Impact of Ospemifene on Quality of Life and Sexual Function in Young Survivors of Cervical Cancer: A Prospective Study

Treatment of Genitourinary Syndrome of Menopause in Breast Cancer and Gynecologic Cancer Survivors: Retrospective Analysis of Efficacy and Safety of Vaginal Estriol, Vaginal Dehydroepiandrosterone and Ospemifene

OBJECTIVES

To compare the efficacy and safety of three different treatment options (vaginal estriol, vaginal dehydroepiandrosterone (DHEA), and ospemifene) for treating genitourinary syndrome of menopause (GSM) in breast cancer and gynecologic cancer survivors.

METHODS

A retrospective comparative analysis was performed among 185 cancer survivors (including breast, endometrial, ovarian, cervical, and vulvar cancer) affected by GSM. Women were divided into three groups according to the prescribed therapy (vaginal estriol, vaginal DHEA, and ospemifene). Safety and efficacy of therapies were assessed over a 6-month follow-up. Improvement in symptoms was compared using the following questionnaires: Female Sexual Function Index, Female Sexual Distress Scale, Visual Analogue Scale (VAS)-dyspareunia, VAS-vulvar pain, Short Form (36) Health Survey, and Patients' Impression of Global Improvement. Cancer recurrence was evaluated according to oncological protocol.

RESULTS

After the 6-month follow-up, no significant endometrial thickening or cancer recurrence was observed in any group. The rate of sexually active women significantly increased in all groups, as well as the frequency of sexual intercourse. Scores on questionnaires assessing women's sexual function significantly improved in all patients. Women also complained of less vulvar pain and dyspareunia. Safety and efficacy of treatment were comparable between the three groups for all items except for dyspareunia. Patients taking ospemifene complained of less dyspareunia than those receiving local hormone treatment.

CONCLUSIONS

Vaginal estriol, vaginal DHEA, and ospemifene were effective in improving symptoms of GSM in cancer survivors and were not associated with cancer recurrence over the 6-month follow-up. Ospemifene was more effective than local hormones in treating dyspareunia.

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.

Ospemifene and vulvovaginal atrophy: an update of the clinical profile for post-menopausal women

INTRODUCTION

The demand for effective and safe treatments of genitourinary syndrome (GSM) in post-menopausal women (PMW) is growing. Published data on the efficacy and safety of ospemifene (OSP) prompt an updated literature review to enlighten possible improvements in the GSM treatment.

AREA COVERED

We searched articles published in English from 2010 to 2023 through Medline (PubMed) and Embase databases with Boolean terms: OSP, PMW, GSM, endometrium, breast cancer, cardiometabolic syndrome, bone metabolism, adherence to treatment, and patient satisfaction. We selected randomized controlled trials (RCTs) and observational and cross-sectional studies and completed the search manually.

EXPERT OPINION

Of the 157 retrieved records, 25 primary studies met the inclusion criteria (15 regarding efficacy and safety, two for additional effects, and four for adherence and satisfaction with the OSP treatment). Seven RCTs involved nearly 5,000 patients, 10 out of 18 prospective observational studies 563, and six retrospective analyses 356,439. Evidence of OSP treatment in PMW with GSM relies on RCTs and remarkable real-world data. The 25 primary studies showcased the high clinical response to symptoms, the favorable safety profile of OSP with very few adverse events, a neutral impact on the endometrium, breast, bone, and thrombosis, and the possible improvement of cardiovascular risk factors.

Sexual function status after adjuvant radiation including vaginal cuff brachytherapy in survivors of cancer cervix

CONTEXT

Adjuvant radiation therapy plays an important role in the management of high-risk cervical cancer after radical hysterectomy or inadvertent hysterectomy. The prime concern with the use of dual modality is steep decline in sexual well-being in cervical cancer survivors. Intravaginal brachytherapy (IVBT) delivered by vaginal cylinder or ovoids is essential for local control but at the cost of impairment of sexual function.

AIM

The purpose of this study was to assess the sexual well-being of cervical cancer survivors, who underwent surgery followed by adjuvant radiation and compare the subgroups of ovoids with sorbo brachytherapy.

SETTINGS AND DESIGN

This was an observational, cross-sectional, and analytical study, whereby we evaluated sexual function of cervical cancer survivors by the Female Sexual Function Index (FSFI) instrument.

SUBJECTS AND METHODS

Seventy-five women, identified as cervical cancer survivors who had received adjuvant radiation and IVBT, were administered FSFI questionnaire in face-to-face interviews.

RESULTS

The mean age of 75 interviewed women was 48.64 years. Fifty survivors had received IVBT with a sorbo applicator and twenty-five with ovoids. FSFI full score ranged from 4.4 to 32.40. The mean full score for the whole group was 11.3. The mean FSFI full score was 24.91 (± standard deviation [SD] 5.71) in the ovoid group versus 4.49 (± SD 0.35) in the sorbo group. On Pearson's correlation analysis, age and type of brachytherapy were significantly correlated with FSFI full score (P = 0.006) with correlation coefficient of - 0.312 and - 0.948, respectively.

CONCLUSIONS

Sexual dysfunction was found prevalent in 83% of cervical cancer survivors. The patients treated with IVBT with sorbo had worse sexual functioning than those treated with ovoids.

Can the Tilburg Frailty Indicator predict post-operative quality of recovery in patients with gynecologic cancer? A prospective cohort study

OBJECTIVE

Frailty is a marker of physiologic decline within multiple organ systems. The Tilburg Frailty Indicator (TFI) is an instrument for assessing frailty. We evaluated the ability of the TFI to predict the quality of post-operative recovery in patients with gynecologic cancer and explored the associations between frailty, post-operative complications, and length of stay.

METHODS

We conducted a prospective cohort study of patients scheduled for radical gynecologic cancer surgery between May 2021 and January 2022, and defined a TFI score ≥5 as 'frailty'. Our primary outcome was the post-operative quality of recovery based on the Quality of Recovery-15 (QoR-15), and the secondary outcomes were post-operative complications and length of stay. Multiple logistic regression was used to examine the relationship between frailty and outcomes. We developed receiver operating characteristics (ROCs) and assessed areas under the ROC curves (AUCs) to explore the ability of frailty to predict the quality of post-operative recovery.

RESULTS

A total of 169 patients were included. The prevalence of frailty using the TFI was 47.9% in this cohort. In the multivariate regression analysis, frailty emerged as a significant predictor of the 3-day QoR-15 score (aOR 11.69, 95% CI 4.26 to 32.08; p˂0.001) and complications (aOR 10.05, 95% CI 1.66 to 60.72; p=0.012). Frailty was not associated with length of stay (aOR 2.12, 95% CI 0.87 to 5.16; p=0.099). The combination of the TFI, American Society of Anesthesiologists (ASA) classification, and types of cancer resulted in an increase in the AUC compared with the TFI alone (AUC 0.796, 95% CI 0.727 to 0.865; p˂0.05).

CONCLUSIONS

The use of the TFI may assist surgeons in estimating the risk with respect to post-operative quality of recovery and complications in patients with gynecologic cancer. Combining the TFI with ASA classification and cancer type is expected to improve the predictive ability of poor quality of recovery.

Brachytherapy impacts on sexual function: An integrative review of the literature focusing on cervical cancer

There is growing awareness of the importance of sexual health in the quality of life of cancer patients and survivors. Brachytherapy, a vital component for the curative treatment of cervical cancer, leads to both direct and indirect sequelae that result in vaginal and sexual morbidity. The emergence of 3D image-guided adaptive brachytherapy has led to a better understanding of dose-and-effect relationships for critical organs-at-risk and there are new recommendations for vaginal dose reporting in the ongoing EMBRACE II study. An understanding of the vagina as an organ-at-risk and its dose-and-effect relationships can help brachytherapists limit dose to the vagina and improve sexual morbidity. Brachytherapists play a critical role in the primary and secondary prevention of vaginal and sexual sequelae resulting from treatment. Through close surveillance and recognition of common symptoms, brachytherapists can intervene with effective strategies to prevent and treat vaginal and sexual symptoms. This review summarizes the current literature on dosimetric factors that may predict for vaginal morbidity. It will focus on quantitative and qualitative reports of brachytherapy-related vaginal toxicity and sexual dysfunction. Lastly, it will review the available evidence supporting clinical interventions to mitigate the development and progression of vaginal and sexual sequelae to improve functional quality post-treatment.

Hyaluronic Acid: A Valid Therapeutic Option for Early Management of Genitourinary Syndrome of Menopause in Cancer Survivors?

Genitourinary syndrome of menopause (GSM) is a chronic condition affecting a large number of women, with a major impact on their urogenital health and sexual function. It occurs at midlife because estrogen levels decline with menopause enhancing aging-related changes of the functional anatomy of the urogenital system. Unfortunately, GSM may occur early in the lifespan of women or be exacerbated following anticancer treatments, such as chemotherapy, ionizing radiation, or surgical removal of reproductive organs. Symptoms of GSM are often under-reported by women, under-estimated and under-diagnosed by health care providers (HCPs), and subsequently under-treated, despite their profound negative impact on the quality of life. The mainstay of vaginal treatments is local estrogen therapy (LET) ensuring an effective management of moderate to severe symptomatic GSM. However, LET is generally contraindicated in women with a history of hormone receptor positive cancer, due to the fear of increased recurrence or possible interference with endocrine adjuvant therapies. Among non-hormonal treatments, hyaluronic acid-based moisturizers have shown promising clinical results both in healthy women and in cancer patients or survivors. Its strong water-binding properties provide lubricating and moisturizing effects, which contribute to maintaining a proper level of hydration and viscoelasticity in several body parts, including the urinary tract and genital tissues. Hyaluronic acid-based moisturizers are effective, safe, and well tolerated; therefore, they may represent a valid option for the early management of GSM-associated symptoms in every woman with a history of cancer who is unable or unwilling to undergo hormone-based therapies. Hence, the aim of this review was to provide an overview of GSM etiology and treatment in women with natural or iatrogenic menopause, with a focus on the use of hyaluronic acid as a prophylactic treatment in the context of an integrated management protocol for cancer patients.

Sexual Dysfunction in Cervical Cancer Survivors: A Scoping Review

Sexual function in cervical cancer survivors declines significantly after treatments irrespective of the modality used. Only a few studies have looked at their psychosexual needs, perception, and acceptance of psychosexual support. This review summarizes findings of current qualitative as well as quantitative studies to understand the plight of cervical cancer survivors regarding sexual dysfunction and the management issues. The effect of gynecologic cancers on sexuality depends on multiple factors such as psychosexual factors, biologic factors, and age. Younger patients have poorer outcomes with a more pronounced impact on sexual well-being. Radicality of surgery has direct correlation with sexual dysfunction. Low or no sexual interest, lack of lubrication, dyspareunia, and reduced vaginal caliber are frequently found. For too long, researchers have focused on defining the prevalence and types of sexual problems after various cancer treatments. The area that continues to be neglected is the evaluation of effective interventions to prevent or treat cancer-related sexual dysfunction. In particular, mental health and medical specialists need to collaborate to create cost-effective treatment programs. Collaborative intervention with gynecologists, sexologists, radiotherapists, and nursing staff would be beneficial to optimize the sexual wellness of cancer survivors and their spouses.

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.

SERMs suppresses the growth of ERα positive cervical cancer xenografts through predominant inhibition of extra-nuclear ERα expression

The role of estrogens and estrogen receptors (ER) in cervical cancer (CC) is not well established. However, epidemiological studies and abundant evidence from genetically engineered mouse models support such hypothesis. In this study, we have addressed estrogen responsiveness in a human CC cell line xenograft mouse model. We assessed the sensitivity of Ethynyl Estradiol (EE), SERMs (fulvestrant, MPP) and a non-SERM (EGCG) to competitively modulate the growth of ERα+^ve MS751 CC xenografts. We also checked the agonistic-antagonistic propensity of the above treatments to alter the histology of ovariectomised mouse uterine cervix. Chronic EE treatment encouraged the growth of ERα+^ve MS751 CC xenografts, while SERMs and EGCG significantly decreased tumor formation. SERMs were found to inhibit ERα expression, localized within cytoplasmic and membrane compartments. Conversely, ERα was not inducible and EE administration suppressed the growth of ERα-^ve HeLa CC xenografts. SERMs competitively induced atrophic features to uterine cervix, with MPP giving rise to mucinous metaplasia in the ectocervix. We have demonstrated that, estrogen sensitivity mediated through ERα has promoted CC tumorigenesis. This in turn was modulated by SERMs, predominantly through inhibition of extra-nuclear ERα expression. Though, induction of hyper-estrogenic status in the ectocervix, might underrate the utility of SERMs in ERα+^ve CC.

Cancer-related cognitive impairment (CRCI), depression and quality of life in gynecological cancer patients: a prospective study

PURPOSE

Cancer-related cognitive impairment (CRCI) has been reported in non-central nervous system neoplasms survivors. The purpose of this study was to evaluate the perception of cognitive decrement in patients undergoing surgical and / or medical therapy for gynecological cancers.

METHODS

All women diagnosed with primary gynecological cancer and undergoing active medical treatment have been enrolled in a prospective study. Before starting treatment (T1) and 6 months after the end of treatment (T2), patients were interviewed to evaluate the effects of cancer treatment on perceived cognitive function (using FACT-Cog -version 3), on depression (using Beck Depression Inventory-II test) and on quality of life (using EORTC-QLQC-30). Age, education level, marital status, lifestyle, menopausal state at diagnosis, cancer type, cancer FIGO stage, treatment modality was also recorded. The differences between baseline and post-treatment results have been evaluated with Student's t test. The results have been stratified by the menopausal state at diagnosis, type of tumor (endometrial, cervical, ovarian, vulvar) disease stage and type of treatment (chemotherapy or radiotherapy).

RESULTS

Seventy-three patients were included. A significant reduction in perceived cognitive impairments was demonstrated at T2 (CogPCI: 61.35 ± 13.83 vs 55.05 ± 16.56; p < 0.05). On the contrary, a significant improvement was shown in depression state (BDII: 21.14 ± 11.23 vs 12.82 ± 12.33, p < 0.005). The menopausal state at surgery, tumor site, stage and treatment modality seem to influence the variables analyzed.

CONCLUSION

CRCI is a true risk also in gynecological cancer survivors. The cognitive impairment does not seem to be dependent on depression state after treatment or to a menopausal condition. Assessing cognitive decline in cancer survivorship is essential for ensuring the optimum quality of life and functioning.

Pilot study of fractional CO2 laser therapy for genitourinary syndrome of menopause in gynecologic cancer survivors

PURPOSE

The objectives of this study were to evaluate the feasibility and efficacy of fractional CO₂ laser therapy in gynecologic cancer survivors.

METHODS

This was a pilot, multi-institutional randomized sham-controlled trial of women with gynecologic cancers with dyspareunia and/or vaginal dryness. Participants were randomized to fractional CO₂ laser treatment or sham laser treatment. The primary aim was to estimate the proportion of patients who had improvement in symptoms based on the Vaginal Assessment Scale (VAS). Secondary aims included changes in sexual function assessed using the Female Sexual Functioning Index (FSFI) and urinary symptoms assessed using the the Urinary Distress Inventory (UDI-6).

RESULTS

Eighteen women participated in the study, ten in the treatment arm and eight in the sham arm. The majority of participants had stage I (n = 11, 61.1 %) or II (n = 3, 16.7 %) endometrial cancer with adenocarcinoma histology (n = 9, 50 %). In total, 15 (83.3 %) of the participants completed all treatments and follow-up visit. There was no difference in the change in the median VAS score from baseline to follow-up. However, there was an improvement in change in the median total FSFI score with treatment compared with sham (Δ 6.5 vs -0.3, p = 0.02). The change in the median UDI-6 score was lower in the treatment arm (Δ -14.6 vs -2.1, p = 0.17), but this was not statistically significant. There were no reported serious adverse events.

CONCLUSIONS

Fractional CO₂ laser therapy is feasible in gynecologic cancer survivors, with preliminary evidence of safety. In addition, there was preliminary evidence of improvement in sexual function compared with sham treatment. Clinicaltrial.gov Identifier: NCT03372720 (OSU-17261; NCI-2017-02051).

Ospemifene efficacy and safety data in women with vulvovaginal atrophy

Vulvovaginal atrophy (VVA) is a frequent, underreported and underdiagnosed condition. Ospemifene is a third-generation Selective Estrogen Receptor Modulator (SERM) that has been shown to be effective in women with VVA and dyspareunia, vaginal dryness and vulvar vestibular symptoms. Some of the possible side effects included by FDA and EMA are hot flushes, headache, muscle spasms, vaginal bleeding and vaginal discharge. Ospemifene does not increase the incidence of endometrial cancer or hyperplasia. While the efficacy is comparable with that of estrogenic treatments, ospemifene is not only well tolerated and safe but also reduces bone turnover in postmenopausal women, and available data indicate no safety concerns for breast tissue.

Trans-Mucosal Efficacy of Non-Thermal Plasma Treatment on Cervical Cancer Tissue and Human Cervix Uteri by a Next Generation Electrosurgical Argon Plasma Device

Non-invasive physical plasma (NIPP) generated by non-thermally operated electrosurgical argon plasma sources is a promising treatment for local chronic inflammatory, precancerous and cancerous diseases. NIPP-enabling plasma sources are highly available and medically approved. The purpose of this study is the investigation of the effects of non-thermal NIPP on cancer cell proliferation, viability and apoptosis and the identification of the underlying biochemical and molecular modes of action. For this, cervical cancer (CC) single cells and healthy human cervical tissue were analyzed by cell counting, caspase activity assays, microscopic and flow-cytometric viability measurements and molecular tissue characterization using Raman imaging. NIPP treatment caused an immediate and persisting decrease in CC cell growth and cell viability associated with significant plasma-dependent effects on lipid structures. These effects could also be identified in primary cells from healthy cervical tissue and could be traced into the basal cell layer of superficially NIPP-treated cervical mucosa. This study shows that NIPP treatment with non-thermally operated electrosurgical argon plasma devices is a promising method for the treatment of human mucosa, inducing specific molecular changes in cells.

Molecular Effects and Tissue Penetration Depth of Physical Plasma in Human Mucosa Analyzed by Contact- and Marker-Independent Raman Microspectroscopy

Noninvasive epithelial tissue treatment with cold atmospheric plasma (CAP) is a promising option for local treatment of chronic inflammatory and precancerous lesions as well as various mucosal cancer diseases. Atmospheric pressure plasma jets (APPJ) are well-characterized and medically approved plasma sources. There are numbers of medically approved plasma sources for the treatment of epithelial diseases; however, little is known about the biochemical effects of CAP at the plasma-tissue interface. Furthermore, the actual penetration depth of CAP into tissue is currently unclear. Noninvasive and marker-independent Raman microspectroscopy was employed to assess the molecular effects of CAP on single cells and primary human cervical tissue samples. CAP treatment showed immediate and persisting changes of specific molecular tissue components determined by multivariate analysis. Raman imaging identified CAP-dependent changes in the morphology of the tissue, as well as molecular tissue components. The expression of the different components was not significantly altered within 24 h of incubation. DNA and lipids showed the strongest changes upon CAP treatment, which were traced to the basal cell layer of cervical epithelium, corresponding to an average functional plasma penetration depth of roughly 270 μm. In this study, Raman microspectroscopy is shown to be a promising method for molecular single-cell and solid tissue characterization. Regarding CAP treatment of tissues, Raman microspectroscopy could be suitable for the screening of biological mechanisms as well as for future contact- and marker-independent monitoring of plasma tissue effects.

Ospemifene for the treatment of menopausal vaginal dryness, a symptom of the genitourinary syndrome of menopause

Introduction: Vulvovaginal atrophy (VVA), a component of the genitourinary syndrome of menopause, is a progressive condition due to decline in estrogen leading to vaginal and vulvar epithelial changes. Accompanying symptoms of dryness, irritation, burning, dysuria, and/or dyspareunia have a negative impact on quality of life. Ospemifene is a selective estrogen receptor modulator (SERM) approved by the FDA for moderate to severe dyspareunia and vaginal dryness due to postmenopausal VVA. Areas covered: PubMed was searched from inception to March 2019 with keywords ospemifene and vulvar vaginal atrophy to review preclinical and clinical data describing the safety and efficacy of ospemifene for vaginal dryness and dyspareunia due to VVA. Covered topics include efficacy of ospemifene on vaginal cell populations, vaginal pH, and most bothersome VVA symptoms; imaging studies of vulvar and vaginal tissues; effects on sexual function; and safety of ospemifene on endometrium, cardiovascular system, and breast. Expert opinion: Ospemifene is significantly more effective than placebo in all efficacy analyses studied, working through estrogen receptors and possibly androgen receptors. Safety as assessed by adverse events was generally comparable to that with placebo and to other SERMs, and/or adverse events were not clinically meaningful. No cases of endometrial or breast cancer were reported.

Randomized, Double-Blind, Placebo-Controlled Study of Modified Erzhi Granules in the Treatment of Menopause-Related Vulvovaginal Atrophy

Objective

To evaluate the clinical therapeutic efficacy and safety of modified Erzhi granules (MEG) in patients with menopause-related vulvovaginal atrophy (VVA).

Methods

This randomized, double-blind, placebo-controlled study comprised two groups, including the treatment and control groups. Patients receive MEG and placebo for 12 weeks, respectively. Vaginal health score (VHS), vaginitis score, vaginal maturation index (VMI), female sexual function index (FSFI), and modified Kupperman Index (modified KI) were used as efficacy endpoints and assessed at baseline, 4, 8, and 12 weeks during administration, and 4 weeks after drug withdrawal. At baseline and 12 weeks, serum estradiol (E₂), follicle stimulating hormone (FSH), pelvic ultrasound, breast ultrasound, and other safety parameters were measured, recording adverse events.

Results

At 12 weeks, VHS, percentage of superficial cells in the vaginal epithelium and FSFI were significantly increased, while vaginitis score, percentage of basal cells in the vaginal epithelium, and modified KI were significantly decreased in comparison with baseline and control group (all P<0.05); these differences persisted for up to 4 weeks after drug withdrawal. The placebo group showed no significant change during treatment compared with baseline values (p>0.05). Serum E₂ and FSH levels, endometrial thickness, and breast thickness in all patients were within the normal ranges before and after treatment, with no serious adverse reactions observed.

Conclusion

MEG significantly alleviates menopause-related vulvovaginal atrophy, with no overt adverse effects on the endometrium, breast, hepatic, and renal functions.