Treating Sexual Dysfunction in Breast Cancer Survivors

Sexual dysfunction is prevalent in women with breast cancer, a consequence of treatment that affects pre- and postmenopausal women. However, the safety and efficacy of available treatments remain understudied, according to Shari B. Goldfarb, MD, Medical Oncologist, Breast Medicine Service, Memorial Sloan Kettering Cancer Center (MSKCC), NY.

"The majority of women with early-stage breast cancer are alive and disease-free at 5 years," Dr Goldfarb said at the 2015 Breast Cancer Symposium.

"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," she said. "There are many new promising drugs in development."

In a recent study at MSKCC, 76% of women reported sexual problems after breast cancer treatment, including reduced desire and problems related to lubrication and/or orgasm. Pain with intercourse and body image concerns were also reported.

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

"We know that there are sexual side effects from all the therapies that we give, and often endocrine therapy is one of the biggest culprits," said Dr Goldfarb.

Targeted adverse events reported during the Suppression of Ovarian Function Trial and Tamoxifen and Exemestane Trial analysis included hot flashes (91%), vaginal dryness (52.4%), decreased libido (45%), dyspareunia (31%), and urinary incontinence (13%).

"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."

Management Strategies

Because sexual dysfunction in women is often multifactorial in nature, Dr Goldfarb discussed the various treatments and multiple steps:

• Lubricants
  Water-based lubricants improve dryness, decrease pain with intercourse, and minimize friction and irritation. These 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 used just 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, said 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.
• Sleeves/dilators
  These devices come in silicone, pyrex, and plastic. The key is to start small, said Dr Goldfarb, and have the patient slowly work her way up as you use these with lubricants.
• Estradiol vaginal tablets
  The clinical significance of systemic estradiol absorption is unknown, said 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," Dr Goldfarb 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."