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Cuarto Debate. Tratamiento del Síndrome Genitourinario de la menopausia

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José Luis Neyro Bilbao

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Cuarto Debate. Tratamiento del Síndrome Genitourinario de la menopausia

  1. 1. GMV Madrid, 22.02.19
  2. 2. Tratamiento del síndrome genito-urinario de la menopausia. Vía vaginal. Dr. José Luis Neyro Servicio de Ginecología y Obstetricia. Hospital Universitario Cruces Universidad del País Vasco UPV – EHU. Bilbao - España www.neyro.com
  3. 3. Vía vaginal vs Vía oral
  4. 4.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  5. 5.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  6. 6. Vulvovaginitis (concepto antiguo) Estado inflamatorio regional con origen en la mucosa vaginal Relacionado con microorganismos:  Colonización externa  Desequilibrio de la microbiota Trastornos tróficos:  Vaginitis atrófica (hipoE) Otros:  Dermatopatías, etc. Verstraelen H, Verheslt R, . Vaneechoutte M et al. The epidemiology of bacterial vaginosis in relation to sexual behaviour. BMC Infect Dis. 2010; 10: 81.
  7. 7. 7 Verstraelen H, Verheslt R, . Vaneechoutte M et al. The epidemiology of bacterial vaginosis in relation to sexual behaviour. BMC Infect Dis. 2010; 10: 81. Bacterial vaginosis (BV) has been most consistently linked to sexual behaviour, and the epidemiological profile of BV mirrors that of established sexually transmitted infections (STIs). It remains a matter of debate however whether BV pathogenesis does actually involve sexual transmission of pathogenic micro- organisms from men to women.
  8. 8. ALTERACIONES NO INFECCIOSAS ALTERACIONES INFECCIOSAS - candidiasis - vaginosis bacteriana - tricomoniasis Lactobacilos “protectores” Otros microorganismos Verstraelen H, Verheslt R, . Vaneechoutte M et al. The epidemiology of bacterial vaginosis in relation to sexual behaviour. BMC Infect Dis. 2010; 10: 81. Todas las situaciones que dañen la anatomía o la fisiología de la vagina
  9. 9.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  10. 10. Maturitas. 2014 Nov;79(3):349-54. doi: 10.1016/j.maturitas.2014.07.013. Epub 2014 Aug 19. Menopause. 2014 Oct;21(10):1063-8. doi: 10.1097/GME.0000000000000329. Climacteric. 2014 Oct;17(5):557-63. doi: 10.3109/13697137.2014.946279. Epub 2014 Aug 25. J Sex Med. 2014 Dec;11(12):2865-72. doi: 10.1111/jsm.12686. Epub 2014 Aug 25.
  11. 11. Maturitas. 2014 Nov;79(3):349-54. doi: 10.1016/j.maturitas.2014.07.013. Epub 2014 Aug 19. Vulvovaginal Atrophy Terminology Consensus Conference Panel David Portman, MD (Co-Chair); Margery Gass, MD, NCMP (Co-Chair); Sheryl Kings-berg, PhD (Conference Moderator); David Archer, MD, NCMP; Gloria Bachmann,MD; Lara Burrows, MD, MSc; Murray Freedman, MS, MD; Andrew Goldstein, MD; Irwin Goldstein, MD; Debra Heller; MD, Cheryl Iglesia, MD; Risa Kagan, MD, NCMP; Susan Kellogg Spadt, PhD, CRNP; Michael Krychman, MD; Lila Nachtigall, MD, NCMP; Rossella Nappi, MD, PhD; JoAnn Pinkerton, MD, NCMP; Jan Shifren, MD, NCMP; James Simon, MD, NCMP; Cynthia Stuenkel, MD, NCMP.
  12. 12. Maturitas. 2014 Nov;79(3):349-54. doi: 10.1016/j.maturitas.2014.07.013. Epub 2014 Aug 19. Genitourinary syndrome of menopause (GSM)
  13. 13. Maturitas. 2014 Nov;79(3):349-54. doi: 10.1016/j.maturitas.2014.07.013. Epub 2014 Aug 19. Genitourinary syndrome of menopause (GSM)
  14. 14. Fisiopatología del SGUM Semmens, JP, Wagner G. Estrogen Deprivation and Vaginal Function in Postmenopausal Women JAMA. 1982;248(4):445-448. Heinemann C, Reid G. Vaginal microbial diversity among postmenopausal women with and without hormone replacement therapy. Can J Microbiol. 2005 Sep;51(9):777-81.
  15. 15. Factores Predisponentes Reacciones alérgicas o inflamatorias Trauma / Cuerpos extraños Menopausia, Fallo ovárico prematuro -IOP, Amenorrea hipotalámica, runners-deportistas de élite Radiación (externa, colpostatos, etc) Anticonceptivos, sobre todo CSG (solo gestágenos) Trastornos endocrinológicos Parto y lactancia natural NAMS. Position statement. 2007 Palacios S. SEGO, 2012
  16. 16. ALTERACIONES NO INFECCIOSAS Atrofia vaginal peri y post-Mp Simon JA et al. Poster presented at North American Menopause Association Annual Meeting 2007 SÓLO EL 25% DE LAS PACIENTES CONSULTA POR ATROFIA VAGINAL
  17. 17. Branch F, Woodruff TJ, Mitro SD et al. Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001–2004. Environmental Health, 2015 DOI 10.1186/s12940-015-0043-6
  18. 18. Branch F, Woodruff TJ, Mitro SD et al. Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001–2004. Environmental Health, 2015 DOI 10.1186/s12940-015-0043-6 Diethyl phthalate (DEP) and di-n-butyl phthalate (DnBP) US reproductive-aged women, NHANES 2001-2004
  19. 19. Branch F, Woodruff TJ, Mitro SD et al. Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001–2004. Environmental Health, 2015 DOI 10.1186/s12940-015-0043-6 monoethyl phthalate (MEP) and mono-n-butyl phthalate (MnBP) NHANES 2001-2004
  20. 20. Branch F, Woodruff TJ, Mitro SD et al. Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001–2004. Environmental Health, 2015 DOI 10.1186/s12940-015-0043-6 Results of our study suggest that vaginal douching may be a source of human exposure to DEP Diethyl phthalate among frequent users and contribute to racial/ethnic disparities in DEP exposure. This study adds weight to existing recommendations from health professionals that discourage the practice of douching.
  21. 21.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  22. 22. 22 Monterrosa A, Portela K. Manejo de la atrofia vulvovaginal. Rev Chil Obstet Ginecol. 2014; 79(6): 489-501. Alternativas terapéuticas en el SGUM.
  23. 23. NOMBRE TIPO COMPOSICIÓN Dermisoja Lubricante e hidratante Agua, glicerina, propilenglicol, alcohol, isoflavonas de soja agliconas, camomilla recutita, lecitina, carbómero, polisorbato 80, EDTA disódico, metilparabeno sódico. Fisogen gel Lubricante e hidratante Agua, glicerol, propilenglicol, pluracare E 1500, celosize PCG 10, germaben II, CM-glucano, Nipaguard DMDMH, Tween 20, EDTA sa disódica, carragenina purificada, ácido cítrico, merquat-5, extracto glicólico de camomila, tocoferol acetato (vitamina E) Flucosil Lubricante e hidratante Agua, glicerina, biosacárido gum-1, poliacrilamida, fenoxietanol, metilparaben-etilparaben-butilparaben- propilparaben-isobutilparaben, sorbato potásico, goma xantano, ácido láctico Frolein íntimo Hidratante con isoflavonas Agua glicerina, hidroxyetil etilcelulosa, ácido cítrico, fenoxietanol, exacto de Hidratante interno cum laude Hidratante Agua, glicerina, parafina líquida, esterato de sucrosa, glicéridos hidrogenados de palma, policarbófilo, carbómero, propilparabeno, metilparabeno, hidróxido sódico Hidratante isdin Lubricante e hidratante Agua, glicerina, eglicerilpoliacrilato, petrolato, parafina líquida, glicérido hidrogenado de palma, carbómero sódico, ácido poliacrílico, metilparabeno, ácido sórbico Hidratante vulvar isdin Hidratante Agua, parafina líquida, poliacrilato gliceril, PEG-8 Beeswax, polyperfluoromethylisopropyl eéter, PEG- 6 isostearato, carbómero sódico, aceite de borago officinalis, laureth-9, imidazolidinyl urea, metilparabeno, bisabonol, propilparabeno, BHT Iserén gel Lubricante e hidratante con isoflavonas Agua, glicerina, parafina líquida, hidróxido sódico, carbómero, extracto de soja estandarizado, fenoxietanol- metilparaben-etilparaben-butilparaben- Muvagyn Hidratante con isoflavonas hialuronato sódico, agua, propilenglicol, alcohol etílico, extracto de camomila, fosfolípidos vegetales, extracto glicólico, carbómero, metilparaben sódico, colesterol, imidazolidinil urea, trietanolamina, EDTA disódico, propilparabeno sódico, dl-a-tocoferil acetato. Ninagel Favorecedor de la excitabilidad local Agua, arginina, glicerina, carbómero sódico, aloe barbadensis, quaternium-15 Phytosoya gel Hidratante con isoflavonas Glicerina, parafina líquida, hidróxido sódico, carbómero, extracto de soja estandarizado, fenoxietanol-metilparaben- etilparaben-butilparaben-propilparaben- isobutilparaben Replens Hidratante efecto prolongado Agua purificada, policarbófilo, aceite mineral, glicerina, glicérido de aciete de palma hidrogenado, carbómero homoplímero tipo B, ácido sórbico e hidróxido sódico Saugella attiva Lubricante e hidratante Agua, glicerina, propilenglicol, sorbitol,González SP. Acta Ginecol. 2009
  24. 24. Constantino y Guaraldi (2008)  Eficacia y seguridad de óvulos vaginales de ácido hialurónico en la atrofia vaginal de mujeres postmenopáusicas. Le Donne y cols (2010)  Óvulos vaginales con ácido hialurónico frente a otros con genisteína sobre el epitelio atrófico en mujeres postmenopáusicas. Ácido Hialurónico en Regeneración Mucosa Vaginal Valoración de síntomas y signos de atrofia vaginal: picazón, ardor, dispareunia, inflamación vaginal e irritación en 130 mujeres. Disminución significativa de la sequedad vaginal en la visita después de 7, 14 y 28 días (p<0,001). Conclusión: seguro y efectivo, especialmente cuando la terapia hormonal no está indicada. Conclusión: ambos tratamientos mejoraron significativamente los síntomas genitales (p<0,001).
  25. 25. Centella Asiática 25 La acción de la centella asiática se debe a sus tres ingredientes activos principales: ácido asiático, asiaticósido y madecasósido (Soon-Sun Hong et al. 2005) Acción cicatrizante, regeneradora, reparadora y renovadora de la piel y mucosas (M. José Alonso., 2009). Facilita la curación de heridas (Somboonwong J et al. 2012 ) Estimulan la activación fibroblástica y la producción de colágeno I y III, (Paolino D et al. 2012 ). Estimula la maduración de la cicatriz por la producción de colágeno tipo I y reduce la respuesta inflamatoria (B. Somashekar Shetty et al. 2006).
  26. 26.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  27. 27. Espitia FJ, Orozco H. Estriol vs estrógenos conjugados de origen equino en el tratamiento del síndrome genitourinario de la menopausia. Ginecol Obstet Mex. 2018 febrero;86(2):117-126.
  28. 28. Espitia FJ, Orozco H. Estriol vs estrógenos conjugados de origen equino en el tratamiento del síndrome genitourinario de la menopausia. Ginecol Obstet Mex. 2018 febrero;86(2):117-126.
  29. 29. Espitia FJ, Orozco H. Estriol vs estrógenos conjugados de origen equino en el tratamiento del síndrome genitourinario de la menopausia. Ginecol Obstet Mex. 2018 febrero;86(2):117-126. Se encontraron diferencias significativas, entre los dos grupos.  en el tiempo de desaparición de los síntomas, que fue menor en el grupo de estriol (4.8 ± 1.05 semanas vs 6.33 ± 1.02 ± 1.02 semanas; p = 0.012)  en los efectos secundarios, que también fueron menores en el grupo de estriol (7.5 ± 2.4% vs 9.6 ± 2.7%; p = 0.024). A pesar del tiempo prolongado de la terapia hormonal, las concentraciones séricas de E2 permanecieron dentro del nivel posmenopáusico normal y no hubo un solo caso de hiperplasia o ADC endometrial, lo que es concordante con la bibliografía revisada.
  30. 30. Dosis total de Estrógenos vaginales  1 comp de 10 mcg cada día x 14 días = 140 mcg  1 comp cada 3-4 días x 50 semanas = 1000 mcg 140 mcg + 1000 mcg __________ 1140 mcg Dosis total de Estrógenos vaginales: 1.14 mg de estradiol natural….en un año¡¡¡
  31. 31. Cuando se usan dosis bajas de TE los progestágenos generalmente no son requeridos. Baber RJ. IMS recommendations on womens midlife health and menopause hormone therapyy Climacteric 2016 ; 19 (2) 109-150 TE : Vaginal
  32. 32. S. Palacios, A. Mejía, JL. Neyro (2015) Treatment of the genitourinary syndrome of menopause, Climacteric, 18:sup1, 23-29, DOI: 10.3109/13697137.2015.1079100
  33. 33. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD001500.
  34. 34. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD001500. Oestrogen tablets vs placebo or other regimens. Improvement in symptoms (participant-assessed at end point).
  35. 35. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD001500. Oestrogen tablets vs placebo or other regimens, Endometrial thickness.
  36. 36. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD001500. Oestrogen tablets vs placebo or other regimens, Increase in maturation indices at end point.
  37. 37. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD001500. Oestrogen tablets vs placebo or other regimens, Adverse events (breast disorders).
  38. 38. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD001500. Oestrogen tablets vs placebo or other regimens, Adverse events (total adverse events).
  39. 39. Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD001500. Oestrogen tablets vs placebo or other regimens, Adherence to treatment.
  40. 40.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  41. 41. Zerbinati N, Serati M, Origoni M et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci 2014. DOI: 10.1007/s10103-014-1677-2.
  42. 42. Zerbinati N, Serati M, Origoni M et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci 2014. DOI: 10.1007/s10103-014-1677-2. Haematoxylin and eosin staining of a patient’s vaginal mucosa before treatment (a, c) and 2 months after treatment (b, c). a In the atrophic mucosa, the epithelium is very thin since it is formed by few layers of cells, and the epithelial-connective junction presents an even feature; b the epithelium appears much thicker since it is constituted by many layers with visible large intermediate and shedding superficial cells.
  43. 43. Zerbinati N, Serati M, Origoni M et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci 2014. DOI: 10.1007/s10103-014-1677-2. The underlying connective tissue is provided with papillae indenting the epithelial-connective junction. C. Comparative microphotographs (before and 2 months after treatment) of atrophic vaginal mucosa biopsies demonstrating striking structural recovery features 2 months after treatment in all the patients
  44. 44. Zerbinati N, Serati M, Origoni M et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci 2014. DOI: 10.1007/s10103-014-1677-2. Histochemical PAS reaction for glycogen identification (red) in the vaginal epithelium before treatment (a) and 2 months after treatment (b). a Atrophic mucosa: glycogen is present in a few superficial cells of the thin epithelium; b remark on high content of glycogen in the epithelial intermediate and superficial layers. Deep papillae of connective tissue indenting the epithelium are also clearly observable
  45. 45. Zerbinati N, Serati M, Origoni M et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci 2014. DOI: 10.1007/s10103-014-1677-2. Electron microscopy of vaginal mucosa connective tissue 2 months after treatment. a In fibroblasts, a widely extended rough endoplasmic reticulum, constituted by membranes with attached ribosomes forming cisternae and dilated vesicles (V), is visible. N: nucleus, RER: rough endoplasmic reticulum, M: mitochondria, G: Golgi apparatus
  46. 46. Zerbinati N, Serati M, Origoni M et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci 2014. DOI: 10.1007/s10103-014-1677-2. The results strongly support the hypothesis that a new production of collagen and ground substance components within the connective tissue and glycogen and acidic mucins within the epithelium can rebalance and restore vaginal mucosa from atrophy induced by the absence of ovarian estrogens, resulting in a highly significant improvement in clinical symptoms
  47. 47.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  48. 48. Labrie,L Derogatis L, Archer DF, et al. Effect of Intravaginal Prasterone on Sexual Dysfunction in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med dec 2015, 12; 2: 2401-12.
  49. 49. SÍNTESIS ESTEROIDEA
  50. 50. Labrie F, et al. Intracrinology: role of the family of 17 beta-hydroxysteroid dehydrogenases in human physiology and disease. J Mol Endocrinol 2000;25(1):1-16. Intracrinología: es la transformación del precursor inactivo DHEA en esteroides sexuales activos que actúan en las mismas células donde se sintetizan y posteriormente se inactivan, sin liberación significativa de hormonas a la circulación.
  51. 51. Labrie F, Archer DF, Martel C et al. Combined data of intravaginal prasterone against vulvovaginal Atrophy of menopause. Menopause 2017;24(11):1246-56. DHEA a lo largo de la vida reproductiva y hasta la edad avanzada.
  52. 52. Labrie F. Intracrinology. Mol Cell Endocrinol 1991;78(3):C113-C118. Endocrinología vs Intracrinología
  53. 53. Labrie F, Derogatis L, Archer DF et al. Effect of Intravaginal Prasterone on Sexual Dysfunction in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med 2015;12:2401–2412. Effect of daily intravaginal application of 0.0% and 0.50% dehydroepiandrosterone (DHEA; prasterone) for 6 and 12 weeks Desire domain of Female Sexual Function Index Arousal domain of Female Sexual Function Index
  54. 54. Labrie F, Derogatis L, Archer DF et al. Effect of Intravaginal Prasterone on Sexual Dysfunction in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med 2015;12:2401–2412. Effect of daily intravaginal application of 0.0% and 0.50% dehydroepiandrosterone (DHEA; prasterone) for 6 and 12 weeks Lubrication domain of Female Sexual Function Index Orgasm domain of Female Sexual Function Index
  55. 55. Labrie F, Derogatis L, Archer DF et al. Effect of Intravaginal Prasterone on Sexual Dysfunction in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med 2015;12:2401–2412. Effect of daily intravaginal application of 0.0% and 0.50% dehydroepiandrosterone (DHEA; prasterone) for 6 and 12 weeks Satisfaction domain of Female Sexual Function Index Pain domain of Female Sexual Function Index
  56. 56. Labrie F, Derogatis L, Archer DF et al. Effect of Intravaginal Prasterone on Sexual Dysfunction in Postmenopausal Women with Vulvovaginal Atrophy. J Sex Med 2015;12:2401–2412. Effect of daily intravaginal application of 0.0% and 0.50% dehydroepiandrosterone (DHEA; prasterone) for 6 and 12 weeks Total score of Female Sexual Function Index
  57. 57.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  58. 58. Moreno AC, Sikka SK, Thacker HL. Genitourinary syndrome of menopause in breast cancer survivors:Treatments are available. Cleve Clin J Med. 2018 Oct;85(10):760-766. doi: 10.3949/ccjm.85a.17108.
  59. 59. Moreno AC, Sikka SK, Thacker HL. Genitourinary syndrome of menopause in breast cancer survivors:Treatments are available. Cleve Clin J Med. 2018 Oct;85(10):760-766. doi: 10.3949/ccjm.85a.17108.
  60. 60. Moreno AC, Sikka SK, Thacker HL. Genitourinary syndrome of menopause in breast cancer survivors:Treatments are available. Cleve Clin J Med. 2018 Oct;85(10):760-766. doi: 10.3949/ccjm.85a.17108. FDA-approved labeling notes for treatments for genitourinary syndrome of menopause.1
  61. 61. Moreno AC, Sikka SK, Thacker HL. Genitourinary syndrome of menopause in breast cancer survivors:Treatments are available. Cleve Clin J Med. 2018 Oct;85(10):760-766. doi: 10.3949/ccjm.85a.17108. FDA-approved labeling notes for treatments for genitourinary syndrome of menopause. 2
  62. 62. Moreno AC, Sikka SK, Thacker HL. Genitourinary syndrome of menopause in breast cancer survivors:Treatments are available. Cleve Clin J Med. 2018 Oct;85(10):760-766. doi: 10.3949/ccjm.85a.17108.  Vaginal estrogen is an effective and safe option to treat GSM in women with either estrogen receptor-negative or estrogen receptor-positive breast cancer. It often completely cures the symptoms without any notice able increase in serum estrogen levels.  Vaginal DHEA therapy is a non-estrogen option shown to effectively treat GSM without increasing systemic levels of estrogen or testosterone. This profile makes vaginal DHEA therapy a particularly attractive treatment for symptoms of GSM in women at risk for breast cancer.
  63. 63. Moreno AC, Sikka SK, Thacker HL. Genitourinary syndrome of menopause in breast cancer survivors:Treatments are available. Cleve Clin J Med. 2018 Oct;85(10):760-766. doi: 10.3949/ccjm.85a.17108.  Use of an estrogen receptor agonist/antagonist in breast cancer survivors needs careful consideration.  Ospemifene has antiestrogenic effects that make it a good option for women with bone loss and those at high risk for breast cancer, but it should not be used concurrently with tamoxifen or raloxifene.  Additionally, ospemifene does not cause uterine hyperplasia, so it can be used in women with a uterus.
  64. 64. Faubion SS, Larkin LS, Stuenkel CS, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from NAMS and IS for the Study of Women’s Sexual Health. Menopause 2018, 25, 6: 1-13
  65. 65. Faubion SS, Larkin LS, Stuenkel CS, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from NAMS and IS for the Study of Women’s Sexual Health. Menopause 2018, 25, 6: 1-13 Factors affecting decision-making regarding local hormone therapy
  66. 66. Faubion SS, Larkin LS, Stuenkel CS, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from NAMS and IS for the Study of Women’s Sexual Health. Menopause 2018, 25, 6: 1-13 Non-pharmacologic treatment strategies for the management of GSM
  67. 67. Faubion SS, Larkin LS, Stuenkel CS, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from NAMS and IS for the Study of Women’s Sexual Health. Menopause 2018, 25, 6: 1-13 Pharmacologic treatments for management of GSM
  68. 68. Faubion SS, Larkin LS, Stuenkel CS, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from NAMS and IS for the Study of Women’s Sexual Health. Menopause 2018, 25, 6: 1-13  Individualize treatment, taking into account risk of recurrence, severity of symptoms, effect on QOL, and personal preferences  Moisturizers and lubricants, pelvic floor physical therapy, and dilator therapy are first-line treatments  Involve treating oncologist in decision making when considering the use of local hormone therapies  Ospemifene, an oral SERM, has not been studied in women at risk for breast cancer and is not FDA-approved for use in women with or at high risk for breast cancer  Off-label use of compounded vaginal testosterone or estriol is not recommended  Laser therapy may be considered in women who prefer a non-hormone approach; women must be counseled regarding lack of long-term safety and efficacy data General guidelines
  69. 69. Faubion SS, Larkin LS, Stuenkel CS, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from NAMS and IS for the Study of Women’s Sexual Health. Menopause 2018, 25, 6: 1-13 1. Women at high risk for breast cancer 2. Women with ER-positive breast cancers on tamoxifen. 3. Women with ER-positive breast cancers on AIs. 4. Women with triple-negative breast cancers. 5. Women with metastatic disease. Management of GSM in specific patient populations
  70. 70.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  71. 71. S. Palacios, A. Mejía, JL. Neyro (2015) Treatment of the genitourinary syndrome of menopause, Climacteric, 18:sup1, 23-29, DOI: 10.3109/13697137.2015.1079100
  72. 72. S. Palacios, A. Mejía & J. L. Neyro (2015) Climacteric, 18:sup1, 23-29.
  73. 73. Vaginal estrogen use was not associated with a higher risk of cardiovascular disease or cancer. Our findings lend support to the safety of vaginal estrogen use, a highly effective treatment for genitourinary syndrome of menopause. Bhupathiraju SN, Grodstein F, Stampfer, MJ et al. Vaginal estrogen use and chronic disease risk in the Nurses’ Health Study. Menopause. 2018 Dec 17.
  74. 74.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  75. 75. Defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired sexual function; and urinary symptoms of urgency, dysuria, and recurrent urinary tract infections (UTIs). Shifren JL, Gass, MLS. The North American Menopause Society Recommendations for Clinical Care of Midlife Women. Menopause, 21, 10, 2014 Genitourinary syndrome of menopause (GSM)
  76. 76. Women with GSM / VVA should consider non-hormonal vaginal lubricants and moisturizers as initial therapy. (Level II) All women with GSM / VVA should be counseled about available management strategies and provided with information about the efficacy, risks, and benefits of non-hormonal and hormonal interventions. (Level II) Shifren JL, Gass, MLS. The North American Menopause Society Recommendations for Clinical Care of Midlife Women. Menopause, Vol. 21, No. 10, 2014 Genitourinary syndrome of menopause (GSM)
  77. 77. IMS 2016 Los Tx. prolongados siempre se requieren Mejoría en IUU y vejiga hiperactiva No se han identificado riesgos NAMS 2017 Tx. Dosis baja E es efectiva y segura Ospemifeno DHEA Alternativas AACE – ACE 2017 Evidencia I, A Consenso 2010 TH – Síndrome Genitourinario de la menopausia Baber RJ, Panay N, Fenton A . The IMS Writing Group . Climacteric 2016 ; 19:109-150 Pinkerton JV .Menopause 2017 ; 24(7): 1-26 Cobin RH, Endocrine Practice 2017 ; 23 (7):869-880
  78. 78. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause, Vol. 25, No. 11, 2018
  79. 79. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause, Vol. 25, No. 11, 2018 The genitourinary syndrome of menopause (vaginal symptoms)  Low-dose vaginal estrogen preparations are effective and generally safe for the treatment of VVA, with minimal systemic absorption, and preferred over systemic therapies when ET is considered only for GSM.  For women with breast cancer, low-dose vaginal estrogen should be considered and prescribed in consultation with their oncologists.  Progestogen therapy is not needed with low-dose vaginal ET, but randomized trial data are lacking beyond 1 year; postmenopausal bleeding in women using low-dose vaginal ET must be thoroughly evaluated.  Non-estrogen prescription therapies that improve VVA in postmenopausal women include ospemifene and intravaginal DHEA.
  80. 80.  Introducción general: más allá de las vaginitis.  Diagnóstico actual y manejo clínico.  Polivalencia de la vía vaginal: la natural...  Estrógenos: la forma lógica de abordaje.  ¿Puede ayudar el Laser local?  ¿Y alguna novedad real para el SGUM?  ¿En situaciones especiales o riesgo de cáncer?  Análisis de la evidencia y propuesta de manejo.  Recomendaciones “oficiales”.  Reflexión final y conclusiones. Tratamiento vaginal del SGU de menopausia. www.neyro.com
  81. 81. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26, 2: 124-31, 2019
  82. 82. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26, 2: 124-31, 2019
  83. 83. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26, 2: 124-31, 2019
  84. 84. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26, 2: 124-31, 2019
  85. 85. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26, 2: 124-31, 2019
  86. 86. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26, 2: 124-31, 2019
  87. 87. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26, 2: 124-31, 2019 Most physicians preferred prescribing US FDA-approved vaginal ET at the lowest effective dose possible and were comfortable prescribing it. However, fewer were comfortable prescribing vaginal ET to women with an elevated risk or personal history of breast cancer, despite medical societies supporting its use in consultation with an oncologist when nonhormonal therapies fail to improve symptoms. Vaginal products that have negligible absorption of estradiol may be viable choices for these women, suggesting the need for more studies in this population.
  88. 88. Kingsberg SA, Larkin L, Krychman M, et al. WISDOM survey: attitudes and behaviors of physicians toward vulvar and vaginal atrophy (VVA) treatment in women including those with breast cancer history. Menopause, Vol. 26,2: 124-31, 2019  More OB/GYNs than PCPs prescribed VVA treatment, especially vaginal estrogens, for menopausal women, but both groups generally had similar attitudes and behaviors regarding VVA treatment.  Physician comfort was low when prescribing to women with a history of breast cancer, despite women’s health medical societies supporting vaginal estrogen use in women with a history of estrogen-dependent breast cancer who were unresponsive to non-hormonal therapies when offered in consultation with their oncologist.  Los obstetras y ginecólogos prescribieron tratamiento para la AVV más que MAP, especialmente estrógenos vaginales, para mujeres menopáusicas, pero ambos grupos generalmente tuvieron actitudes y comportamientos similares con respecto al tratamiento con AVV.  La comodidad del médico fue baja cuando se prescribió a mujeres con antecedentes de cáncer de mama, a pesar de las sociedades médicas de salud de mujeres apoyan el uso vaginal de estrógenos en mujeres con antecedentes de cáncer de mama dependiente de estrógenos que no respondían a terapias no hormonales cuando se ofrecieron en consulta con su oncólogo.
  89. 89. Marsden J, on behalf of the British Menopause Society. BMS consensus statement: The risks and benefits of HRT before and after a breast cancer diagnosis. Post Reproductive Health, 0(0) 1–5. 2019. DOI: 10.1177/2053369119825716
  90. 90. Marsden J, on behalf of the British Menopause Society. BMS consensus statement: The risks and benefits of HRT before and after a breast cancer diagnosis. Post Reproductive Health, 0(0) 1–5. 2019. DOI: 10.1177/2053369119825716 The impact of lifestyle risk factors on the absolute risk of breast cancer diagnosis in women at population risk: Comparison of HRT with other lifestyle risk factors.
  91. 91. Marsden J, on behalf of the British Menopause Society. BMS consensus statement: The risks and benefits of HRT before and after a breast cancer diagnosis. Post Reproductive Health, 0(0) 1–5. 2019. DOI: 10.1177/2053369119825716 Summary 1 In women with a low underlying risk of breast cancer (i.e. most of the population): 1. The benefits of HRT in the short-term (up to five years’ use) for symptom relief will exceed potential harm; 2. The risk of breast cancer diagnosis associated with HRT is equivalent to, or less than that of, other lifestyle risk factors for breast cancer; 3. Communicating risk in terms of absolute excess risk with framing, minimizes bias and misinterpretation;
  92. 92. Marsden J, on behalf of the British Menopause Society. BMS consensus statement: The risks and benefits of HRT before and after a breast cancer diagnosis. Post Reproductive Health, 0(0) 1–5. 2019. DOI: 10.1177/2053369119825716 Summary 2 In women with a low underlying risk of breast cancer (i.e. most of the population): 4. The potential risk of breast cancer diagnosis associated with unopposed or combined HRT should not be discussed in isolation of its other short- and long term benefits and risks; 5. In women at high risk, if the use of HRT is considered, this should only be for the management of estrogen deficiency symptoms.
  93. 93. “Riesgo, incertidumbre e ignorancia han sido los males de nuestro tiempo. Los pueblos y las personas que han tenido éxito se han preocupado de cambiar el tercer factor. El riesgo y la incertidumbre son fijos” John Maynard Keynes, 1929

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