Sex is a part of life, and both change after cancer. As treatments for cancer become more advanced and survival rates increase—the overall 5-year relative survival rate is 88% for breast cancer among women of all ages—many women will become long-term survivors. But when patients’ sexual functioning is compromised as a result of cancer treatment, so is their quality of life.
At the AONN+ 2019 Midyear Conference, Leah S. Millheiser, MD, stressed the importance of incorporating sexual preservation into survivorship care and armed navigators with enough knowledge to broach the necessary, but sometimes difficult, subject of sex.
“As a gynecologist working in sexual medicine, I often see late effects of cancer treatment and quality-of-life issues,” said Dr Millheiser, Director of the Female Sexual Medicine Program at Stanford University Medical Center. “Every day I hear women say, ‘I’ve gotten through breast cancer. It’s in the back of my mind that it could come back, but right now all I want is for my sex life to go back to normal. It’s so important to me as a woman, it’s part of who I am, it’s part of my relationship, and I feel like I’m failing.’”
According to Dr Millheiser, survivors of cancer often feel it’s not appropriate to bring up sexual functioning concerns to the providers who saved their lives. This makes it all the more important for their providers to bring it up.
The Most Common Sexual Concerns
About 50% of women with breast or gynecologic cancers will experience long-term sexual dysfunction following treatment (although Dr Millheiser maintains the number is likely higher). The treatments with the greatest impact on sexual function are also the most common: chemotherapy, surgery, hormonal manipulation, and radiation therapy. Compounding the effects of these treatments, other drugs prescribed to patients with cancer can have a negative impact on sexual function, including antianxiety, antinausea, and pain medications; and neuromodulators, antidepressants, and sleep aids.
Although women can experience a myriad of issues related to sexual functioning, including emotional distress, difficulty with orgasm, and pain with genital manipulation, the 2 most common concerns are loss of desire for sex and vaginal dryness/pain with sex (dyspareunia). These conditions are related to change in hormonal function, often from treatment-induced menopause. But the good news is, effective treatments exist.
Flibanserin is the only FDA-approved treatment for low libido in premenopausal women and has been shown to positively affect desire. Off-label, bupropion and buspirone have also demonstrated some improvements in sexual function.
Genitourinary syndrome of menopause (GSM) encompasses all of the symptoms associated with estrogen deficiency after menopause or early menopause from cancer treatment. This could include dryness, burning, decreased genital arousal/orgasmic intensity, and discomfort with sex. According to Dr Millheiser, the first-line approach for treatment of GSM in patients with ER+/PR+ cancer should be nonhormonal therapies: vaginal moisturizers, personal lubricants, and vaginal dilators. Second-line approaches should include vaginal estrogen therapy, followed by nonestrogen therapies (ospemifene and prasterone).
Women with dyspareunia have more difficulty with natural lubrication, so, “when in doubt, use lube,” she said. She encourages liberal use of vaginal lubricants (she prefers silicone to water-based lubricants) and moisturizers, making sure to teach patients the difference. Moisturizers are meant to be used as maintenance therapy several times a week, while personal lubricants should be used during sex.
If a woman prefers oil-based lubricants (another good option, according to Dr Millheiser), remind her that these cannot be used in conjunction with latex condoms. “Women after 50 want to have sex, and they want to have comfortable sex,” she said. But condom use is low, and sexually transmitted infections are being diagnosed more and more often in older populations, likely due to the fact that older women aren’t concerned about pregnancy.
Low-dose vaginal estrogen therapy is the most effective treatment for symptoms of GSM in women who do not respond to nonhormonal remedies. There are 4 commercially available options to deliver a low dose of estrogen to local vaginal tissue: cream, ring, tablet, or suppository.
Every woman undergoing pelvic radiation should be started on dilator therapy to preserve her sexual function, she said. Narrowing/shortening of the vaginal canal due to estrogen loss makes sex painful, but once the vaginal canal is significantly shorter, dilator therapy is unlikely to make a substantial difference.
Have that conversation before therapy starts, she urged. Tell them that radiation will affect healthy tissue in the vagina, and the body will produce scar tissue. She starts radiation patients on dilators with or without estrogen therapy or a vaginal moisturizer (15-30 minutes/day with lubricant) during treatment, unless it is too painful. “Way too many women say, ‘No one told me this would happen,’” she said.
Normalizing the Conversation
According to Dr Millheiser, it is crucial to discuss and normalize these issues, and to reframe the “new normal” when it comes to sex, as this can be incredibly helpful to survivors. She is frank with patients, telling them, “You’re going to have to work harder, and realize that body image and orgasms change.”
To diminish fear and anxiety, encourage patients to choose a time when symptoms are well controlled, and strive for intimacy before intercourse. “I tell patients their goal is to maintain intimacy: feeling good and feeling connected,” she said. “Sex will eventually come back. Hug, kiss, touch…sometimes these things need to be relearned.”
Orgasmic concerns are also common after treatment. Women often cite less intense orgasms or difficulty reaching orgasm due to menopausal changes in nerve conduction, nerve damage due to surgery, diminished blood flow, lack of mindfulness, anxiety, etc. Encourage patients to engage in self-stimulation, she advised. This can help a woman understand what makes her feel good after treatment, and she can in turn communicate that to her partner. And, she added, “Vibrator therapy is a very real thing.”
Treating the Cause
Keep in mind that causes of low libido after a cancer diagnosis are multifactorial and could be related to body image issues, relationship changes, menopause, fatigue, side effects from medications, depression, anxiety, or pain, and primary treatment should be directed at the most likely inciting cause.
Some issues might be overlooked in the course of cancer treatment. Many women associate beauty and sexuality with hair, so losing it can be devastating. A woman with neuropathy in her fingers might say it doesn’t feel right when she touches her partner. A woman who becomes aroused from nipple stimulation might feel broken after losing a breast. Encourage patients to broach these tough subjects and speak freely, she said.
Dr Millheiser encourages talking to patients and identifying any sexual dysfunction or need for counseling or sex therapy very early on.
“There is this misconception that cancer brings couples closer together, but unfortunately we know the opposite to be true,” she noted. “If there are relationship concerns before a cancer diagnosis, these concerns will get worse after diagnosis.”
Cognitive behavioral therapy has demonstrated some effectiveness in women with anorgasmia and sexual arousal disorder, but it is less effective in women with a lack of sexual interest. Sensate focus is a mainstay of sex therapy and focuses on overcoming anxiety and increasing intimacy while taking performance and orgasm off the table.
“Sexual dysfunction is a multifactorial problem and requires a multidisciplinary approach,” she said. “But as long as a woman knows what to expect, she’s going to be better off. Always let your patients know what’s going to happen to their sexual function.”