A 52-year-old woman 18 months postmenopause presents with hot flushes, genitourinary syndrome of menopause (GSM), and dyspareunia. She has a history of estrogen receptor-positive breast cancer treated with tamoxifen 3 years ago, currently in remission. The safest first-line treatment for her genitourinary symptoms is:
- A Systemic combined HRT (estrogen + progestogen)
- B Low-dose vaginal estrogen cream or pessary
- C Ospemifene (selective estrogen receptor modulator) oral tablet
- D Prasterone (intravaginal DHEA) ✓
Explanation
In women with hormone receptor-positive breast cancer, systemic HRT is contraindicated and even low-dose vaginal estrogen carries theoretical risk of increasing systemic estrogen levels, though data on local estrogen safety in breast cancer survivors are mixed. Prasterone (intravaginal DHEA/dehydroepiandrosterone), approved for dyspareunia due to GSM, is metabolised locally to androgens and estrogens within vaginal tissue with minimal systemic absorption; it is considered the safest option in breast cancer survivors per NAMS 2020 guidelines. Ospemifene is a systemic SERM with potential estrogenic activity and is contraindicated in breast cancer survivors.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.