Addressing Sexual Function After Breast Cancer Therapy
by Shari Goldfarb, MD, Jeanne Carter, PhD, and Maura Dickler, MD
The majority of women with early-stage breast cancer will become long-term survivors. Therefore, increased attention to quality of life and symptoms should occur both during treatment and throughout survivorship. Common breast cancer treatments of chemotherapy and endocrine therapy may induce menopause in premenopausal women, resulting in hot flashes, increased vaginal dryness, itchiness, pain with vaginal penetration or gynecologic exams, changes in sexual response, decreased sexual interest, and recurrent urinary infections.
Aromatase inhibitors, such as anastrozole (Arimidex®), letrozole (Femara®), and exemestane (Aromasin®), are used to treat postmenopausal women with early-stage and advanced disease. These medications result in extremely low levels of estrogen, which can also cause urinary symptoms, vaginal dryness, and sexual health issues. An understanding of the potential side effects of each therapy is essential in order to make informed medical decisions about available treatment options.
Common symptoms experienced by women with breast cancer include hot flashes, vaginal dryness, decreased sexual interest, pain with intercourse, and difficulties with orgasm.
Sexual dysfunction is a consequence of breast cancer treatment that profoundly affects the lives of both premenopausal and postmenopausal women. Sexual difficulties can be attributed to multiple factors, consisting of physiological (menopause), psychological (anxiety/ depression), and interpersonal (your relationship with your partner) components. If you are experiencing any sexual side effects from your treatment, you should discuss them with your doctor. Sexual side effects of breast cancer treatment can be treated with a myriad of techniques.
Over-the-counter vaginal health products can be used to address sexual side effects in women treated for breast cancer. These include water-based lubricants, silicone-based lubricants, and vaginal moisturizers.
Dr. Jeanne Carter
Water-based lubricants, such as K-Y Jelly and Astroglide, can improve dryness, increase comfort with sexual activity, and decrease pain with intercourse. They are also safe to use with latex condoms. Silicone-based lubricants, such as K-Y Intrigue and Eros Body Glide, have all the benefits of water-based lubricants and are longer lasting. Vaginal moisturizers, such as Replens, K-Y Liquibeads, and Vitamin E, are suppositories that hydrate the tissues when inserted into the vagina and assist in improving dryness, itchiness, elasticity, and irritation. However, it is not uncommon for women to need to apply vaginal moisturizers at least three to five times per week, and you must use them regularly to realize their full potential.
Counseling and sex therapy can also be effective treatment options. They can help women understand the impact of treatment on sexuality, increase sexual knowledge, reduce fear about intimacy, learn strategies to address pain, promote vaginal health, expand the sexual repertoire, and promote positive sexual identity.
Dr. Maura Dickler
Some studies suggest strengthening the pelvic floor and increasing blood flow to the pelvis may be helpful in improving arousal and may have possible restorative effects. Strategies for addressing pain and promoting pelvic floor health in women with breast cancer include dilator therapy, pelvic floor exercises, and increasing blood flow to the pelvic floor.
Dilator therapy mechanically stretches vaginal tissue. It is used to decrease pain with intercourse or gynecologic exams and to prevent or treat vaginal stenosis and adhesions. Pelvic floor exercises are performed daily to stretch and relax pelvic floor muscles, which improves control and strength of the pelvic muscles. This helps decrease pain with intercourse or gynecologic exams and may improve pelvic blood flow. Increasing blood flow to the pelvic floor may promote circulation and arousal response and may have rehabilitative effects by drawing oxygenated blood into the pelvis. Methods include pelvic floor exercises, vibrators, and self-stimulation.
Estrogens are effective for the treatment of menopause-induced vaginal dryness, but hormone replacement therapy has been shown to increase recurrence rates in women with breast cancer. The safety of intravaginal estrogen in breast cancer survivors is unknown. While it is clear that lowering estrogen levels is ideal in preventing recurrences, the absolute estrogen level to minimize risk is unclear. A clinical trial examining intravaginal estrogen use in postmenopausal women on aromatase inhibitors who are experiencing sexual side effects is currently underway at Memorial Sloan- Kettering Cancer Center.
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Dr. Shari Goldfarb is an assistant attending physician on the Breast Cancer Medicine Service and in the Health Outcomes Research Group at Memorial Sloan-Kettering Cancer Center in New York, NY, and instructor of Medicine at Weill Medical College of Cornell University. Dr. Jeanne Carter is head of the Female Sexual Medicine and Women’s Health Program at Memorial Sloan-Kettering. Dr. Maura Dickler is an associate attending physician on the Breast Cancer Medicine Service at Memorial Sloan-Kettering and associate professor of Medicine at Weill Medical College of Cornell University.
This article was published in Coping® with Cancer magazine, September/October 2011.