Treating Sexual Dysfunction in Breast Cancer Survivors

San Francisco, CA—Sexual dysfunction is prevalent in women with breast cancer, and is a consequence of treatment that pre- and postmenopausal women receive. As reported at the 2015 Breast Cancer Symposium, however, the safety and efficacy of available treatments remain understudied at this time.

“The majority of women with early-stage breast cancer are alive and disease-free at 5 years,” said Shari B. Goldfarb, MD, Medical Oncologist, Breast Medicine Service, Memorial Sloan Kettering Cancer Center (MSKCC), New York. “Therefore, we have to start paying increased attention to quality of life and symptoms during treatment and throughout survivorship. Supportive measures with lubricants, moisturizers, physical therapy, and counseling may be of help, but the safety of vaginal estrogen remains unclear.”

“Rigorous testing of interventions in randomized controlled trials is needed,” she added, “but there are many new promising drugs in development.”

In a study at MSKCC, researchers found that 76% of women reported sexual problems after breast cancer treatment, with sexual dysfunction involving desire, arousal, lubrication, and/or orgasm. Pain with intercourse and body image concerns were also reported to varying degrees.

According to a patient survey, chemotherapy, anxiety, a new cancer diagnosis, hormonal therapy, surgery, and a change of relationship with their partner were factors patients felt contributed to their worsening sexual function.

Targeted adverse events that were reported during the Suppression of Ovarian Function Trial (SOFT) and the Tamoxifen and Exemestane Trial (TEXT) included hot flashes (91%), vaginal dryness (52.4%), decreased libido (45%), and dyspareunia (31%).

“These issues are really prevalent and have to be addressed,” said Dr Goldfarb. “In the women who underwent ovarian suppression, dyspareunia (painful sexual intercourse) was also reported in about 25% to 30% of patients.”

Because sexual dysfunction in women is often multifactorial in nature, Dr Goldfarb noted that treatment also requires multiple steps.

• Lubricants. Water-based lubricants improve dryness, decrease pain with intercourse, and minimize friction and irritation. They have a short duration of action, and need to be applied frequently. Silicone-based lubricants are longer-lasting, but are also messier.
• Moisturizers. Moisturizers are not just used as needed— they are used all the time. They can help hydrate vaginal tissue and improve dryness, pruritus, elasticity, and irritation. Replens, hyaluronic acid, and vitamin E are frequently used moisturizers, according to Dr Goldfarb.
• Counseling/sex therapy. Counseling can help patients understand the impact of treatment effects on sexuality while increasing sexual knowledge, reducing fear about intimacy, and promoting a more positive sexual identity.
• Pelvic floor therapy. Physical therapy helps to stretch and relax the pelvic floor muscles. It is used to decrease pain of intercourse and gynecologic exams by promoting circulation of pelvic blood flow.
• Dilators. These devices come in silicone, pyrex, and plastic. The key is to start small, and have patients slowly work their way up as they use these with lubricants, explained Dr Goldfarb.
• Estradiol vaginal tablets. The clinical significance of systemic estradiol absorption is unknown, noted Dr Goldfarb, but recent formulations have been shown to provide statistically significant improvement in the domains of desire, pain, lubrication, orgasm, and satisfaction.
• Altering contributing medications (eg, selective serotonin reuptake inhibitors). New targets for drugs include serotonin receptors. “We know that neurotransmitters and hormones play a role in desire, arousal, and orgasm,” said Dr Goldfarb. “And benefits have been seen in pre- and postmenopausal women.”

“Sexual function for women is complicated and multifactorial,” she concluded. “Decision for treatment is a balance between perceived need and concerns. It must be an informed discussion where you go through risks and benefits, and hear the patient’s preferences.”