Evaluation of efficacy and effect of topical low-dose testosterone (3 mg/mL) on estradiol levels by mass spectrometry in breast cancer patients receiving ovarian suppression and aromatase inhibitor therapy

Evaluation of efficacy and effect of topical low-dose testosterone (3 mg/mL) on estradiol levels by mass spectrometry in breast cancer patients receiving ovarian suppression and aromatase inhibitor therapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of efficacy and effect of topical low-dose testosterone (3 mg/mL) on estradiol levels by mass spectrometry in breast cancer patients receiving ovarian suppression and aromatase inhibitor therapy Patrícia Taranto, Diogo de Brito Sales, Fernando Cotait Maluf, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4325612/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Sep, 2024 Read the published version in Breast Cancer Research → Version 1 posted 7 You are reading this latest preprint version Abstract Background Premenopausal, high-risk, hormone receptor-positive breast cancer patients are often treated with ovarian suppression in combination with aromatase inhibitors. This combination has important adverse effects, particularly in sexual function, such as vaginal dryness and loss of libido. There is no effective therapy for reduced sexual function in this setting. Our study aimed to determine the efficacy and safety, particularly regarding sexual function, of a low-dose, topical testosterone gel administration. Methods This is a pilot, single-center study, designed to evaluate the efficacy of topical testosterone gel (3 mg/day) in improving sexual function in 29 premenopausal patients on ovarian suppression in combination with an aromatase inhibitor. The primary safety endpoint was to determine serum estradiol, measured by liquid chromatography-mass spectrometry monthly for three consecutive months. The primary efficacy endpoint was assessed by means of the Female Sexual Function Index questionnaire, which include various domains of sexual function such as libido, sexual satisfaction and vaginal lubrication. Results We report the results on 29 patients. Twenty-two patients (75%) completed the 3-month treatment, and seven discontinued treatment. One was excluded after the first visit because she was postmenopausal, one had a mild skin reaction and five discontinued treatment over the three months mainly due to logistical difficulties related to the COVID-19 pandemic. A total of 29 patients maintained the value of baseline mass spectrometry assay for estradiol of less than 2.7 pg/mL during the 3-month treatment in all three measurements. We observed a significant improvement in Female Sexual Function Index measures over the visits, with an increase from a mean of 11.7 at baseline to 19.1 in the third month (p < 0.001), with the greatest improvement observed between the second and third months. Regarding the domains of the questionnaire evaluated separately, desire, excitement, lubrication, orgasm and satisfaction all showed significant improvement over three months of the protocol. Conclusions Our findings suggest that topical testosterone seems to be safe and may be effective in improving sexual function in patients on ovarian suppression and AI. A randomized phase 2 study is warranted. Trial registration The project was submitted and approved through the hospital's SGPP platform in 11/26/2019 (Project No. SGPP: 3938-19) and CAAE (Research Ethics Committee) (CAAE No: 25609719.5.0000.007) Breast Cancer Menopause Libido Testosterone Aromatase inhibitors Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The treatment of early-stage, hormone receptor-positive breast cancer includes surgery, chemotherapy and/or radiotherapy, followed by hormone therapy, particularly with aromatase inhibitors (AI) and tamoxifen for at least 5 years (1) . In premenopausal patients at high risk of recurrence, the standard treatment consists of ovarian suppression to block hormonal production through the gonadal pathway, combined with tamoxifen or AI (2) . Recently, a meta-analysis confirmed the benefit of ovarian suppression in the treatment of premenopausal patients, especially those who remained premenopausal after chemotherapy or who did not undergo chemotherapy, with improved survival and lower recurrence rates in patients who were treated with non-tamoxifen-based hormonal therapy (3) . However, the use of AI increases the frequency of hormonal side effects, leading to worsening of vaginal dryness, loss of libido, and other symptoms that significantly affect quality of life (4) . These symptoms are often more pronounced in premenopausal women treated with ovarian suppression (5) due to the abrupt chemical menopause. The treatment of vaginal atrophy and loss of libido remains a significant challenge. Intravaginal estriol or testosterone may mitigate local adverse effects with no systemic increase in estradiol levels, but consequently lack systemic effect (6–8) . Systemic estrogen/progesterone replacement improves symptoms attributed to hormone deprivation, but may increase the risk of breast cancer development and recurrence (9–15) . As for testosterone, the data is scarce regarding systemic replacement to improve symptoms attributed to hormone therapy (6–7) . Testosterone is converted to estradiol by the activity of the aromatase enzyme, thus potentially increasing the risk of breast cancer recurrence. The use of AIs, however, may prevent such conversion and provide safety for this strategy. Prompted by this unmet need, we conducted a pilot study designed to evaluate the efficacy and safety of topical testosterone gel (3 mg/day) in the skin, with systemic absorption, in improving sexual function for premenopausal women with breast cancer receiving ovarian suppression and AIs, without increasing estradiol levels. Methods This is a prospective, single-arm intervention pilot study involving 29 premenopausal patients with hormone-positive breast cancer undergoing ovarian suppression and aromatase inhibitor therapy. The study was conducted at the Center for Oncology and Hematology Família Dayan Daycoval, at Hospital Israelita Albert Einstein. The selection of only premenopausal women was based on the greater symptomatology experienced by patients during hormonal blockade compared to postmenopausal women. The project received a grant from AMIGOH project for its implementation. Objectives The primary objective was to evaluate the effect of low-dose topical testosterone supplementation (3 mg/mL) on serum estradiol levels measured by mass spectrometry in premenopausal patients with breast cancer undergoing ovarian suppression and aromatase inhibitor therapy. The secondary objective was to assess the efficacy of topical testosterone in improving sexual symptoms such as libido and vaginal dryness. Inclusion Criteria We included female, premenopausal patients with hormone-positive breast cancer receiving adjuvant or metastatic treatment with ovarian suppression and aromatase inhibitors for at least three months, experiencing symptoms related to hormone therapy. Baseline E2 (estradiol) levels had to be < 2.7 pg/mL. Exclusion Criteria We excluded patients with any contraindication or hypersensitivity to topical testosterone use, known pre-existing psychiatric disorder, history of alcohol or illicit drug abuse, and use of antidepressants or any other medication that may influence sexual dysfunction that was initiated within three months before enrollment in the study protocol. Use of other medications containing any type of hormone or intravaginal laser therapy within the last 15 days before the patient's initiation in the protocol was also prohibited. Study Design This is a pilot, single-arm, prospective, interventionist study aimed at evaluating the effect of topical testosterone use on the elevation of estradiol levels (Figure 1). The treatment consists of daily applications of topical testosterone gel at a dose of 1 pump (equivalent to 1mL containing 3mg of testosterone) on the skin of the inner thigh for 12 weeks. The safety of the treatment is assessed through monthly measurements of E2 during the treatment period. E2 values < 2.72 pg/mL are considered appropriate and safe for the continuation of treatment. Additionally, possible changes in sexual symptoms, such as libido, were evaluated using the Female Sexual Function Index (FSFI) questionnaire. This questionnaire, validated in Portuguese, consists of 19 questions with responses ranging from 0 to 5, indicating increasing levels of function in the areas assessed. It aims to assess the woman's sexual function in the past four weeks, particularly in relation to female sexual response across six main domains: sexual desire, sexual arousal, vaginal lubrication, orgasm, sexual satisfaction, and pain (16) . The questionnaire generates a final score ranging from 2 to 36, with higher scores indicating better perception of the patient's sexual function across the mentioned domains (Table 1). At each clinic visit, the patients completed the FSFI questionnaire and underwent serum estradiol measurements using mass spectrometry. The scheduled visits for each patient were distributed as follows: the first visit (visit 1) for inclusion interview, protocol explanation, and signing of the informed consent form (ICF), followed by visits with a monthly interval for baseline FSFI questionnaire administration, estradiol evaluation by mass spectrometry, and reapplication of the questionnaire (visits 2-4). During these visits, patients were also questioned about the progression of hormone therapy symptoms and possible side effects of the treatment. After the recruitment of patients, the questionnaires were analyzed along with the results of the E2 tests. Patients with E2 measurements > 2.72 pg/mL in at least 2 assessments during testosterone replacement treatment would be excluded from the study. If this increase occurred in more than 5% of the total recruited patients, the study would be terminated. Participants signed the ICF at the beginning of the recruitment, and the study was evaluated and approved by the Research Ethics Committee of the Hospital Israelita Albert Einstein. Figure 1: Study design Statistical Methods Planning Categorical variables were described using absolute frequencies and percentages, while numerical variables were presented as means and standard deviations, or medians and quartiles, along with minimum and maximum values (17) . The distributions of numerical variables were assessed using histogram and boxplot graphs, as well as the Shapiro-Wilk (18) normality test. To investigate variations in the FSFI instrument score between visits, a generalized estimating equation model with Tweedie distribution and autoregressive correlation structure of order 1 was adjusted, and the results were presented as estimated means, 95% confidence intervals, and p-values for comparisons with the value at visit 1. The analyses were performed using the SPSS software, considering a significance level of 5%. The data were collected as described in the article by Pacagnella et al., with questions 17, 18, and 19 reversed (19) . The scoring of the FSFI scores was also calculated according to the recommendations of the article, as follows: Table 1: Calculation of Sexual Function Score Sample size estimation The study was conducted with a convenience sample of 29 women. No formal sample size calculation was performed as this was a pilot study. Results A total of twenty-nine patients were included, of whom 22 completed the 3-month treatment. One patient was excluded after one visit upon discovering she was in the postmenopausal period; one patient discontinued treatment due to a mild skin reaction, which was resolved after discontinuation, and five patients discontinued treatment over the course of three months mainly due to logistical difficulties, primarily related to the COVID-19 pandemic (Figure 2). Figure 2. Study participants throughout the clinic visits The age of the participants ranged from 30.7 to 51.4 years, with a mean age of 40.7 years. The most frequent T stage was T2 (46.2%), and the most common nodal stage was N1a (30.8%). Three patients had metastatic disease (Table 2). Regarding treatment characteristics, 22 (84.6%) received adjuvant chemotherapy, and 21 (80.8%) received adjuvant radiotherapy. The most common hormone therapy regimen was goserelin + exemestane, in 14 cases (53.8%). Table 2: Characteristics of participants and treatment Safety All 29 evaluated patients maintained E2 values < 2.7 pg/mL during the three months of treatment across the three measurements. Efficacy We observed a significant increase in FSFI scores over time, with significant differences starting from Visit 3. The estimated mean score at Visit 1 was 11.7, which increased to 16.3 at Visit 3 and 19.1 at Visit 4 (Figure 3). Figure 3. Description of the total Female Sexual Function Index (FSFI) score over the visits. The adjusted models to assess the evolution of sexual function scores show that for desire, arousal, lubrication, orgasm, satisfaction, and total FSFI score, there is a significant increase from Visit 1 starting from Visit 3. Regarding pain, we did not observe significant changes compared to Visit 1 (Figure 4, Table 3). Figure 4. Description of Female Sexual Function Index domain scores over the visits. Table 3. Evolution od Sexual Function Measures Across Visits Toxicity Regarding adverse effects during treatment, we observed hair growth in five participants (17.2%), with one participant in Visit 2, five in Visit 3, and four in Visit 4. Skin changes/reactions were observed in three participants (10.3%), with three in Visit 2 and none in Visits 3 and 4. In addition, mood changes were observed in eight participants (27.6%), with one case in Visits 2, 3, and 4, five cases only in Visit 2, one case only in Visit 3, and one case only in Visit 4. The percentages were calculated based on the total of 29 initial participants. All reported changes were considered mild (grade 1) by the patients. Discussion Patients undergoing treatment for breast cancer with ovarian suppression and aromatase inhibitors experience significant hormonal side effects due to hormonal deprivation, such as vaginal dryness and loss of libido. Our study demonstrated the feasibility of delivering low doses of systemic testosterone to improve sexual function without increasing estradiol levels. The treatment of vaginal atrophy and loss of libido remains a significant challenge. The safety of intra-vaginal testosterone use has been evaluated in women with breast cancer (6) , with no observed increase in serum estradiol levels during treatment (7) . The improvement associated with its application, however, is limited to local effects, such as vaginal atrophy, with no significant impact on systemic effects of ovarian suppression, such as libido, hot flashes, metabolic changes, sleep disturbances, and irritability. Similarly, the use of low-dose intravaginal estriol (0.005%) has also been evaluated in women with breast cancer undergoing adjuvant treatment with AI, with evidence of safety in this replacement therapy, as there was no detection of increased serum estradiol levels or hormonal levels of FSH and LH in treated patients (8) . However, the benefit is also limited to the local application area. Furthermore, the methodology used for analyzing serum estradiol levels was not homogeneous among the studies, limiting the sensitivity of the methods for detecting low concentrations of estradiol. Currently, it is known that the measurement of estradiol levels in these patients should ideally be performed using mass spectrometry. This technique is highly sensitive and provides more accurate results as there is no interference or interaction of other molecules in the assay, such as biotin, leading to more precise results. Therefore, MS is the preferred technique for evaluating breast cancer patients undergoing ovarian suppression combined with AI (9) . Several studies evaluated the impact of hormone replacement in patients with a history of breast cancer. The HABITS study, prematurely terminated due to alarming results, showed that after a 2-year follow-up, there was a more than 2-fold increase in the risk of breast cancer recurrence in women who received hormone replacement therapy with estrogen and progestogen-based compounds (12) . The Stockholm study also evaluated hormone replacement therapy in a similar setting and was halted due to the results of the HABITS study. However, in its update, recurrence rates were not as high as those found in the HABITS study (13) . Regarding hormonal treatment in patients with breast cancer, The LIBERATE study evaluated the use of tibolone in improving vasomotor symptoms caused by hormone therapy (14) . In this study, despite symptom improvement, there was a significant increase in breast cancer recurrence in patients who used the medication. More recently, a longitudinal study conducted in Denmark evaluated postmenopausal patients with luminal breast cancer who received or did not receive adjuvant hormone therapy and who used some form of systemic or vaginal hormone replacement. This study showed a 16% increase in the risk of breast cancer recurrence in 10 years, particularly with vaginal replacement, without a statistically significant impact on the mortality of these women. Although the study did not specify the exact type of hormone replacement used, a sub-analysis of the study showed that those who received adjuvant therapy with an AI had a higher recurrence rate compared to those who used tamoxifen (15) . Systemic testosterone replacement therapy may also pose risks as it is converted to estradiol by aromatase enzyme activity (6) . However, by using an AI, this risk may be mitigated. For this reason, patients were required to be on AI treatment for breast cancer to prevent the conversion of testosterone to estradiol (20) . Our study demonstrated the safety of topical testosterone gel replacement, with undetectable E2 levels measured throughout the 3-month treatment protocol. Furthermore, the data showed a significant improvement in sexual satisfaction symptoms continuously throughout the treatment, with statistical significance observed between the second and third month of replacement. This finding was supported by an increase in the total score of FSFI, with statistically significant benefits observed in almost all domains assessed by the questionnaire, which are not restricted to local effects related to vaginal atrophy. Among the evaluated patients, there was a small percentage of treatment discontinuation, mainly due to logistical difficulties and the need for outpatient evaluation to complete the questionnaire and collect the testosterone. This percentage was influenced by the fact that the majority of the study took place during the COVID-19 pandemic, which caused anxiety among patients about going to the hospital, in addition to the restrictions imposed by the isolation of infected individuals and their contacts. Furthermore, one patient experienced a local recurrence of breast tumor in the last month of treatment, requiring surgical intervention followed by systemic treatment. This patient had E2 measurements consistently below 2.7 pg/mL throughout the treatment and was already under observation for a suspicious lesion months before entering the protocol, indicating that her recurrence was not associated with the use of the treatment. Despite the positive results regarding the safety of testosterone replacement and the significant improvement observed in the total scores and key domains evaluated by the FSFI during the treatment, our study has several limitations. Firstly, the number of treated patients is small due to the pilot nature of the study, aimed at determining the relative safety regarding serum estradiol levels. Secondly, the follow-up period is short to assess possible recurrences and long-term benefits since the patients were treated for only three months per the protocol. Thirdly, the absence of a placebo group precludes a formal analysis of the potential benefits of the medication. However, the data obtained justify the conduction of a larger study with participant blinding and the inclusion of a control group treated with placebo gel. Fourthly, our study did not measure serum testosterone for pharmacokinetic and pharmacodynamic evaluation due to logistical and cost limitations. Lastly, the study focused on the patients' sexual function quality and did not include validated questionnaires for other domains of quality of life that may be related to hormonal suppression. Nevertheless, the primary outcome of the study was achieved, and promising results were obtained regarding symptom improvement. The results obtained in the study justify the implementation of larger-scale protocols to assess the role of this treatment in improving the quality of life of breast cancer patients and its safety regarding hormonal levels and potential long-term breast cancer recurrence. Conclusions Our data demonstrate the maintenance of undetectable serum levels of estradiol during the 3-month use of topical testosterone. The study also suggests efficacy in improving sexual symptoms such as libido and vaginal dryness in patients with breast cancer undergoing ovarian suppression with aromatase inhibitors. Abbreviations E2 - Estradiol by Mass Spectrometry MS - Mass Spectrometry FSFI - Female Sexual Function Index AI - Aromatase Inhibitor DFS - Disease-Free Survival ICF - Informed Consent Form Declarations Authors´ Contributions Substantial contributions to the acquisition, analysis, or interpretation of the data: PT, ACB, AL, GS. Drafting the work or revising it critically for important intellectual content: PT, ACB, LMP GS. Final approval of submitted version: PT, DS, ACB, AL, GS, RAKG, LMP FCM. Agreement to be personally accountable for contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature: all authors. All authors read and approved the final manuscript. Acknowledgements All patients participants, Hospital Israelita Albert Einstein and AMIGO H for the funding and Edna Terezinha Rother for all support. Funding This work was supported by funding from the AMIGO H in Hospital Israelita Albert Einstein. Availability of data and materials The datasets generated and/or analysed during the current study are available upon request. Ethics approval and consent to participate The study was approved by the hospital's SGPP platform in 11/26/2019 (Project No. SGPP: 3938-19) and CAAE (Research Ethics Committee) (CAAE No: 25609719.5.0000.007). All patients were informed in writing and following oral consultation. All patients have provided written consent before inclusion in the study. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Waks AG, Winer EP. Breast cancer treatment: a review. JAMA. 2019;321(3):288–300. Pagani O, Regan MM, Walley BA, Fleming GF, Colleoni M, Lang I, et al. Adjuvant exemestane with ovarian suppression in premenopausal breast cancer. N Engl J Med. 2014;371(2):107–18. Gray R, Francis BR, Regan P. M, Effects of ovarian or suppression on breast cancer recurrence and survival: patient-level meta-analyses of 14,999 pre-menopausal woman in 25 randomized trials. 2023 ASCO Annual Meeting. Oral Abstract Session. Fallowfield L, Cella D, Cuzick J, Francis S, Locker G, Howell A. Quality of life of postmenopausal women in the arimidex, tamoxifen, alone or in combination (ATAC) adjuvant breast cancer trial. J Clin Oncol. 2004;22(21):4261–71. Bui KT, Willson ML, Goel S, Beith J, Goodwin A. Ovarian suppression for adjuvant treatment of hormone receptor-positive early breast cancer. Cochrane Database Syst Rev. 2020;3(3):CD013538. Melisko ME, Goldman ME, Hwang J, Luca A, Fang S, Esserman LJ, et al. Vaginal testosterone cream vs estradiol vaginal ring for vaginal dryness or decreased libido in women receiving aromatase inhibitors for early-stage breast cancer: a randomized clinical trial. JAMA Oncol. 2017;3(3):313–9. Witherby S, Johnson J, Demers L, Mount S, Littenberg B, Maclean CD, et al. Topical testosterone for breast cancer patients with vaginal atrophy related to aromatase inhibitors: a phase I/II study. Oncologist. 2011;16(4):424–31. Sánchez-Rovira P, Hirschberg AL, Gil-Gil M, Bermejo-De Las Heras B, Nieto-Magro C. A phase II prospective, randomized, double-blind, placebo-controlled and multicenter clinical trial to assess the safety of 0.005% estriol vaginal gel in hormone receptor-positive postmenopausal women with early stage breast cancer in treatment with aromatase inhibitor in the adjuvant setting. Oncologist. 2020;25(12):e1846–54. Santen RJ, Demers L, Ohorodnik S, Settlage J, Langecker P, Blanchett D, et al. Superiority of gas chromatography/tandem mass spectrometry assay (GC/MS/MS) for estradiol for monitoring of aromatase inhibitor therapy. Steroids. 2007;72(8):666–71. Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet. 2019;394(10204):1159–68. Glaser RL, York AE, Dimitrakakis C. Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study. BMC Cancer. 2019;19(1):1271. Holmberg L, Anderson H. HABITS steering and data monitoring committees. HABITS (hormonal replacement therapy after breast cancer–is it safe?), a randomised comparison: trial stopped. Lancet. 2004;363(9407):453–5. Rutqvist LE, Johansson H, Stockholm Breast Cancer Study Group. Long-term follow-up of the randomized Stockholm trial on adjuvant tamoxifen among postmenopausal patients with early stage breast cancer. Acta Oncol. 2007;46(2):133–45. Kenemans P, Bundred NJ, Foidart JM, Kubista E, von Schoultz B, Sismondi P, LIBERATE Study Group, et al. Safety and efficacy of tibolone in breast-cancer patients with vasomotor symptoms: a double-blind, randomised, non-inferiority trial. Lancet Oncol. 2009;10(2):135–46. Cold S, Cold F, Jensen MB, Cronin-Fenton D, Christiansen P, Ejlertsen B. Systemic or vaginal hormone therapy after early breast cancer: a Danish observational cohort Study. J Natl Cancer Inst. 2022;114(10):1347–54. Pacagnella RC, Martinez EZ, Vieira EM. [Construct validity of a Portuguese version of the Female Sexual Function Index]. Cad Saude Publica. 2009;25(11):2333–44. Portuguese. Altman DG. Practical statistics for medical research. London: Chapman & Hall/CRC; 1991. Faraway JJ. Extending the linear model with R: generalized linear, mixed effects and nonparametric regression models. Boca Raton: Chapman & Hall/CRC; 2006. Pacagnella RC, Vieira EM, Rodrigues Junior OM, Souza C. [Cross-cultural adaptation of the Female Sexual Function Index]. Cad Saude Publica. 2008;24(2):416–26. Portuguese. Glaser R, Dimitrakakis C. Testosterone and breast cancer prevention. Maturitas. 2015;82(3):291–5. Tables Table 1 . Calculation of Sexual Function Scores Score Formula Mínimum value Maximum value Sexual desire 0,6*sum (f01, f02) 1,2 6 Arousal 0,3*sum (f03, f04, f05, f06) 0 6 Lubrification 0,3*sum (f07, f08, f09, f10) 0 6 Orgasm 0,4*sum (f11, f12, f13) 0 6 Satisfaction 0,4*sum (f14, f15, f16) 0,8 6 Pain 0,4*sum (f17, f18, f19) 0 6 Total score Sum of scores across all domains 2,0 36 In the article a total score is not mentioned, however we kept this because it was calculated in the database by the researcher. Table 2. Characteristics of Participants and Treatment Demographic Data Age (years) Mean (standard deviation) 40,7 (6,2) Minimum – Maximum 30,7 - 51,4 T-stage, n (%) 1ª 2 (7,7) 1b 3 (11,5) 1c 3 (11,5) 2 12 (46,2) 3 5 (19,2) X 1 (3,8) Number of affected lymph nodes, n (%) 0 5 (19,2) 0(i+) 1 (3,8) 1mi 3 (11,5) 1a 8 (30,8) 1b 4 (15,4) 2a 3 (11,5) 2b 1 (3,8) X 1 (3,8) Presence of metastasis, n (%) No 23 (88,5) Yes 3 (11,5) Surgery, n (%) Yes 25 (96,2) No 1 (3,8) Adjuvant chemotherapy,, n (%) Yes 22 (84,6) No 4 (15,4) Adjuvant chemotherapy regimen, n (%) ACdd + T 10 (45,5) TC x 6 5 (22,7) AC + T 1 (4,5) Other 6 (27,3) Total 22 (100,0) If other regimen, which one? n (%) ddEC-T 1 (16,7) EC-T 1 (16,7) Taxol-->FEC 1 (16,7) TCH 1 (16,7) TCH x6 1 (16,7) TCHP adjuvant 1 (16,7) Total 6 (100,0) Adjuvant Hormone Therapy Regimen, n (%) Goserelin+ Exemestane 14 (53,8) Goserelin + Letrozole 9 (34,6) Goserelin + Tamoxifen 1 (3,8) continuation.. ...continuation Goserelin + Exemestane 1 (3,8) Goserelin + Palbociclib + Anastrozole 1 (3,8) Letrozol 1 (3,8) Received adjuvant radiotherapy, n (%) Yes 21 (80,8) No 5 (19,2) n=29. Table 3. Evolution of Sexual Function Measures Across Visits Visit 1 Visit 2 Visit 3 Visit 4 Sexual desire Mean * 1,9 (1,5; 2,3) 2,3 (2,0; 2,7) 2,8 (2,4; 3,2) 3,3 (2,8; 3,7) p-value** Reference 0,063 0,001 <0,001 Arousal Mean * 1,6 (1,1; 2,1) 1,9 (1,4; 2,4) 2,6 (2,1; 3,1) 3,1 (2,6; 3,6) p-value** Reference 0,101 <0,001 <0,001 Lubrication Mean * 1,9 (1,3; 2,4) 2,1 (1,4; 2,8) 2,8 (2,1; 3,5) 3,2 (2,6; 3,8) p-value** Reference 0,487 0,018 <0,001 Orgasm Mean* 1,6 (1,0; 2,2) 1,9 (1,3; 2,5) 2,5 (1,8; 3,1) 3,2 (2,4; 4,0) p-value** Reference 0,172 0,001 <0,001 Satisfaction Mean * 2,4 (1,9; 2,9) 2,6 (2,0; 3,2) 3,2 (2,6; 3,7) 3,5 (2,8; 4,1) p-value** Reference 0,566 0,003 0,009 Pain Mean * 2,3 (1,5; 3,0) 2,4 (1,6; 3,2) 2,5 (1,8; 3,2) 2,9 (2,1; 3,6) p-value** Reference 0,736 0,588 0,244 FSFI total score Mean (95% CI)* 11,7 (9,1; 14,3) 13,1 (10,4; 15,9) 16,3 (13,7; 18,9) 19,1 (16,3; 21,9) p-value** Reference 0,190 <0,001 <0,001 *Means and confidence intervals estimated by mixed models (95% CI) **: p-value for comparisons relative to visit 1. FSFI: Female Sexual Function Index. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Sep, 2024 Read the published version in Breast Cancer Research → Version 1 posted Editorial decision: Revision requested 27 May, 2024 Reviews received at journal 13 May, 2024 Reviewers agreed at journal 13 May, 2024 Reviewers invited by journal 13 May, 2024 Editor assigned by journal 01 May, 2024 Submission checks completed at journal 01 May, 2024 First submitted to journal 25 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Schvartsman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYFADCQbGB0CKh48ItYwNUC3MBiAtbKRoYZMA0QS1yEekP3/ws83Gnn92j1nl1xw7GTYG5oePbuDRYngjx7Cxty0tccadM2a3ZbclAx3GZmycg0/LjBzGBp4zhxMMJNLSbktuYwZq4WGTxq8l/WHjnzOH7UFaiiW31RPWIi+RYNjMU3GYcYNE8jHGj9sOE9ZiwPPGcLZMBdAvN5IPSzNuO87DxkzAL/Lt6Q8+vjEAhtiMxMaPP7dV2/OzNz98jNeWA0gcZh4wiUc52JYGJA7jDwKqR8EoGAWjYGQCAGcIRb2ojDHUAAAAAElFTkSuQmCC","orcid":"","institution":"Hospital Israelita Albert Einstein","correspondingAuthor":true,"prefix":"","firstName":"Gustavo","middleName":"","lastName":"Schvartsman","suffix":""}],"badges":[],"createdAt":"2024-04-25 17:43:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4325612/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4325612/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13058-024-01886-7","type":"published","date":"2024-09-16T15:56:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56196144,"identity":"f5bcd03d-aeb2-4db6-bf80-68b4f37158e9","added_by":"auto","created_at":"2024-05-09 18:07:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":109264,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4325612/v1/a6eebeb6bb7cdd5e02f9f234.png"},{"id":56196910,"identity":"bce0d2e5-a082-40c9-a6fa-e64b55a5c754","added_by":"auto","created_at":"2024-05-09 18:15:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42191,"visible":true,"origin":"","legend":"\u003cp\u003eStudy participants throughout the clinic visits\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4325612/v1/65fded2cfb699ae33a996899.png"},{"id":56195207,"identity":"778a395a-3276-40eb-99d7-6d71f8776723","added_by":"auto","created_at":"2024-05-09 17:59:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":9998,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of the total Female Sexual Function Index (FSFI) score over the visits.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4325612/v1/3075d1f9bc65ced316f8fa6d.png"},{"id":56196150,"identity":"7b4f6fdc-c5ee-4ca2-a31c-4ff2660d2e78","added_by":"auto","created_at":"2024-05-09 18:08:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":75468,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of Female Sexual Function Index domain scores over the visits.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4325612/v1/2f7eb4efa2b827b30f9cd97d.png"},{"id":65103834,"identity":"ff7f6d6c-06a4-43ec-b878-4c750f098edd","added_by":"auto","created_at":"2024-09-23 16:08:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":798341,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4325612/v1/45a0c6fc-f0c3-426d-85a5-9dd8d4d7523f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of efficacy and effect of topical low-dose testosterone (3 mg/mL) on estradiol levels by mass spectrometry in breast cancer patients receiving ovarian suppression and aromatase inhibitor therapy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe treatment of early-stage, hormone receptor-positive breast cancer includes surgery, chemotherapy and/or radiotherapy, followed by hormone therapy, particularly with aromatase inhibitors (AI) and tamoxifen for at least 5 years\u003csup\u003e(1)\u003c/sup\u003e. In premenopausal patients at high risk of recurrence, the standard treatment consists of ovarian suppression to block hormonal production through the gonadal pathway, combined with tamoxifen or AI\u003csup\u003e(2)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRecently, a meta-analysis confirmed the benefit of ovarian suppression in the treatment of premenopausal patients, especially those who remained premenopausal after chemotherapy or who did not undergo chemotherapy, with improved survival and lower recurrence rates in patients who were treated with non-tamoxifen-based hormonal therapy\u003csup\u003e(3)\u003c/sup\u003e. However, the use of AI increases the frequency of hormonal side effects, leading to worsening of vaginal dryness, loss of libido, and other symptoms that significantly affect quality of life\u003csup\u003e(4)\u003c/sup\u003e. These symptoms are often more pronounced in premenopausal women treated with ovarian suppression\u003csup\u003e(5)\u003c/sup\u003e due to the abrupt chemical menopause.\u003c/p\u003e \u003cp\u003eThe treatment of vaginal atrophy and loss of libido remains a significant challenge. Intravaginal estriol or testosterone may mitigate local adverse effects with no systemic increase in estradiol levels, but consequently lack systemic effect\u003csup\u003e(6\u0026ndash;8)\u003c/sup\u003e. Systemic estrogen/progesterone replacement improves symptoms attributed to hormone deprivation, but may increase the risk of breast cancer development and recurrence \u003csup\u003e(9\u0026ndash;15)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs for testosterone, the data is scarce regarding systemic replacement to improve symptoms attributed to hormone therapy\u003csup\u003e(6\u0026ndash;7)\u003c/sup\u003e. Testosterone is converted to estradiol by the activity of the aromatase enzyme, thus potentially increasing the risk of breast cancer recurrence. The use of AIs, however, may prevent such conversion and provide safety for this strategy. Prompted by this unmet need, we conducted a pilot study designed to evaluate the efficacy and safety of topical testosterone gel (3 mg/day) in the skin, with systemic absorption, in improving sexual function for premenopausal women with breast cancer receiving ovarian suppression and AIs, without increasing estradiol levels.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a prospective, single-arm intervention pilot study involving 29 premenopausal patients with hormone-positive breast cancer undergoing ovarian suppression and aromatase inhibitor therapy. The study was conducted at the Center for Oncology and Hematology Fam\u0026iacute;lia Dayan Daycoval, at Hospital Israelita Albert Einstein. The selection of only premenopausal women was based on the greater symptomatology experienced by patients during hormonal blockade compared to postmenopausal women. The project received a grant from AMIGOH project for its implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary objective was to evaluate the effect of low-dose topical testosterone supplementation (3 mg/mL) on serum estradiol levels measured by mass spectrometry in premenopausal patients with breast cancer undergoing ovarian suppression and aromatase inhibitor therapy.\u003c/p\u003e\n\u003cp\u003eThe secondary objective was to assess the efficacy of topical testosterone in improving sexual symptoms such as libido and vaginal dryness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe included female, premenopausal patients with hormone-positive breast cancer receiving adjuvant or metastatic treatment with ovarian suppression and aromatase inhibitors for at least three months, experiencing symptoms related to hormone therapy. Baseline E2 (estradiol) levels had to be \u0026lt; 2.7 pg/mL.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe excluded patients with any contraindication or hypersensitivity to topical testosterone use, known pre-existing psychiatric disorder, history of alcohol or illicit drug abuse, and use of antidepressants or any other medication that may influence sexual dysfunction that was initiated within three months before enrollment in the study protocol. Use of other medications containing any type of hormone or intravaginal laser therapy within the last 15 days before the patient\u0026apos;s initiation in the protocol was also prohibited.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a pilot, single-arm, prospective, interventionist study aimed at evaluating the effect of topical testosterone use on the elevation of estradiol levels (Figure 1). The treatment consists of daily applications of topical testosterone gel at a dose of 1 pump (equivalent to 1mL containing 3mg of testosterone) on the skin of the inner thigh for 12 weeks. The safety of the treatment is assessed through monthly measurements of E2 during the treatment period. E2 values \u0026lt; 2.72 pg/mL are considered appropriate and safe for the continuation of treatment. Additionally, possible changes in sexual symptoms, such as libido, were evaluated using the Female Sexual Function Index (FSFI) questionnaire. This questionnaire, validated in Portuguese, consists of 19 questions with responses ranging from 0 to 5, indicating increasing levels of function in the areas assessed. It aims to assess the woman\u0026apos;s sexual function in the past four weeks, particularly in relation to female sexual response across six main domains: sexual desire, sexual arousal, vaginal lubrication, orgasm, sexual satisfaction, and pain\u003csup\u003e(16)\u003c/sup\u003e. The questionnaire generates a final score ranging from 2 to 36, with higher scores indicating better perception of the patient\u0026apos;s sexual function across the mentioned domains (Table 1). At each clinic visit, the patients completed the FSFI questionnaire and underwent serum estradiol measurements using mass spectrometry. The scheduled visits for each patient were distributed as follows: the first visit (visit 1) for inclusion interview, protocol explanation, and signing of the informed consent form (ICF), followed by visits with a monthly interval for baseline FSFI questionnaire administration, estradiol evaluation by mass spectrometry, and reapplication of the questionnaire (visits 2-4). During these visits, patients were also questioned about the progression of hormone therapy symptoms and possible side effects of the treatment. After the recruitment of patients, the questionnaires were analyzed along with the results of the E2 tests. Patients with E2 measurements \u0026gt; 2.72 pg/mL in at least 2 assessments during testosterone replacement treatment would be excluded from the study. If this increase occurred in more than 5% of the total recruited patients, the study would be terminated. Participants signed the ICF at the beginning of the recruitment, and the study was evaluated and approved by the Research Ethics Committee of the Hospital Israelita Albert Einstein.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 1: Study design\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Methods Planning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCategorical variables were described using absolute frequencies and percentages, while numerical variables were presented as means and standard deviations, or medians and quartiles, along with minimum and maximum values\u003csup\u003e(17)\u003c/sup\u003e. The distributions of numerical variables were assessed using histogram and boxplot graphs, as well as the Shapiro-Wilk\u003csup\u003e(18)\u003c/sup\u003e normality test. To investigate variations in the FSFI instrument score between visits, a generalized estimating equation model with Tweedie distribution and autoregressive correlation structure of order 1 was adjusted, and the results were presented as estimated means, 95% confidence intervals, and p-values for comparisons with the value at visit 1. The analyses were performed using the SPSS software, considering a significance level of 5%. The data were collected as described in the article by Pacagnella et al., with questions 17, 18, and 19 reversed\u003csup\u003e(19)\u003c/sup\u003e. The scoring of the FSFI scores was also calculated according to the recommendations of the article, as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Calculation of Sexual Function Score\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size estimation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted with a convenience sample of 29 women. No formal sample size calculation was performed as this was a pilot study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of twenty-nine patients were included, of whom 22 completed the 3-month treatment. One patient was excluded after one visit upon discovering she was in the postmenopausal period; one patient discontinued treatment due to a mild skin reaction, which was resolved after discontinuation, and five patients discontinued treatment over the course of three months mainly due to logistical difficulties, primarily related to the COVID-19 pandemic (Figure 2).\u003c/p\u003e\n\u003cp\u003eFigure 2. Study participants throughout the clinic visits\u003c/p\u003e\n\u003cp\u003eThe age of the participants ranged from 30.7 to 51.4 years, with a mean age of 40.7 years. The most frequent T stage was T2 (46.2%), and the most common nodal stage was N1a (30.8%). Three patients had metastatic disease (Table 2). Regarding treatment characteristics, 22 (84.6%) received adjuvant chemotherapy, and 21 (80.8%) received adjuvant radiotherapy. The most common hormone therapy regimen was goserelin + exemestane, in 14 cases (53.8%).\u003c/p\u003e\n\u003cp\u003eTable 2: Characteristics of participants and treatment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSafety\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 29 evaluated patients maintained E2 values \u0026lt; 2.7 pg/mL during the three months of treatment across the three measurements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEfficacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe observed a significant increase in FSFI scores over time, with significant differences starting from Visit 3. The estimated mean score at Visit 1 was 11.7, which increased to 16.3 at Visit 3 and 19.1 at Visit 4 (Figure 3).\u003c/p\u003e\n\u003cp\u003eFigure 3. Description of the total Female Sexual Function Index (FSFI) score over the visits.\u003c/p\u003e\n\u003cp\u003eThe adjusted models to assess the evolution of sexual function scores show that for desire, arousal, lubrication, orgasm, satisfaction, and total FSFI score, there is a significant increase from Visit 1 starting from Visit 3. Regarding pain, we did not observe significant changes compared to Visit 1 (Figure 4, Table 3).\u003c/p\u003e\n\u003cp\u003eFigure 4. Description of Female Sexual Function Index domain scores over the visits.\u003c/p\u003e\n\u003cp\u003eTable 3. Evolution od Sexual Function Measures Across Visits\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eToxicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding adverse effects during treatment, we observed hair growth in five participants (17.2%), with one participant in Visit 2, five in Visit 3, and four in Visit 4. Skin changes/reactions were observed in three participants (10.3%), with three in Visit 2 and none in Visits 3 and 4. In addition, mood changes were observed in eight participants (27.6%), with one case in Visits 2, 3, and 4, five cases only in Visit 2, one case only in Visit 3, and one case only in Visit 4. The percentages were calculated based on the total of 29 initial participants. All reported changes were considered mild (grade 1) by the patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePatients undergoing treatment for breast cancer with ovarian suppression and aromatase inhibitors experience significant hormonal side effects due to hormonal deprivation, such as vaginal dryness and loss of libido. Our study demonstrated the feasibility of delivering low doses of systemic testosterone to improve sexual function without increasing estradiol levels.\u003c/p\u003e \u003cp\u003eThe treatment of vaginal atrophy and loss of libido remains a significant challenge. The safety of intra-vaginal testosterone use has been evaluated in women with breast cancer\u003csup\u003e(6)\u003c/sup\u003e, with no observed increase in serum estradiol levels during treatment\u003csup\u003e(7)\u003c/sup\u003e. The improvement associated with its application, however, is limited to local effects, such as vaginal atrophy, with no significant impact on systemic effects of ovarian suppression, such as libido, hot flashes, metabolic changes, sleep disturbances, and irritability. Similarly, the use of low-dose intravaginal estriol (0.005%) has also been evaluated in women with breast cancer undergoing adjuvant treatment with AI, with evidence of safety in this replacement therapy, as there was no detection of increased serum estradiol levels or hormonal levels of FSH and LH in treated patients\u003csup\u003e(8)\u003c/sup\u003e. However, the benefit is also limited to the local application area. Furthermore, the methodology used for analyzing serum estradiol levels was not homogeneous among the studies, limiting the sensitivity of the methods for detecting low concentrations of estradiol. Currently, it is known that the measurement of estradiol levels in these patients should ideally be performed using mass spectrometry. This technique is highly sensitive and provides more accurate results as there is no interference or interaction of other molecules in the assay, such as biotin, leading to more precise results. Therefore, MS is the preferred technique for evaluating breast cancer patients undergoing ovarian suppression combined with AI\u003csup\u003e(9)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSeveral studies evaluated the impact of hormone replacement in patients with a history of breast cancer. The HABITS study, prematurely terminated due to alarming results, showed that after a 2-year follow-up, there was a more than 2-fold increase in the risk of breast cancer recurrence in women who received hormone replacement therapy with estrogen and progestogen-based compounds\u003csup\u003e(12)\u003c/sup\u003e. The Stockholm study also evaluated hormone replacement therapy in a similar setting and was halted due to the results of the HABITS study. However, in its update, recurrence rates were not as high as those found in the HABITS study\u003csup\u003e(13)\u003c/sup\u003e. Regarding hormonal treatment in patients with breast cancer, The LIBERATE study evaluated the use of tibolone in improving vasomotor symptoms caused by hormone therapy\u003csup\u003e(14)\u003c/sup\u003e. In this study, despite symptom improvement, there was a significant increase in breast cancer recurrence in patients who used the medication.\u003c/p\u003e \u003cp\u003eMore recently, a longitudinal study conducted in Denmark evaluated postmenopausal patients with luminal breast cancer who received or did not receive adjuvant hormone therapy and who used some form of systemic or vaginal hormone replacement. This study showed a 16% increase in the risk of breast cancer recurrence in 10 years, particularly with vaginal replacement, without a statistically significant impact on the mortality of these women. Although the study did not specify the exact type of hormone replacement used, a sub-analysis of the study showed that those who received adjuvant therapy with an AI had a higher recurrence rate compared to those who used tamoxifen\u003csup\u003e(15)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSystemic testosterone replacement therapy may also pose risks as it is converted to estradiol by aromatase enzyme activity\u003csup\u003e(6)\u003c/sup\u003e. However, by using an AI, this risk may be mitigated. For this reason, patients were required to be on AI treatment for breast cancer to prevent the conversion of testosterone to estradiol \u003csup\u003e(20)\u003c/sup\u003e. Our study demonstrated the safety of topical testosterone gel replacement, with undetectable E2 levels measured throughout the 3-month treatment protocol. Furthermore, the data showed a significant improvement in sexual satisfaction symptoms continuously throughout the treatment, with statistical significance observed between the second and third month of replacement. This finding was supported by an increase in the total score of FSFI, with statistically significant benefits observed in almost all domains assessed by the questionnaire, which are not restricted to local effects related to vaginal atrophy.\u003c/p\u003e \u003cp\u003eAmong the evaluated patients, there was a small percentage of treatment discontinuation, mainly due to logistical difficulties and the need for outpatient evaluation to complete the questionnaire and collect the testosterone. This percentage was influenced by the fact that the majority of the study took place during the COVID-19 pandemic, which caused anxiety among patients about going to the hospital, in addition to the restrictions imposed by the isolation of infected individuals and their contacts.\u003c/p\u003e \u003cp\u003eFurthermore, one patient experienced a local recurrence of breast tumor in the last month of treatment, requiring surgical intervention followed by systemic treatment. This patient had E2 measurements consistently below 2.7 pg/mL throughout the treatment and was already under observation for a suspicious lesion months before entering the protocol, indicating that her recurrence was not associated with the use of the treatment.\u003c/p\u003e \u003cp\u003eDespite the positive results regarding the safety of testosterone replacement and the significant improvement observed in the total scores and key domains evaluated by the FSFI during the treatment, our study has several limitations. Firstly, the number of treated patients is small due to the pilot nature of the study, aimed at determining the relative safety regarding serum estradiol levels. Secondly, the follow-up period is short to assess possible recurrences and long-term benefits since the patients were treated for only three months per the protocol. Thirdly, the absence of a placebo group precludes a formal analysis of the potential benefits of the medication. However, the data obtained justify the conduction of a larger study with participant blinding and the inclusion of a control group treated with placebo gel. Fourthly, our study did not measure serum testosterone for pharmacokinetic and pharmacodynamic evaluation due to logistical and cost limitations. Lastly, the study focused on the patients' sexual function quality and did not include validated questionnaires for other domains of quality of life that may be related to hormonal suppression. Nevertheless, the primary outcome of the study was achieved, and promising results were obtained regarding symptom improvement.\u003c/p\u003e \u003cp\u003eThe results obtained in the study justify the implementation of larger-scale protocols to assess the role of this treatment in improving the quality of life of breast cancer patients and its safety regarding hormonal levels and potential long-term breast cancer recurrence.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur data demonstrate the maintenance of undetectable serum levels of estradiol during the 3-month use of topical testosterone. The study also suggests efficacy in improving sexual symptoms such as libido and vaginal dryness in patients with breast cancer undergoing ovarian suppression with aromatase inhibitors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eE2 - Estradiol by Mass Spectrometry\u003c/p\u003e\n\u003cp\u003eMS - Mass Spectrometry\u003c/p\u003e\n\u003cp\u003eFSFI - Female Sexual Function Index\u003c/p\u003e\n\u003cp\u003eAI - Aromatase Inhibitor\u003c/p\u003e\n\u003cp\u003eDFS - Disease-Free Survival\u003c/p\u003e\n\u003cp\u003eICF - Informed Consent Form\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026acute; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubstantial contributions to the acquisition, analysis, or interpretation of the data:\u003cins cite=\"mailto:Patricia%20Taranto\" datetime=\"2023-09-27T11:38\"\u003e\u0026nbsp;\u003c/ins\u003ePT, ACB,\u003cins cite=\"mailto:Patricia%20Taranto\" datetime=\"2023-09-27T11:38\"\u003e\u0026nbsp;\u003c/ins\u003eAL, GS. Drafting the work or revising it critically for important intellectual content: PT, ACB, LMP GS. Final approval of submitted version: PT, DS, ACB, AL, GS, RAKG, LMP FCM. Agreement to be personally accountable for contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature: all authors. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients participants, Hospital Israelita Albert Einstein and AMIGO H for the funding and Edna Terezinha Rother for all support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by funding from the AMIGO H in Hospital Israelita Albert Einstein. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the hospital\u0026apos;s SGPP platform in 11/26/2019 (Project No. SGPP: 3938-19) and CAAE (Research Ethics Committee) (CAAE No: 25609719.5.0000.007). All patients were informed in writing and following oral consultation. All patients have provided written consent before inclusion in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWaks AG, Winer EP. Breast cancer treatment: a review. JAMA. 2019;321(3):288\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePagani O, Regan MM, Walley BA, Fleming GF, Colleoni M, Lang I, et al. Adjuvant exemestane with ovarian suppression in premenopausal breast cancer. N Engl J Med. 2014;371(2):107\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGray R, Francis BR, Regan P. M, Effects of ovarian or suppression on breast cancer recurrence and survival: patient-level meta-analyses of 14,999 pre-menopausal woman in 25 randomized trials. 2023 ASCO Annual Meeting. Oral Abstract Session.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFallowfield L, Cella D, Cuzick J, Francis S, Locker G, Howell A. Quality of life of postmenopausal women in the arimidex, tamoxifen, alone or in combination (ATAC) adjuvant breast cancer trial. J Clin Oncol. 2004;22(21):4261\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBui KT, Willson ML, Goel S, Beith J, Goodwin A. Ovarian suppression for adjuvant treatment of hormone receptor-positive early breast cancer. Cochrane Database Syst Rev. 2020;3(3):CD013538.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelisko ME, Goldman ME, Hwang J, Luca A, Fang S, Esserman LJ, et al. Vaginal testosterone cream vs estradiol vaginal ring for vaginal dryness or decreased libido in women receiving aromatase inhibitors for early-stage breast cancer: a randomized clinical trial. JAMA Oncol. 2017;3(3):313\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWitherby S, Johnson J, Demers L, Mount S, Littenberg B, Maclean CD, et al. Topical testosterone for breast cancer patients with vaginal atrophy related to aromatase inhibitors: a phase I/II study. Oncologist. 2011;16(4):424\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026aacute;nchez-Rovira P, Hirschberg AL, Gil-Gil M, Bermejo-De Las Heras B, Nieto-Magro C. A phase II prospective, randomized, double-blind, placebo-controlled and multicenter clinical trial to assess the safety of 0.005% estriol vaginal gel in hormone receptor-positive postmenopausal women with early stage breast cancer in treatment with aromatase inhibitor in the adjuvant setting. Oncologist. 2020;25(12):e1846\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanten RJ, Demers L, Ohorodnik S, Settlage J, Langecker P, Blanchett D, et al. Superiority of gas chromatography/tandem mass spectrometry assay (GC/MS/MS) for estradiol for monitoring of aromatase inhibitor therapy. Steroids. 2007;72(8):666\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet. 2019;394(10204):1159\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlaser RL, York AE, Dimitrakakis C. Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study. BMC Cancer. 2019;19(1):1271.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmberg L, Anderson H. HABITS steering and data monitoring committees. HABITS (hormonal replacement therapy after breast cancer\u0026ndash;is it safe?), a randomised comparison: trial stopped. Lancet. 2004;363(9407):453\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRutqvist LE, Johansson H, Stockholm Breast Cancer Study Group. Long-term follow-up of the randomized Stockholm trial on adjuvant tamoxifen among postmenopausal patients with early stage breast cancer. Acta Oncol. 2007;46(2):133\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKenemans P, Bundred NJ, Foidart JM, Kubista E, von Schoultz B, Sismondi P, LIBERATE Study Group, et al. Safety and efficacy of tibolone in breast-cancer patients with vasomotor symptoms: a double-blind, randomised, non-inferiority trial. Lancet Oncol. 2009;10(2):135\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCold S, Cold F, Jensen MB, Cronin-Fenton D, Christiansen P, Ejlertsen B. Systemic or vaginal hormone therapy after early breast cancer: a Danish observational cohort Study. J Natl Cancer Inst. 2022;114(10):1347\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePacagnella RC, Martinez EZ, Vieira EM. [Construct validity of a Portuguese version of the Female Sexual Function Index]. Cad Saude Publica. 2009;25(11):2333\u0026ndash;44. Portuguese.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAltman DG. Practical statistics for medical research. London: Chapman \u0026amp; Hall/CRC; 1991.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaraway JJ. Extending the linear model with R: generalized linear, mixed effects and nonparametric regression models. Boca Raton: Chapman \u0026amp; Hall/CRC; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePacagnella RC, Vieira EM, Rodrigues Junior OM, Souza C. [Cross-cultural adaptation of the Female Sexual Function Index]. Cad Saude Publica. 2008;24(2):416\u0026ndash;26. Portuguese.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlaser R, Dimitrakakis C. Testosterone and breast cancer prevention. Maturitas. 2015;82(3):291\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Calculation of Sexual Function Scores\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"89%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFormula\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003eM\u0026iacute;nimum value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eSexual desire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e0,6*sum (f01, f02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e1,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eArousal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e0,3*sum (f03, f04, f05, f06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eLubrification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e0,3*sum (f07, f08, f09, f10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eOrgasm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e0,4*sum (f11, f12, f13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eSatisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e0,4*sum (f14, f15, f16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e0,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e0,4*sum (f17, f18, f19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.391752577319586%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSum of scores across all domains\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2,0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003e36\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the article a total score is not mentioned, however we kept this \u0026nbsp; because it was calculated in the database by the researcher.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eCharacteristics of Participants and Treatment\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"398\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic Data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eMean (standard deviation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e40,7 (6,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eMinimum \u0026ndash; Maximum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e30,7 - 51,4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eT-stage, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e1\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e2 (7,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e3 (11,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e1c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e3 (11,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e12 (46,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e5 (19,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eNumber of affected lymph nodes, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e5 (19,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e0(i+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e1mi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e3 (11,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e8 (30,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e4 (15,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e2a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e3 (11,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e2b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003ePresence of metastasis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e23 (88,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e3 (11,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eSurgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e25 (96,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eAdjuvant chemotherapy,, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e22 (84,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e4 (15,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eAdjuvant chemotherapy regimen, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eACdd + T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e10 (45,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eTC x 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e5 (22,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eAC + T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (4,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e6 (27,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e22 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eIf other regimen, which one? n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eddEC-T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eEC-T\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eTaxol--\u0026gt;FEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eTCH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eTCH x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eTCHP adjuvant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e6 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eAdjuvant Hormone Therapy Regimen, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eGoserelin+ Exemestane\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e14 (53,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eGoserelin + Letrozole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e9 (34,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eGoserelin + Tamoxifen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003econtinuation..\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003e...continuation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eGoserelin + Exemestane\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eGoserelin + Palbociclib + Anastrozole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eLetrozol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e1 (3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eReceived adjuvant radiotherapy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e21 (80,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.94235588972431%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.05764411027569%\"\u003e\n \u003cp\u003e5 (19,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003en=29.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Evolution of Sexual Function Measures Across Visits\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"631\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisit 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisit 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisit 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisit 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eSexual desire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\" valign=\"bottom\"\u003e\n \u003cp\u003eMean *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\" valign=\"top\"\u003e\n \u003cp\u003e1,9 (1,5; 2,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,3 (2,0; 2,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,8 (2,4; 3,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e3,3 (2,8; 3,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ep-value**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eArousal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eMean *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003e1,6 (1,1; 2,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e1,9 (1,4; 2,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,6 (2,1; 3,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e3,1 (2,6; 3,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ep-value**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eLubrication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eMean *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003e1,9 (1,3; 2,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,1 (1,4; 2,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,8 (2,1; 3,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e3,2 (2,6; 3,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ep-value**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eOrgasm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eMean*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003e1,6 (1,0; 2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e1,9 (1,3; 2,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,5 (1,8; 3,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e3,2 (2,4; 4,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ep-value**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eSatisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eMean *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003e2,4 (1,9; 2,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,6 (2,0; 3,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e3,2 (2,6; 3,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e3,5 (2,8; 4,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ep-value**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,566\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eMean *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003e2,3 (1,5; 3,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,4 (1,6; 3,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,5 (1,8; 3,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e2,9 (2,1; 3,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ep-value**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eFSFI total score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003eMean (95% CI)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003e11,7 (9,1; 14,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e13,1 (10,4; 15,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e16,3 (13,7; 18,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e19,1 (16,3; 21,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.02852614896989%\"\u003e\n \u003cp\u003ep-value**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.54199683042789%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e0,190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.80982567353407%\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Means and confidence intervals estimated by mixed models (95% CI)\u003c/p\u003e\n\u003cp\u003e**: p-value for comparisons relative to visit 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFSFI: Female Sexual Function Index.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"breast-cancer-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brcr","sideBox":"Learn more about [Breast Cancer Research](http://breast-cancer-research.biomedcentral.com)","snPcode":"13058","submissionUrl":"https://submission.nature.com/new-submission/13058/3","title":"Breast Cancer Research","twitterHandle":"@BCRJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breast Cancer, Menopause, Libido, Testosterone, Aromatase inhibitors","lastPublishedDoi":"10.21203/rs.3.rs-4325612/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4325612/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePremenopausal, high-risk, hormone receptor-positive breast cancer patients are often treated with ovarian suppression in combination with aromatase inhibitors. This combination has important adverse effects, particularly in sexual function, such as vaginal dryness and loss of libido. There is no effective therapy for reduced sexual function in this setting. Our study aimed to determine the efficacy and safety, particularly regarding sexual function, of a low-dose, topical testosterone gel administration.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis is a pilot, single-center study, designed to evaluate the efficacy of topical testosterone gel (3 mg/day) in improving sexual function in 29 premenopausal patients on ovarian suppression in combination with an aromatase inhibitor. The primary safety endpoint was to determine serum estradiol, measured by liquid chromatography-mass spectrometry monthly for three consecutive months. The primary efficacy endpoint was assessed by means of the Female Sexual Function Index questionnaire, which include various domains of sexual function such as libido, sexual satisfaction and vaginal lubrication.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe report the results on 29 patients. Twenty-two patients (75%) completed the 3-month treatment, and seven discontinued treatment. One was excluded after the first visit because she was postmenopausal, one had a mild skin reaction and five discontinued treatment over the three months mainly due to logistical difficulties related to the COVID-19 pandemic. A total of 29 patients maintained the value of baseline mass spectrometry assay for estradiol of less than 2.7 pg/mL during the 3-month treatment in all three measurements. We observed a significant improvement in \u003cem\u003eFemale Sexual Function Index\u003c/em\u003e measures over the visits, with an increase from a mean of 11.7 at baseline to 19.1 in the third month (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the greatest improvement observed between the second and third months. Regarding the domains of the questionnaire evaluated separately, desire, excitement, lubrication, orgasm and satisfaction all showed significant improvement over three months of the protocol.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur findings suggest that topical testosterone seems to be safe and may be effective in improving sexual function in patients on ovarian suppression and AI. A randomized phase 2 study is warranted.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe project was submitted and approved through the hospital's SGPP platform in 11/26/2019 (Project No. SGPP: 3938-19) and CAAE (Research Ethics Committee) (CAAE No: 25609719.5.0000.007)\u003c/p\u003e","manuscriptTitle":"Evaluation of efficacy and effect of topical low-dose testosterone (3 mg/mL) on estradiol levels by mass spectrometry in breast cancer patients receiving ovarian suppression and aromatase inhibitor therapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 17:59:44","doi":"10.21203/rs.3.rs-4325612/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-27T08:30:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-13T20:01:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303235454355132131525260936914663874777","date":"2024-05-13T19:14:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-13T15:58:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-01T14:00:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-01T13:36:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer Research","date":"2024-04-25T17:31:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"breast-cancer-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brcr","sideBox":"Learn more about [Breast Cancer Research](http://breast-cancer-research.biomedcentral.com)","snPcode":"13058","submissionUrl":"https://submission.nature.com/new-submission/13058/3","title":"Breast Cancer Research","twitterHandle":"@BCRJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"943ad4da-462f-4abc-b8fb-df4c5fe9974f","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-23T15:59:07+00:00","versionOfRecord":{"articleIdentity":"rs-4325612","link":"https://doi.org/10.1186/s13058-024-01886-7","journal":{"identity":"breast-cancer-research","isVorOnly":false,"title":"Breast Cancer Research"},"publishedOn":"2024-09-16 15:56:56","publishedOnDateReadable":"September 16th, 2024"},"versionCreatedAt":"2024-05-09 17:59:44","video":"","vorDoi":"10.1186/s13058-024-01886-7","vorDoiUrl":"https://doi.org/10.1186/s13058-024-01886-7","workflowStages":[]},"version":"v1","identity":"rs-4325612","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4325612","identity":"rs-4325612","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}