Laser de CO2, radiofrequência e promestrieno no tratamento da síndrome genitourinária da menopausa entre usuárias de terapia adjuvante para câncer de mama: aspectos vaginais clínicos e histomorfométricos
Data
2023-05-31
Autores
Cantarelli, Gabriela Cruz 
Orientadores
Patriarca, Marisa Teresinha
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Objetivo: Avaliar os efeitos vaginais clínicos e histológicos antes e após o uso do LASER de CO2 (LCO2), Radiofrequência Fracionada (RF) e Promestrieno (CT) para tratamento dos sintomas moderados a graves da Síndrome Genitourinária da Menopausa (SGUM) em mulheres portadoras de câncer de mama utilizando terapia endócrina adjuvante. Métodos: Foram elegíveis mulheres em tratamento para câncer de mama com terapia endócrina adjuvante (tamoxifeno ou anastrozol), apresentando sintomas moderados a graves da SGUM, graduados por meio da Escala Visual Analógica (EVA). As participantes foram submetidas à avaliação clínica, que incluía exame ginecológico para obtenção do Índice de Saúde Vaginal (ISV) e a biópsia vaginal. Depois, foram randomizadas para os grupos LCO2, RF e CT. Os grupos tratados com energia receberam três aplicações mensais consecutivas. O CT foi orientado para uso domiciliar de promestrieno, 1g ao dia por 21 dias e, posteriormente, duas vezes por semana por quatro meses. A visita de acompanhamento foi realizada quatro meses após o início do tratamento repetindo o protocolo inicial e também incluiu avaliação do grau de satisfação pós-tratamento mensurada pela escala Likert. Resultados: 62 pacientes (21 no grupo LCO2, 20 no RF e 21 no CT) concluíram o estudo e apresentaram amostras pré e pós-tratamento adequadas para análise. Houve redução significativa da intensidade dos sintomas da SGUM (p < 0,05), assim como aumento do ISV (p < 0,001) após os tratamentos, em todos os grupos, independente da terapia endócrina adjuvante em uso. A maioria das amostras pré e pós-tratamento não apresentou parâmetros clássicos de atrofia. Foi observado aumento do número de papilas estromais entre as usuárias de tamoxifeno e redução da frequência desse achado após tratamento (p = 0,019), alcançando número semelhante às usuárias de anastrozol pré e pós-tratamento. Além disso, independente do momento da avaliação, a espessura média do epitélio vaginal em usuárias de tamoxifeno foi maior que as em uso de anastrozol (p = 0,002). Nenhum efeito colateral adverso clínico ou histológico foi observado. Conclusão: As alterações histológicas compatíveis com atrofia entre as mulheres com câncer de mama em uso de terapia endócrina adjuvante e com sintomas moderados a graves da SGUM foram achados raros, mostrando dissociação clínica e histológica. Embora tenham sido identificadas algumas diferenças nos achados clínicos e histológicos vaginais entre usuárias de tamoxifeno e anastrozol, a intensidade dos sintomas da SGUM foi semelhante entre elas. Os sinais e sintomas da SGUM melhoraram de forma semelhante em todos os grupos de tratamento, independentemente da terapia adjuvante utilizada e sem qualquer dano tecidual, demonstrando que o LCO2 e a RF podem constituir alternativas eficazes e seguras para o controle da SGUM em mulheres com câncer de mama em uso de terapia endócrina adjuvante, uma vez que seus resultados foram semelhantes ao promestrieno, cujos benefícios já são consagrados.
Objective: To evaluate clinical and histological vaginal aspects before and after treatment of Genitourinary Syndrome of Menopause (GSM) with CO2 LASER (CO2L), fractional radiofrequency (RF) and promestriene (CT), in breast cancer survivors using adjuvant endocrine therapy (BCSA) and with moderate to severe symptoms of GSM. Methods: Female BCSA presenting moderate to severe symptoms of GSM were eligible for the study. The GSM symptoms were graded using the Visual Analog Scale (VAS), and the patients underwent a clinical evaluation including a standardized gynecological exam, to access Vaginal Health Index (VHI) and to obtain a vaginal biopsy. After that, they were randomized to CO2L, RF and CT groups. The energy groups received three consecutive monthly outpatient vulvovaginal energy applications. The CT group was instructed to use 1g of promestriene at home, daily for 21 days and, subsequently, 1g, twice a week for four months. The follow-up visit was performed four months after the beginning of treatment and included a patient satisfaction evaluation using the 5-points Likert scale. Results: Sixty-two patients concluded the treatment and had adequate pre- and post-treatment vaginal samples to analysis, 21 in the CO2L group, 20 in the RF and 21 in the CT. There was a statistically significant decrease in the intensity of GSM symptoms (p < 0.05), as well as an improvement in VHI (p < 0.001) after treatment, similarly in all treatment groups, regardless of the type of hormonal adjuvant therapy being used. Most of the pre- and post-treatment samples did not show characteristic atrophy parameters. An increased number of stromal papillae among tamoxifen users was observed with a reduction of that parameter after treatment (p = 0.019), achieving a similar frequency observed among anastrozole users in pre- and post-treatment. Furthermore, regardless the moment of evaluation, the mean thickness of the epithelium in tamoxifen users was greater than in anastrozole users (p = 0.002). No relevant clinical or histological adverse effects were observed. Conclusion: There was a clinical and histological dissociation among BCSA with GSM. Although some differences on histological and clinical vaginal signs between tamoxifen and anastrozole users were identified, the intensity of GSM symptoms was similar between them. Moreover, the signs and symptoms of GSM improved similarly in all treatment groups regardless of the adjuvant therapy used, without any histological structure side effect. This demonstrates that the CO2L and RF could be alternative treatments for GSM in BCSA, since the results were similar to the promestriene treatment, that already has well established benefits in GSM treatment.
Objective: To evaluate clinical and histological vaginal aspects before and after treatment of Genitourinary Syndrome of Menopause (GSM) with CO2 LASER (CO2L), fractional radiofrequency (RF) and promestriene (CT), in breast cancer survivors using adjuvant endocrine therapy (BCSA) and with moderate to severe symptoms of GSM. Methods: Female BCSA presenting moderate to severe symptoms of GSM were eligible for the study. The GSM symptoms were graded using the Visual Analog Scale (VAS), and the patients underwent a clinical evaluation including a standardized gynecological exam, to access Vaginal Health Index (VHI) and to obtain a vaginal biopsy. After that, they were randomized to CO2L, RF and CT groups. The energy groups received three consecutive monthly outpatient vulvovaginal energy applications. The CT group was instructed to use 1g of promestriene at home, daily for 21 days and, subsequently, 1g, twice a week for four months. The follow-up visit was performed four months after the beginning of treatment and included a patient satisfaction evaluation using the 5-points Likert scale. Results: Sixty-two patients concluded the treatment and had adequate pre- and post-treatment vaginal samples to analysis, 21 in the CO2L group, 20 in the RF and 21 in the CT. There was a statistically significant decrease in the intensity of GSM symptoms (p < 0.05), as well as an improvement in VHI (p < 0.001) after treatment, similarly in all treatment groups, regardless of the type of hormonal adjuvant therapy being used. Most of the pre- and post-treatment samples did not show characteristic atrophy parameters. An increased number of stromal papillae among tamoxifen users was observed with a reduction of that parameter after treatment (p = 0.019), achieving a similar frequency observed among anastrozole users in pre- and post-treatment. Furthermore, regardless the moment of evaluation, the mean thickness of the epithelium in tamoxifen users was greater than in anastrozole users (p = 0.002). No relevant clinical or histological adverse effects were observed. Conclusion: There was a clinical and histological dissociation among BCSA with GSM. Although some differences on histological and clinical vaginal signs between tamoxifen and anastrozole users were identified, the intensity of GSM symptoms was similar between them. Moreover, the signs and symptoms of GSM improved similarly in all treatment groups regardless of the adjuvant therapy used, without any histological structure side effect. This demonstrates that the CO2L and RF could be alternative treatments for GSM in BCSA, since the results were similar to the promestriene treatment, that already has well established benefits in GSM treatment.