81 [0.91; 6.72]; p = 0.011) in the hyaluronic acid group. There were no differences in itching/irritation, pain or vaginal pH in either group. Hyaluronic acid treatment was well tolerated.

CONCLUSIONS

A single injection session of cross-linked hyaluronic acid is effective in reducing vulvovaginal symptoms and sexual dysfunction compared with placebo at 12 weeks, making it a suitable management option for moderate to severe vulvovaginal atrophy symptoms.

TRIAL REGISTRATION

NCT04219722 (https://clinicaltrials.gov/study/NCT04219722).

Bibliometric Analysis of Platelet-Rich Plasma Treatment for Hair Restoration, Facial Rejuvenation, Dental Procedures, and Gynecological Rejuvenation

Introduction

Autologous platelet-rich plasma (PRP) technologies offer an attractive treatment option for various medical fields. Owing to its high concentration of growth factors, PRP has been posited to induce proliferation, differentiation, and angiogenesis at the cellular level, as well as wound-healing and remodeling at the tissue level. The goal of the present bibliometric analysis was to characterize the growing body of literature concerning PRP use in various medical applications.

Methods

A comprehensive literature search was performed on June 28, 2024, using Web of Science and SCOPUS databases, covering all available publications in selected categories from 2001 to present.

Results

PRP use for hair restoration had both the greatest number of total publications among the investigated applications, whereas PRP use in dental procedures had the longest-standing history of publications. PRP use in hair restoration and facial rejuvenation had the greatest number of placebo-controlled and double-blinded randomized controlled trials; however, the impact of results may suffer from a lack of consistency in PRP preparation and outcome measurement between different studies.

Conclusion

To effectively validate the utility of PRP across various medical interventions, careful consideration of methodology should be undertaken for future studies to ensure validity of results.

Cannulated intravaginal injection technique (CIVIT) A Novel Vaginal Injection Technique

Non-surgical procedures such as fillers, PRP and derivatives, energy-based devices and adipose derivate mesenchymal stem cell treatments are begun to be used in women genital area for both functional and aesthetic purposes. After theproduction of injectable HA for genital use, patients were able to benefit more effectively from these applications and its use in the vagina became more common. In our study, we aimed to demonstrate a new intravaginal injection technique, Cannulated Intravaginal Injection Technique (CIVIT) that we can perform vaginal injection more homogenously and less traumatic and more effectively to the entire vaginal mucosa. Retrospectively, the data of 44 patients who underwent intravaginal injection of HA manufactured for genital use at a private Female Health Clinic were analyzed. Of the 44 patients, 21 were injected using the random needling technique, and 22 were injected using CIVIT. All patients had symptoms of genitourinary syndrome (GUS), a vaginal health index below 15, and were compared based on the Female Sexual Function Index (FSFI) and visual analogue scale (VAS) for GUS before and after the procedures. It was observed that all post-injection values, except for FSFI arousal (p = 0.539), were statistically significantly higher in the CIVIT group (P = 0.001). Post injection dryness, dyspareunia and discomfort values decreased significantly in the CIVIT group compared to the Random Needling group. Our new technique, CIVIT, and random injection, which is a frequently used technique, are two effective techniques for vaginal rejuvenation. However, CIVIT is significantly more effective than the random technique in improving genitourinary symptoms, vaginal health index and sexual function.

Optimizing the regenerative potential of vaginal fibroblasts: The role of autologous platelet-rich plasma and hyaluronic acid in vitro

OBJECTIVE

Many postmenopausal women suffering from vulvovaginal atrophy are looking for non-hormonal treatments. Platelet-rich plasma (PRP) therapy has emerged as a novel and promising approach for gynecological applications. PRP is an autologous blood product rich in growth factors used to stimulate tissue regeneration. On the other hand, hyaluronic acid (HA) is used as a treatment for vaginal dryness as it improves tissue hydration thanks to its strong capacity to retain water. This study examines the in vitro effects of PRP alone or combined with HA on vaginal fibroblasts (VFs) isolated from mucosal samples of postmenopausal women undergoing surgery for vaginal prolapse.

METHODOLOGY

Vaginal and blood samples were collected from postmenopausal women undergoing pelvic organ prolapse surgery. PRP was prepared alone or combined with HA (PRP-HA) from peripheral blood. Vaginal fibroblasts were isolated via enzymatic dissociation and cultured in 2D and 3D (spheroids) systems. Biological activities were assessed by measuring cell growth, proliferation, senescence, metabolic activity, and collagen accumulation, along with immunocytochemistry for (myo-)fibroblast markers.

RESULTS

VFs cultured with PRP or PRP-HA showed dose-dependent higher proliferation compared with the control condition, with increased S and G2M cell cycle phases correlating with enhanced proliferation. Expression of vimentin, a protein that plays a key role in maintaining cellular structure and function, was stable, while alpha-SMA decreased, indicating a shift from myofibroblasts to fibroblasts. Collagen production, crucial for wound healing and tissue regeneration, increased under PRP or PRP-HA treatment. PRP and PRP-HA also prevented cell senescence in long-term low-density cultures. These findings were consistent across 2D and 3D culture systems.

CONCLUSIONS

This study provides in vitro evidence supporting the potential of PRP and PRP-HA as autologous treatments for vaginal rejuvenation.

Beyond cancer treatment: dermo-aesthetic and other wellness recommendations for breast cancer patients

Breast cancer, a prevalent malignancy among women, has various physical and psychological impacts. This comprehensive review offers an in-depth look at multidisciplinary dermo-aesthetic intervention approaches, emphasizing the balance between oncological therapies and the management of these effects. The information presented spans specialties such as aesthetic medicine, plastic surgery, dermatology, physiotherapy, nutrition, odontology, and gynecology. This review, which serves as a clinical guide, aims to establish a safe protocol for non-medical interventions involving oncologists, physicians, and specialists from various areas in patients with breast cancer focused on improving their quality of life. This work offers personalized and integrative care strategies for the eradication of cancer. However, it is still necessary for patients to consult with their oncologist before undergoing any dermo aesthetic treatment. However, it is still necessary for patients to consult with their oncologist before undergoing any dermo aesthetic treatment.

Effect of Vaginal Laser and Topical Therapies on Vulvovaginal Atrophy Symptoms in Breast Cancer Patients: A Systematic Review and Meta-Analysis

Background: Vulvovaginal atrophy (VVA) significantly impacts the quality of life in breast cancer patients leading to symptoms like vaginal dryness, dyspareunia, and genital discomfort. Quality of life in this context is measured using validated scales like the Vaginal Health Index, Visual Analog Scale (VAS), and the Female Sexual Function Index (FSFI). Methods: We performed a systematic review and meta-analysis to identify effective treatment options for VVA, including topical estrogen, systemic hormone therapy, vaginal DHEA, ospemifene, and non-hormonal methods like intravaginal laser therapy, moisturizers, and lubricants. A systematic search of four databases (MEDLINE, Scopus, CENTRAL, Embase) identified studies on VVA treatment efficacy in breast cancer patients, yielding 13,039 records, with 32 eligible studies and 8 included in the meta-analysis. Results: Significant improvements were found with intravaginal laser therapy, showing notable differences in the Vaginal Health Index (MD = 8.24, p < 0.01), dyspareunia (MD = -4.82, p = 0.05), and dryness (MD = -5.05, p = 0.01). However, no significant changes were observed in FSFI and vaginal pH. Notably only intravaginal laser therapy was included in the meta-analysis, as other treatment options lacked comparable data. Both hormonal and non-hormonal treatments improved quality of life, with laser therapy showing the most substantial effects. Conclusions: Intravaginal laser therapy is an effective treatment for VVA symptoms in breast cancer survivors, particularly in improving the Vaginal Health Index and reducing dyspareunia. Despite the strengths of the study, variability among studies, lack of RCT-s and data limitations, especially on long-term effects, present challenges.

Vulvovaginal Atrophy Following Treatment for Oncogynecologic Pathologies: Etiology, Epidemiology, Diagnosis, and Treatment Options

Vulvovaginal atrophy, characterized by the thinning of vaginal mucosa typically resulting from reduced estrogen levels, is frequently exacerbated by oncogynecologic treatments such as chemotherapy, hormonal therapy, radiotherapy, or surgery. This condition significantly impacts the quality of life for cancer survivors, leading to persistent discomfort, heightened infection risk, and negative effects on sexual function and self-esteem. Despite being a relatively common complication, vulvovaginal atrophy is not always discussed before the start of treatment. Treatments typically mirror those used for natural menopause; however, efficacy and safety data specific to this population are limited due to the exclusion of these patients from clinical trials. A major safety concern is the risk of hormone-sensitive cancer recurrence associated with estrogen therapy, which drives a preference for non-hormonal alternatives. Newer treatments, such as laser therapy, radiofrequency, and vaginal injections, show promise with minimal side effects and hormone-independent mechanisms, though efficacy data varies, highlighting the need for further research. This narrative review explores the epidemiology, risk factors, diagnosis, and management of vulvovaginal atrophy after the treatment for oncogynecologic disorders.

The effects of various therapies on vulvovaginal atrophy and quality of life in gynecological cancer patients: a systematic review

PURPOSE

Tumors affecting the female genital tract and their treatments have the potential to induce adverse modifications in vaginal health and impact personal aspects of patient's lives. Vulvovaginal atrophy is one of the morphological changes observed in individuals with a history of gynecological cancer, influenced both by the biological environment of tumors and the main therapeutic modalities employed. Therefore, the purpose of this study was to identify approaches to treat vulvovaginal atrophy while assessing the impact on the emotional and sexual health of women diagnosed with gynecological cancers.

METHODS

To achieve this goal, a systematic review was conducted following the methodological guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The databases used for literature research were PubMed and Web of Science.

RESULTS

Initially, 886 articles were obtained. After eliminating duplicates and applying inclusion/exclusion criteria, seven articles were selected for analysis. The period of highest publication activity spanned from 2017 to 2020, with the majority conducted in Italy. Five treatment modalities were identified and categorized as vaginal suppository, oral medication, surgical procedure, CO2 laser therapy, and vaginal dilator. Twenty-four outcomes related to vaginal health and 30 outcomes related to overall, sexual, and emotional quality of life were analyzed.

CONCLUSION

In general, all interventions demonstrated the ability to improve vaginal health or, at the very least, the sexual health of patients. Thus, despite limitations, all treatments have the potential to address vulvovaginal atrophy in patients with a history of gynecological cancer.

Sexual Dysfunction and Dyspareunia in the Setting of the Genitourinary Syndrome of Menopause

Sexual dysfunction is a common consequence of the genitourinary syndrome of menopause (GSM). In this book chapter, we discuss the pathophysiology, prevalence, evaluation, and evidence-based management of sexual dysfunction in patients affected by GSM. Additionally, we present an algorithm to guide clinicians in the management and treatment of sexual dysfunction in this setting based on available evidence and best practices.

Genitourinary Syndrome of Menopause in Cancer Survivors

Genitourinary syndrome of menopause (GSM) encompasses the symptoms of estrogen deprivation in the vaginal, vulva, and bladder areas. Because many cancer treatments induce a hypoestrogenic state, GSM is common in cancer survivors. The number of cancer survivors is increasing, and the unique aspects of GSM management for cancer survivors, such as the safety of hormonal therapies, is important to understand. In this review, we cover important considerations in the assessment of GSM; nonpharmacologic, behavioral, integrative, pharmacologic, and medical device treatments for GSM: the unique considerations in GSM by cancer treatment modality; bladder manifestations of GSM; and GSM in specific populations.

Role of Platelet-Rich Plasma in Genitourinary Syndrome of Menopause

The genitourinary syndrome of menopause (GSM) encompasses a range of symptoms linked to the genitourinary tract stemming from the reduction in estrogen levels following menopause. These symptoms may endure throughout a woman's lifetime. Platelet-rich plasma (PRP), known for its capacity to induce angiogenesis and the restoration effects of growth factors, has been widely employed in various disorders, including GSM. This article aims to comprehensively review the existing literature on the utilization of PRP for managing GSM. The search was executed in electronic databases, specifically PubMed, Scopus, and Google Scholar, up until April 2023. Eligible studies were meticulously chosen for inclusion in this systematic review. PRP emerges as a viable alternative for addressing vaginal atrophy, exhibiting favorable outcomes. Notably, it can be considered for patients with contraindications to hormonal therapy. However, the available body of evidence supporting the use of PRP for GSM remains limited. PRP presents itself as a promising agent, offering a patient-friendly, cost-effective alternative modality. To establish the efficacy of PRP in treating GSM definitively, future randomized trials are imperative.

Injection Treatments for Vulvovaginal Atrophy of Menopause: A Systematic Review

BACKGROUND

Injection treatments have been proposed as novel treatment options for Vulvovaginal Atrophy of Menopause (VVA) also known as Genitourinary Syndrome of Menopause (GSM). However, to date data about these treatments are poor.

OBJECTIVE

To assess all available injection treatments for VVA.

METHODS

A systematic review was performed by searching five electronic databases for peer-reviewed studies that assessed injection treatments for VVA.

RESULTS

Eight studies (7 observational and 1 randomized) with 236 women were included. Assessed injection materials were: autologous platelet-rich plasma (PRP) + hyaluronic acid (HA), not cross-linked HA plus calcium hydroxyapatite (NCLHA + CaHA), micro-fragmented adipose tissue (MFAT), hyaluronan hybrid cooperative complexes (HCC), crosslinked HA, microfat and nanofat grafting + PRP, and PRP alone. Improvement in GSM symptoms after treatment was assessed through Visual Analogic Scale (VAS) for GSM symptoms or patient satisfaction, several validated questionnaires (FSFI, VHI, FSD, SF12, ICIQ UI SF, PGI-I, FSDS-R, VSQ), symptoms severity, changes in vaginal mucosa thickness, flora, pH, and expression on vaginal mucosal biopsies of Procollagen I and III and ki67 immunofluorescence or COL1A1 and COL3A1 mRNA. Injection treatments showing significant improvement in GSM-related symptoms were: (i) HCC in terms of VAS for GSM symptoms and FSFI score; (ii) Crosslinked HA in terms of VAS for GSM symptoms, FSFI and VHI score, COL1A1 and COL3A1 mRNA expression on vaginal mucosal biopsies; (iii) NCLHA + CaHA in terms of FSFI score; (iv) PRP + HA in terms of VHI, FSD and SF12 score; (v) microfat and nanofat grafting + PRP in terms of VHI score and FSDS-R score; (vi) PRP alone in terms of VHI and VSQ scores.

CONCLUSIONS

All assessed injection treatments except for MFAT seem to lead to significant improvement in VVA symptoms on validated questionnaires. Further studies are necessary in the field.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Improved sexuality and satisfactory lubrication after genital affirmation surgery using penile skin inversion in transgender women: A satisfaction study

INTRODUCTION

Genital affirmation surgery (GAS) requests are consistently increasing in demand. The gold standard is penile skin inversion, using cutaneous grafting for neovagina creation. The aim is to achieve the most realistic results both physically and functionally. Different studies have contradictory results, and the use of lubrication is insufficiently clear, while the use of sigmoidoplasty has been defended for constant lubrication.

AIMS

Our aim was to evaluate transgender women's sexual function and lubrication after vaginoplasty by penile skin inversion.

METHODS

We performed a prospective study on 45 patients who underwent primary penile inversion vaginoplasty. Participants answered two questionnaires during the follow-up consultation: the Female Sexual Function Index (FSFI) and an 18-item custom questionnaire.

RESULTS

The average FSFI score of our patients was 28.9, up to the cut-off defining a sexual disorder. Compared to the Wylomanski control group, no differences were found for the FSFI score and in the subgroups. Considering lubrication, 69% of the patients were satisfied or very satisfied with their lubrication. Furthermore, 53% reported a fluid release at each orgasm.

CONCLUSION

This study reported high satisfaction for both sexuality and lubrication, proning against penile inversion's GAS bad reputation concerning postoperative lubrication. A squirting effect was described for the first time and was present in 53% of our transpatients.

Efficacy and Safety of Platelet-Rich Plasma Injections for the Treatment of Female Sexual Dysfunction and Stress Urinary Incontinence: A Systematic Review

Introduction: There is no clear evidence in the literature that platelet-rich plasma (PRP) injections improve female sexual dysfunction (FSD) and female stress urinary incontinence (SUI). Objectives: A systematic review was performed to study the efficacy and safety of PRP injections in women with the above pathologies, as well as to explore the optimal dosing, frequency and area of injections, and duration of treatment. Methods: A systematic search on PubMed, Embase and the Cochrane Library database was performed, as well as sources of grey literature from the date of database or source creation to January 2023. After title/abstract and full-text screening, clinical studies on humans evaluating the efficacy of PRP in gynecological disorders using standardized tools were included. Risk of bias was undertaken with RoB-2 for randomized-controlled trials (RCT) and the Newcastle-Ottawa Scale (NOS) for observational studies. Results: Four prospective and one retrospective study explored FSD, while six prospective and one RCT evaluated female SUI. A total of 327 women with a mean age of 51 ± 12 years were included. For FSD, PRP significantly improved the Female Sexual Function Index (FSFI), the Vaginal Health Index (VHI) and the Female Sexual Distress score (FSDS). For SUI, PRP led to a significant improvement in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Urogenital Distress Inventory (UDI-6). The identified RCT reported a significantly higher mean score of ICIQ-SF (p < 0.05) and UDI-6 (p < 0.01) in the midurethral sling group compared to the PRP injections group. Regarding the risk of bias, the RCT was characterized by high risk, whereas the observational studies were of moderate risk. The protocol for PRP injections for FSD is the injection of 2 mL of PRP into the distal anterior vaginal wall once a month for 3 months. For female SUI, 5-6 mL of PRP should be injected into the periurethral area once a month for 3 months. Conclusions: Despite the promising initial results of PRP injections, the level of current evidence is low due to methodological issues in the available studies. It becomes clear that there is an emerging need for high-quality research examining PRP injections for the treatment of FSD and female SUI.

Comparable Efficacy of Submucosal Platelet-Rich Plasma and Combined Platelet-Rich Plasma Noncrosslinked Hyaluronic Acid Injections in Vulvovaginal Atrophy: A Cancer Survivorship Issue

Background: Cancer survivors are often reluctant to discuss sexual complaints with their oncologists and treatment is frequently unsatisfactory due to paucity of controlled studies and inapplicability of vaginal estrogen. We aimed to evaluate efficacy and tolerability of platelet-rich plasma (PRP) injections alone or in combination with noncrosslinked hyaluronic acid compared with standard therapy with topical hyaluronic acid gel in the management of cancer therapy-induced or aggravated vulvovaginal atrophy. Materials and Methods: This prospective, parallel-group comparative study was conducted on 45 female patients with a history of cancer and complaining of symptoms of vulvovaginal atrophy either induced or aggravated by cancer treatment. Patients were randomly divided into three groups (A, B, and C). Group A patients received two submucosal vaginal PRP injections, group B patients received two similar injections of PRP combined with noncrosslinked hyaluronic acid, and group C received a topical vaginal hyaluronic acid gel applied three times weekly for 2 months. Main outcome measures were vulvovaginal atrophy symptom severity and vaginal health index (VHI) scores before treatment (v0), 1 month from baseline (v1), 2 months from baseline (v2), and 3 months after the last visit (v3). Results: Both groups A and B showed greater improvement of frequency of intercourse avoidance than group C. Group A showed greater improvement of dyspareunia than group C. Groups A and B demonstrated greater improvement of vaginal pH, fluid volume, and total VHI scores than group C. Short-term topical hyaluronic acid (HA) was not associated with any significant improvement of vaginal elasticity. Group B showed greater improvement of vaginal dryness and moisture scores than group C. Reported adverse events were injection-related pain in all patients of groups A and B and vaginal spotting in groups A and B. Conclusion: Both PRP and PRP-HA have comparable efficacy and patient-reported treatment satisfaction. PRP injections were better tolerated by patients than PRP-HA. Clinical trial registration number: NCT05782920.

The Future of Breast Cancer Research in the Survivorship Field

Prevalence of survivors of breast cancer has been steadily increasing in the last 20 years. Currently, more than 90% of women diagnosed with early-stage breast cancer are expected to be alive at 5 years from diagnosis thanks to early detection and breakthrough innovations in multimodal treatment strategies. Alongside this advancement in clinical outcomes, survivors of breast cancer might experience several specific challenges and present with unique needs. Survivorship trajectories after diagnosis and treatment of breast cancer can be significantly impacted by long-lasting and severe treatment-related side effects, including physical problems, psychological distress, fertility issues in young women, and impaired social and work reintegration, which add up to patients' individual risk of cancer recurrence and second primary malignancies. Alongside cancer-specific sequelae, survivors still present with general health needs, including management of chronic preexisting or ensuing conditions. Survivorship care should implement high-quality, evidence-based strategies to promptly screen, identify, and address survivors' needs in a comprehensive way and minimize the impact of severe treatment sequelae, preexisting comorbidities, unhealthy lifestyles, and risk of recurrence on quality of life. This narrative review focuses on core areas of survivorship care and discuss the state of the art and future research perspectives in key domains including selected long-term side effects, surveillance for recurrences and second cancers, well-being promotion, and specific survivors' needs.

Sexual dysfunctions in breast cancer patients: evidence in context

INTRODUCTION

In breast cancer patients, endocrine therapy may exert a negative impact on sexual functioning in both genders, with potentially relevant consequences concerning quality of life and treatment adherence. The availability of effective interventions to maintain and/or restore sexual health in breast cancer patients is a key issue to a research agenda.

OBJECTIVES

To summarize and critically discuss the most updated and qualitatively relevant literature on the therapeutic approach to sexual impairment in breast cancer patients, with a focus on patients treated with endocrine therapy.

METHODS

We searched PubMed from its inception to February 2022 for observational and intervention trials including participants with sexual dysfunctions. We were particularly interested in studies of breast cancer patients with sexual dysfunctions while undergoing endocrine therapy. We developed a search strategy with the aim of maximizing the number of articles considered for screening and potential inclusion.

RESULTS

Forty-five studies were selected: 3 observational and 42 intervention studies. Thirty-five studies were exclusively focused on female breast cancer populations. We could not identify studies exclusively focused on or also including male breast cancer patients. Overall, in female patients, the available armamentarium encompasses vaginal lubricants, moisturizers, estrogens, dehydroepiandrosterone, CO2 laser, ospemifene, and counseling. None of these interventions has been demonstrated to completely solve sexual dysfunctions when singularly considered. More favorable outcomes have come from the combination of different therapies.

CONCLUSION

In female breast cancer, future research is oriented toward the gain of evidence on combined therapies and long-term data on safety issues on the most promising interventions. The lack of evidence on sexual disturbances in male breast cancer patients remains a major concern.

Autologous Platelet-Rich Plasma in Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: A Pilot Case Study

BACKGROUND

Postoperative healing after clitoral reconstruction (CR) for female genital mutilation/cutting can be long and painful due to prolonged clitoral re-epithelialization time (up to 3 months). Autologous platelet-rich plasma (A-PRP) might reduce postoperative clitoral epithelialization time and pain.

OBJECTIVES

The authors assessed postoperative clitoral re-epithelialization time and pain after intraoperative clitoral administration of A-PRP.

METHODS

Five consecutive women underwent CR (Foldès technique) followed by the administration of A-PRP Regen Lab SA (Le Mont-sur-Lausanne, Switzerland) plasma and glue, injected inside and applied above the re-exposed clitoris, respectively. We recorded surgical complications, postoperative clitoral pain (visual analogue scale), painkiller intake, time to complete re-epithelialization, and the experienced subjective changes in sexual response and perception of their own body image referred by women.

RESULTS

Sexual distress/dysfunction as well as the desire to be physically and symbolically "repaired" were the reasons behind women's requests for surgery. None of the women suffered from chronic vulvar or non-vulvar pain. All women achieved complete clitoral epithelialization by day 80, 3 women between day 54 and 70, and only 1 woman was still taking 1 g of paracetamol twice a day at 2 months postoperative. She had stopped it before the 3-month control. There were no short- or long-term complications. All women described easier access and stimulation of their clitoris as well as improved sexual arousal, lubrication, and pleasure and claimed to be satisfied with their restored body image.

CONCLUSIONS

A-PRP could expedite postoperative clitoral epithelialization and reduce postoperative pain after CR after female genital mutilation/cutting.

LEVEL OF EVIDENCE: 4

Efficacy of injecting hybrid cooperative complexes of hyaluronic acid for the treatment of vulvar lichen sclerosus: A preliminary study

BACKGROUND

Lichen sclerosus is a chronic relapsing inflammatory skin disease, which involves most commonly the anogenital region. The gold standard in treatment is ultra-potent topical steroids (clobetasol propionate): it aims at controlling the symptoms, stopping further scarring and distortion, and reducing the risk of cancer.

OBJECTIVES

The aim of this preliminary study is to evaluate the efficacy of injecting Hybrid Cooperative Complexes of Hyaluronic Acid (HCC) for the treatment of vulvar lichen sclerosus (VLS).

METHODS

Twenty female adult patients (range: 21-78 years), aged over 18, with histopathological diagnosis of lichen sclerosus and good general conditions were enrolled. Patients underwent HCC infiltration every month, for 3 times. Patients were evaluated at baseline (T0) and after one (T1) and six months (T2) after treatment. During every visit, each patient was studied clinically and with videothermography. Itching, burning sensation, pain, and dyspareunia were reported by patients at T0, T1, and T2. The effectiveness of the treatment on patients' quality of life and sexual function was evaluated using the Dermatology Life Quality Index (DLQI) and the Female Sexual Function Index (FSFI) at T0 and at T2.

RESULTS

The results of this preliminary study are very promising, in fact, all patients had a significant reduction in most symptoms after 1 and 6 months of HCC treatment. The reduction of patients with itching (p value ≤ 0.001), pain (p value = 0.031), and burning sensation (p = 0.004) at 6 months is significant. The analysis of DLQI scores revealed a significant improvement in patients' quality of life. At baseline, the average score of DLQI (±SD) was 5.89 ± 3.68 while at follow-up it was 3.42 ± 2.36 (p = 0.002).

CONCLUSIONS

Our preliminary study has demonstrated the validity and tolerability of HCC infiltrations in patients with VLS, and the effectiveness of HCC in reducing symptoms and, thus, to improve sexuality and patient quality of life.

Platelet rich plasma for the management of urogynecological disorders: the current evidence

PURPOSE OF REVIEW

Our objective is to review the currently available literature on the use of platelet-rich plasma (PRP) in patients with pelvic floor disorders and to critically appraise the latest evidence on the safety and efficacy of the PRP application.

RECENT FINDINGS

The evidence on the use of PRP for the treatment of stress urinary incontinence (SUI) appears promising, although limited to case series, case reports and animal studies. PRP has also been proposed to enhance the surgical outcomes of pelvic organ prolapse (POP) by native tissue repair with promising success rates. The application of PRP in other PFDs including vaginal fistulas, genitourinary syndrome of menopause (GSM), mesh exposure and lichen sclerosus has been also associated with beneficial outcomes and a favorable safety profile.

SUMMARY

The currently available literature indicates that PRP could have a beneficial effect as a single or adjuvant treatment in patients with SUI, POP, GSM, vaginal fistula and genital lichen sclerosus with minimal adverse events. However, valid evidence is still lacking and further well-designed studies are warranted in the field to confirm the validity of the so far reported outcomes.

Efficacy of interventions to manage sexual dysfunction in women with cancer: a systematic review

IMPORTANCE

Cancer and its treatment negatively affect female sexual health and function. The prevalence of female sexual dysfunction after cancer is between 33% and 43%. Numerous studies have addressed treatment options for sexual dysfunction in women with cancer, but it still remains a challenge to select the most efficacious option for patients.

OBJECTIVE

To compile and appraise recent evidence of any interventions for managing sexual dysfunction in female cancer survivors.

EVIDENCE REVIEW

A literature search of the electronic databases MEDLINE, EMBASE, PsycINFO, and Cochrane Central Register of Controlled Trials (January 2011 to February 2021) was conducted using general search terms of "women", "cancer", "intervention", "sexual dysfunction". We included randomized controlled trials (RCTs) and uncontrolled before-after studies that evaluated the efficacy of intervention for female sexual dysfunction in women with history of cancer. Methodological quality of studies was assessed using Risk of Bias (RoB) 2.0 for RCTs and National Institutes of Health (NIH) assessment tools for uncontrolled before-after studies.

FINDINGS

Thirty-six studies were included for qualitative synthesis (14 RCTs (n = 1284), 17 uncontrolled trials (n = 589), and 5 cohort studies (n = 497). Only four studies were at low risk of bias. Topical interventions (vaginal gels or creams) were able to alleviate vaginal dryness and dyspareunia, with intravaginal dehydroepiandrosterone (DHEA) (6.5 mg) gel showing evidence of improved sexual function. Evidence for estriol-lactobacilli vaginal tablets was unreliable due to a small-scale study. Psychoeducational therapy (internet-based cognitive behavioral therapy [CBT]) studies typically were at high risk of bias, but all displayed significant improvements of sexual function. Both laser therapy (fractional CO2 and erbium) and multimodal approach studies were at concerning risk of bias, although suggesting beneficial effects on sexual function.

CONCLUSIONS AND RELEVANCE

The most reliable evidence for improvement was from a study of DHEA vaginal gel, but in general, gels or creams were useful in reducing dyspareunia. Pharmacological, psychoeducational, laser therapy, and multimodal approaches demonstrated potential in managing cancer-related sexual issues, but most were small in size (10-70 participants), with moderate to high risk of bias. Therefore, large-scale, double-blind, RCTs with long-period follow-up, and at low risk of bias are needed to show efficacy for these interventions.

Efficacy of intradermal hyaluronic acid plus polynucleotides in vulvovaginal atrophy: a pilot study

OBJECTIVE

This study aimed to evaluate the safety and efficacy of vulvovaginal intradermal injections of polynucleotides (PN) combined with hyaluronic acid (HA) in postmenopausal women affected by vulvovaginal atrophy (VVA).

MATERIALS AND METHODS

Postmenopausal women affected by VVA were treated with vulvar and vaginal intradermal injections of one prefilled syringe of 2 ml PN/HA every 2 weeks for four sessions. Patients were evaluated at T0 (baseline), T1 (after session 4) and T2 (1 month after session 4). Evaluation of the treatment was assessed by three international validated questionnaires: Vaginal Health Index (VHI), Vulvar Health Index (VuHI) and Female Sexual Function Index (FSFI). The Wilcoxon matched-paired signed-rank test was used to compare the differences in VHI, VuHI, FSFI and FSFI domains within the groups. Statistical significance was set at p < 0.05.

RESULTS

Fifty patients were included in the study (mean age 59.9 ± 7.6 years). Overall, the VHI, VuHI and FSFI reported statistically significant differences between baseline and T1 (p < 0.001) and between baseline and T2 (p < 0.001). All FSFI domains registered a statistically significant increase between baseline and T2 (p < 0.001). No complications or side effects were observed.

CONCLUSIONS

Vulvovaginal intradermal injection of PN/HA is a safe, effective treatment, is not expensive and is a reproducible procedure in postmenopausal women with VVA.

Management of genitourinary syndrome of menopause in breast cancer survivors: An update

There is increasing attention about managing the adverse effects of adjuvant therapy (Chemotherapy and anti-estrogen treatment) for breast cancer survivors (BCSs). Vulvovaginal atrophy (VVA), caused by decreased levels of circulating estrogen to urogenital receptors, is commonly experienced by this patients. Women receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM), that it can in turn lead to pain, discomfort, impairment of sexual function and negatively impact on multiple domains of quality of life (QoL). The worsening of QoL in these patients due to GSM symptoms can lead to discontinuation of hormone adjuvant therapies and therefore must be addressed properly. The diagnosis of VVA is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Systemic estrogen treatment is contraindicated in BCSs. In these patients, GSM may be prevented, reduced and managed in most cases but this requires early recognition and appropriate treatment, but it is normally undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy (VET) because of unknown levels of systemic absorption of estradiol. Lifestyle modifications and nonhormonal treatments (vaginal moisturizers, lubricants, and gels) are the first-line treatment for GSM both in healthy women as BCSs, but when these are not effective for symptom relief, other options can be considered, such as VET, ospemifene, local androgens, intravaginal dehydroepiandrosterone (prasterone), or laser therapy (erbium or CO2 Laser). The present data suggest that these therapies are effective for VVA in BCSs; however, safety remains controversial and a there is a major concern with all of these treatments. We review current evidence for various nonpharmacologic and pharmacologic therapeutic modalities for GSM in BCSs and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. We include recommendations for an approach to the management of GSM in women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

A Novel Technique Combining Human Acellular Dermal Matrix (HADM) and Enriched Platelet Therapy (EPT) for the Treatment of Vaginal Laxity: A Single-Arm, Observational Study

BACKGROUND

There is a paucity of knowledge about cosmetic vaginal tightening procedures; therefore, the present study aimed to describe the clinical effects of a novel combination technique of human acellular dermal matrix (HADM) and enriched platelet therapy (EPT) for the treatment of vaginal laxity.

METHODS

This single-arm, observational study was conducted on 52 patients with grade II to III vaginal relaxation. HADM biological band (U-shaped) was implanted in these patients by submucosal puncture in vagina under anesthesia. This was followed by thrice administration of EPT injection, once at the time surgery followed by each dose at a time interval of one month. Patients were followed up for a period of 6 months based on Female Sexual Function Index (FSFI) and Vaginal Health Index (VHI) scores. Patient satisfaction was measured using Visual Analogue Score (VAS).

RESULTS

About 52 women with median age of 39 years were included in the study. The average time reported to complete HADM surgery was reported as 27 minutes. Following implantation, it was found that labia minora was significantly closed and perineal length was increased from 1.5 to 2.2 cm. Moreover, there was improvement in elasticity, contractility and lubricity of vaginal mucosa. The sexual function scores from pre- to post-surgery were significantly increased (7.95 vs. 30.09; p value: <0.001). The mean VHI score also increased significantly after 6 months of treatment (mean ± S.D. before vs after treatment: 11.2 ± 3.3 vs. 19.6 ± 4.1, P < 0.0001). The mean VAS after surgery was 1.61 ± 0.31. About 96% of the patients did not feel any pain after treatment at 6-month follow-up. No adverse effects were reported in this study.

CONCLUSIONS

These findings supported that combination treatment with HADM and EPT was safe and associated with both improved vaginal laxity and sexual function. These results may provide a novel surgical technique for this prevalent and undertreated condition.

LEVEL OF EVIDENCE IV

Therapeutic Study This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical evaluation of autologous platelet rich plasma injection in post menopausal vulvovaginal atrophy; A pilot study

BACKGROUND

There is lack of published data investigating injection of autologous platelet rich plasma (A-PRP) alone in treatment of postmenopausal VVA.

OBJECTIVES

In this pilot study, we aimed to investigate the safety and efficacy of injection of A-PRP alone in postmenopausal VVA in women without history of cancer breast to explore its utility as a hormone free therapy for postmenopausal VVA and for vulvovaginal rejuvenation.

METHODS

In this pilot study, 47 women with postmenopausal VVA were included. Vulvovaginal condition was evaluated at the baseline by vaginal health index (VHI). Impact of VVA on quality of life and sexual life was evaluated at the baseline by vulvovaginal symptom questionnaire (VSQ). Treatment protocol was 2 sessions of A-PRP injection with one month interval. Response was evaluated one month after the last session by VHI and VSQ. Side effects were also evaluated.

RESULTS

Post menopausal VVA was significantly improved by A-PRP injection as indicated by significant improvement of total VHI score and its items at 1 month post treatment ( p vlue < 0.001). Also, there was significant improvement of burning, hurting, being irritated, being dry, discharge, desire to be intimate, sexual relationships, pain during sexual activity, and dryness during sexual activity at 1 month post treatment as indicated by VSQ ( p value = 0.045 for being dry and < 0.001 for other items).

CONCLUSIONS

A-PRP injection is safe and effective as minimally invasive monotherapy for postmenopausal VVA without history of cancer breast and hence for vulvovaginal rejuvenation.

Female Genitourinary Treatments in Aesthetics

Female genitourinary treatments in aesthetics utilize energy-based treatments and other non-invasive modalities. These include CO2 and Er:YAG lasers, radiofrequency (RF), high-intensity focused electromagnetic energy (HIFEM), hyaluronic acid (HA) injection, platelet-rich plasma (PRP), and silicone thread treatments with an objective to treat sexual dysfunction and symptoms of genitourinary syndrome associated with menopause (GSM), which include atrophic vaginitis, urinary incontinence, and vulvovaginal laxity that is characterized by vaginal dryness, thinning of the epithelium, laxity, prolapse, incontinence, dyspareunia, and increased bacterial infections. The body of evidence is growing for the use of these modalities to improve signs and symptoms of GSM and sexual function, as well as rejuvenate the appearance of external female genitalia. We reviewed the currently available modalities in this rapidly advancing area of expertise.

Interventions to Improve Sexual Health in Women Living with and Surviving Cancer: Review and Recommendations

Sexual health concerns, both physical and psychological, are common and represent an unmet need among women with and surviving cancer. Sexual challenges and conditions negatively impact body image, satisfaction, relationships, well-being, and quality of life, yet are widely reported to be under-recognized and undertreated. To guide clinical care and future research on sexual function in women with cancer, we performed a scoping review of interventions for sexual health concerns, including sexual function, body image, genitourinary symptoms, and hot flashes. Relevant publications between 2005 and 2020 were identified by searching PubMed with a combination of medical subject headings and keywords. Articles were included if they focused on the aforementioned topics, were primary research publications, and included female cancer survivors. Studies focusing on women receiving hormone therapy for breast cancer were also included. A total of 91 investigations conducted in the US and abroad were reviewed. Most commonly, interventions included a component of psychoeducation, although pharmacologic, exercise, and other approaches have been evaluated. Many studies have focused on survivors of breast or gynecologic cancer, among other sampling and methodological limitations. These limitations underscore the need for more work on this vital survivorship issue. Recommendations for future research in this area are also offered.

Materials Selection for the Injection into Vaginal Wall for Treatment of Vaginal Atrophy

Vaginal atrophy caused by the aging process and perineal trauma has a negative impact on women. A new vaginal atrophy treatment is injection of materials into the vaginal wall, including platelet-rich plasma (PRP), autogenous fat graft (AFG), hyaluronic acid (HA), botulinum toxin (BTX), and collagen, but to date their efficacy has not been reviewed. Vaginal wall injection is available only for mild cases of vaginal atrophy or as an adjunct to vaginal surgery. PRP is used mainly to restore vaginal function, and multiple injections are needed to achieve good results in vaginal atrophy. HA, AFG, and collagen are used mainly to augment the vaginal wall. BTX injection can inhibit vaginal muscle spasm and reduce pain during sexual intercourse in patients with vaginismus. Injection of most of these materials into vaginal wall is effective and relatively safe. Vascular embolisms are the most serious complication of vaginal injection and should be prevented. In addition, there has been no randomized double-blind placebo-controlled trial or discussion of methods to avoid serious complications resulting from vaginal injection. Therefore, further studies of the injection of materials into the vaginal wall to treat vaginal atrophy are required, and the procedures should be standardized to benefit more patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Management of vulvovaginal atrophy: Physical therapies. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

INTRODUCTION

For some patients, local hormonal or non-hormonal treatments for genitourinary syndrome of menopause (SGUM) are contraindicated or insufficiently effective. Different physical therapies such as vaginal laser therapy, radiofrequency therapy, photobiomodulation therapy and local injection of hyaluronic acid, autologous fat (lipofilling) and platelet rich plasma (PRP) have been proposed as alternatives.

OBJECTIVE

The objective of this review was to elaborate guidelines for clinical practice regarding the physical therapies proposed for management of vulvovaginal atrophy (AVV).

METHODS

A systematic review of the literature on AVV management with physical therapies was conducted on Medline between January 2014 and December 2020.

RESULTS

Regarding vaginal laser therapy, there are few randomized controlled trials and no formal conclusions can be drawn. The fractional CO2 laser did not demonstrate its superiority over local estrogen therapy. The ERBIUM:YAG laser has not been studied in randomized controlled trials. The lack of follow-up on the vaginal laser and the series of cases reporting risks of vaginal stenosis or chronic pain do not encourage recommending it as a first-line treatment. The literature concerning other physical treatments of AVV is weak concerning the genital area.

CONCLUSION

CO2 or ERBIUM:YAG vaginal lasers are not the first-line treatment for AVV (grade C). In patients with a contraindication to local hormonal treatments, treatment with vaginal CO2 laser or ERBIUM:YAG may be considered after information about the risks (burn, stenosis, pain) (expert opinion). The other physical treatments of SGUM have to be evaluated.

The Emerging Role on the Use of Platelet-Rich Plasma Products in the Management of Urogynaecological Disorders

Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients' satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concentration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections. Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological disorders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

Hyaluronic acid in vulvar and vaginal administration: evidence from a literature systematic review

Vulvovaginal pathology impairs the quality of life of both women in menopause and those who are not. Different therapies have been proposed, mainly related to estrogen therapy in postmenopausal women. However, some contraindications limit its use, and different moisturizers or lubricants have been tested. Hyaluronic acid is a promising and widely used vaginal medical treatment with a moisturizing action and appears to provide a solution. For this reason, we performed a systematic review of the literature. We searched for original articles without date restriction until 30 April 2020. We included all clinical trials which administered local hyaluronic acid in the vulva or vagina. Only English studies and those performed in humans were eligible. Seventeen original studies were included in the review (from randomized controlled trials to longitudinal studies). Hyaluronic acid was generally found to be effective in improving vulvovaginal symptoms (dyspareunia, itching, burning, dryness) and signs (bleeding, atrophy, vaginal pH). In conclusion, hyaluronic acid has the properties to be an efficient moisturizer for women suffering from vulvovaginal atrophy who have contraindications for estrogen therapy and for vulvovaginal signs and symptoms affecting sexual well-being. However, a well-designed randomized controlled trial is needed in order to clarify its efficacy and safety profile.

Modern management of genitourinary syndrome of menopause

The genitourinary syndrome of menopause (GSM) is the accepted term used to describe the broad spectrum of genitourinary tract symptoms and signs caused by the loss of endogenous sex steroids that occurs at the time of and after the menopause. Global improvements in healthcare have resulted in an ageing population. Today, women are spending 40% of their lives in the postmenopausal state, and with 50–70% of postmenopausal women reporting symptomatic GSM, safe and efficacious treatments are needed for this troublesome condition. This article reviews current evidence for non-pharmacological and pharmacological treatments with a focus on novel and minimally invasive procedures such as energy-based devices (CO₂ laser, YAG laser), hyaluronic acid, dehydroepiandrosterone, and selective oestrogen receptor modulators.

Efficacy and Safety of Treatments to Improve Dyspareunia in Breast Cancer Survivors: A Systematic Review

Objective

To analyse all available evidence to validate the effectiveness of a local intervention in the treatment of dyspareunia in breast cancer survivors (BCS).

Methods

We searched the Institute of Scientific Information Web of Knowledge, MEDLINE, PubMed, Scopus, and Cochrane databases for all articles published in peer-reviewed journals up to April 2019. The PICOS standards were: (population) BCS with dyspareunia; (intervention) any type of vulvovaginal treatment; (main outcome) frequency and severity of dyspareunia; (study design) clinical studies.

Results

The literature search strategy identified 252 articles, of which 233 were excluded at various stages of the search. Finally, we systematically reviewed 19 studies, 8 with local hormonal therapies, 7 with local non-hormonal therapies, 3 with laser therapy, and 1 with other interventions. Of the studies, 7 were randomized control trials and 11 were prospective observations. Most of the interventions were shown to be effective and safe in the improvement of dyspareunia.

Conclusion

In addition to the traditional options already analysed in other current reviews, other interesting options are highlighted (such as laser or local dehydroepiandrosterone [DHEA]). Further work on dyspareunia should make use of high-quality trials with large numbers of samples to obtain evidence that could adequately demonstrate key methodological characteristics and harmful effects.

First Use of Thermal Stabilized Hyaluronic Acid Injection in One-Year Follow-Up Patients with Genitourinary Syndrome

Objective

Evaluation of the impact of hyaluronan hybrid cooperative complex (HCC) injections in premenopausal and postmenopausal Italian women affected by vulvar-vaginal atrophy (VVA), one of the symptoms of genitourinary syndrome (GS), on self-reported quality-of-life, vaginal symptoms, and sexual activity, as well as treatment side-effects.

Methods

We surveyed a sample of 26 women affected by VVA with follow-up at 6 and 12 months. Deep intradermal injections of HCC were delivered at 1-month intervals. Evaluation of the treatment impacting the VVA patients was assessed by three international validated questionnaires (Visual Analogic Scale, VAS; health-related quality-of-life test, SF12; Female Sexual Function Index, FSFI). The statistically significant differences between pre- and after-treatment responses have been assessed by Wilcoxon signed-rank test and repeated measures ANOVA test.

Results

At 6–12-month follow-up, general quality-of-life (SF12) did not show any significant improvement. On the contrary, VVA patients showed significant improvements of genital symptoms (VAS) and sexual function (FSFI). Global FSFI score increased by 58% and evidenced important satisfaction (P≤0.05).

Conclusion

Vestibular HCC injection is an office, safe, fast, not expensive, and reproducible procedure effective in vulvar-vaginal atrophy. This study can be used as a pilot for future trials.

Genitourinary Syndrome of Menopause: Current Treatment Options in Breast Cancer Survivors - Systematic Review

Breast cancer survivors (BCS) usually receive treatments which lead to persistent oestrogen suppression, which may cause atrophic vaginitis in a large proportion of these women. The most effective treatments for vulvovaginal atrophy (VVA) are based on local oestrogen therapy. However, these treatments are restricted in BCS due to the controversy over their use in women who had hormone-dependent tumours. Therefore, it is common to find untreated symptoms that affect sexual function and quality of life in BCS, thereby leading to the discontinuation of anti-oestrogenic treatments. This systematic review aims to discuss the current treatment options available for the genitourinary syndrome of menopause (GSM) in BCS. A comprehensive literature search was conducted electronically using Embase and PubMed to retrieve studies assessing treatment options for GSM or VVA in BCS up to April 2020. Studies evaluating treatments in different BCS cohorts were excluded. A total of 29 studies were finally included in the review. Non-hormonal treatments are the first-line treatment for VVA, but when these are not effective for symptom relief, other options can be considered, such as local oestrogen, erbium laser or CO2 laser and local androgens. The present data suggest that these therapies are effective for VVA in BCS; however, safety remains controversial and a major concern with all of these treatments.

Carbon dioxide laser treatment for vulvovaginal atrophy in women treated for breast cancer: Preliminary results of the feasibility EPIONE trial

BACKGROUND AND OBJECTIVE

Quality of life preservation after anti-cancer therapy is a major challenge for breast cancer survivors. Approximately 42-70% of patients who receive systemic therapy for breast cancer, including endocrine therapy, will develop vulvovaginal atrophy (VVA). For these patients, the commonly proposed gel-based treatments for topical applications are restrictive. Recently, innovative, non-hormonal therapeutic approaches, such as laser therapy, have emerged. The purpose of this feasibility study is to investigate the safety and efficacy of CO₂ laser therapy in women with a history of breast cancer.

MATERIAL AND METHODS

This prospective monocentric study included 20 patients with vulvovaginal atrophy who were treated at Henri Mondor University Hospital between 2017 and 2018. We included patients with a vaginal health index (VHI) score<15 and a contraindication for hormone administration due to a history of breast cancer. Two carbon dioxide laser sessions were used. The treatment was delivered using the following settings: vaginal tightening, FinePulse (pulse width 0.9ms), and energy density of 11.5J/cm² that allows coverage of 70% of the targeted vaginal area to be treated. All patients had their follow-up visit at one (M1), three (M3), and six (M6) months after the first treatment to evaluate efficacy of the treatment on vulvovaginal atrophy. Vaginal health index score and female sexual distress (FSD) score were used to assess treatment efficacy and its impact on sexual quality of life. A score≥11 was associated with sexual dysfunction. The vaginal health index and female sexual distress scores were evaluated at baseline, M1, M3, and M6 of follow-up.

RESULTS

The mean age of the patients was 56.1±8.8 years (range, 27-69 years). Seventeen of the 20 patients had experienced menopause (mean menopausal age, 51.25±1.5 years). At inclusion, the mean vaginal health index and the female sexual distress scores were 10.58±1.71 and 21.36±15.10, respectively. Fourteen out of 20 patients (70%) had FSD scores≥11 at the baseline. At M1, the mean vaginal health index score increased significantly to 13.42±2.3 (P=0.03), which represented an improvement of 21% from the baseline. A persistent and significant improvement in the vaginal health index score was observed at M6, with the score increasing to 16.75±4.23 post-treatment (P<0.0001), representing a 34% improvement from the mean baseline score. The mean female sexual distress at M1 was 19.83±13.57, representing a 7% decrease compared to the baseline scores (P<0.01). At M3, the female sexual distress significantly decreased to 13.88±15.58, representing an improvement of 35% (P=0.006). It increased to 10.35±14.7 at M6, representing an improvement of 52% (P=0.001). At M3, 35% of the patients had a female sexual distress score>11, and at M6, only 15% had a female sexual distress score>11. No side effects were reported during follow-up.

CONCLUSION

This pilot feasibility study showed that carbon dioxide laser treatment appears to be an effective and safe method to improve the trophicity and decrease vaginal mucosal dryness in women with vulvovaginal atrophy that developed after systemic breast cancer therapy.

Platelet-derived bio-products: Classification update, applications, concerns and new perspectives

Platelet derived bio-products in the form of platelet rich plasma, plasma rich in growth factors, or plasma-free platelet releasates, are being studied worldwide with the aim of proving their efficacy in tissue regeneration within many different clinical areas, such as traumatology, maxillofacial surgery, ophthalmology, dermatology and otorhinolaryngology, amongst others. The current lack of consensus in the preparation method and application form, or in the quality assessment of each bio-product, precludes adequate interpretation of the relevance of reported clinical outcomes, and, while many in clinicians are very positive about them, many are sceptic. Relevant aspects of these products are considered to propose a classification nomenclature which would aid a comprehensive comparison of clinical outcomes of bio-products of the same characteristics. Finally, the uses of platelet-derived bio-products in in vitro culture (for cell therapy purposes) as a substitute of animal-origin sera, and other future perspectives of applications of platelet-derived bio-products are discussed.

Sexual Health in Menopause

Sexual function worsens with advancing menopause status. The most frequently reported symptoms include low sexual desire (40-55%), poor lubrication (25-30%) and dyspareunia (12-45%), one of the complications of genitourinary syndrome of menopause (GSM). Declining levels of sex steroids (estrogens and androgens) play a major role in the impairment of sexual response; however, psychological and relational changes related with aging and an increase in metabolic and cardiovascular comorbidities should also be taken into account. Although first-line therapeutic strategies for menopause-related sexual dysfunction aim at addressing modifiable factors, many hormonal and non-hormonal, local and systemic treatment options are currently available. Treatment should be individualized, taking into account the severity of symptoms, potential adverse effects and personal preferences.