Expert highlights need for multidisciplinary care in GSM management

In discussing the FDA’s decision to retain the boxed warning for endometrial cancer on estrogen-only systemic therapies, Sameena A. Rahman, MD, emphasizes the continued need for clear, nuanced counseling—especially for patients using low-dose local estrogen for genitourinary syndrome of menopause (GSM).

She notes that patients often confuse systemic and local estrogen risks, worrying that any estrogen exposure increases cancer risk. Rahman explains that the key is helping patients understand systemic absorption differences: Systemic estrogen can create an “unopposed estrogen” environment capable of stimulating the endometrium, whereas low-dose vaginal estrogen products involve minimal, dose-dependent absorption designed only to support vulvovaginal and lower urinary tract tissues. Using plain language—such as framing therapy as “micro-dosing”—helps patients grasp that local treatment does not recreate the systemic exposure patterns associated with endometrial risk. She adds that vaginal DHEA can be a useful option because it carries less perceived risk among patients.

Regarding treatment algorithms, Rahman said she anticipates that the regulatory stance may encourage more clinicians to adopt a layered therapeutic approach for patients with severe GSM—combining systemic hormone therapy for vasomotor and bone benefits with local estrogen or androgen-based therapies for vestibular and urethral symptoms that systemic therapy alone often does not resolve. Many patients, she notes, exhibit significant pathology on exam that they may not report, underscoring the importance of individualized, symptom- and anatomy-guided treatment.

Rahman stresses that overcoming lingering fear from the misinterpreted Women’s Health Initiative (WHI) findings requires intentional education of both patients and colleagues. She advocates precision medicine, visual tools such as mirrors and anatomical models, clear explanation of data, and proactive communication with other clinicians. Sharing current guidelines—such as the collaborative AUA/ACOG/SUFU GSM recommendations—can help reduce confusion and support evidence-based, multidisciplinary care. Social media and professional societies, she adds, play an important role in disseminating accurate information and correcting persistent misconceptions.