Sexual dysfunction in women

with cancer
,.b .d
Sandy J. Falk, M.D. and Don S. Dizon, M.D.
a Sexual Health Program, Dana Farber Cancer Intitute!
b
De"artment o# $btetric, %ynecology, and &e"roducti'e
Medicine, Har'ard Medical School, Har'ard (ni'erity,
c
De"artment o# Internal Medicine, Har'ard Medical School,
Har'ard (ni'erity, and
d
$ncology Sexual Health, Maachuett %eneral Ho"ital Cancer Center, )oton, Maachuett
*""roximatel
y
+, million "eo"le ha'e a hitory o# cancer in the (nited State alone, and the number i ex"ected to increae -ith time.
.hi ha "rom"ted an a""reciation o# the /uality o# li#e
for
ur'i'or. 0omen treated #or cancer identi#y gynecologic iu
e
a a ma1or
concern for both general health and the negati'e im"act on exual #unction that #ollo- the cancer diagnoi and ube/uent
treatment. Unfortunately, issues related to sexual health continue to be undera""reciated. *lthough com"reheni'e
cancer center ha2e ado"ted specialized centers for survivorship issues, including thoe in'ol'ing exual health,
conultation are not -idely a'ailable in mot
communities. We provide background information on treatment exual health,
examine the im"act
women who have received a cancer diagnosis and been ube/uently treated.
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Medicine.5
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With ad'ance in early detec2 t i o n
a n d t r e a t me n t # o r c a n c e r , t h e
n u mb e r o # u r ' i ' o r rnntinues
to increase' and accordingly there
has been an increased awareness of
survivorship issues. It i
etimated t hat a o# January 9:+9
t here -ere +;.< million "eo"le -ith a
hitory o# cancer in the (nited
State, and the number i ex"ected to
increae to += million by 9:99 3+5. For
#emale cancer ur'i'or, gynecologic
iue are a ma1 or concern, and
many o# t hee iue im"act exual
#unction. Some tertiary care center
ha'e de'elo"ed exual health
"rogram "eci#icall y #or thi "atient
"o"ulation, but ex"ert conultation are
not -idely a'ailable. In addition, mot
oncologit are unable or un-illing to
dicu exuality and i nt i macy i n
t he cont ext o# a #ollo-2u" oncology
'iit becaue o# their lack o# training in
thi area, "er
onal dicom#ort, or time
contraint. Int ead, t hee i ue
are rarel y addreed, and -hen
"atient ak about exual
dy#unction, it i generally to the
primary care physician or gyneco-
logist, -ho may be un#amiliar
-ith thee iue a they "ertain to
-omen "re'iouly treated
-
#or
cancer. In thi article, -e -ill
re'ie- exual health iue in -omen
-ho ha'e had a cancer diagnoi and
ube/uent treatment, and -e -ill
#ocu in greater de"th on dy"areunia
and 'aginal tenoi, t-o o# t he
mot common or i gni #i cant
clinical cenario.
OVERVIEW OF SEXUAL
DYSFUNCTION IN WOMEN
TREATED FOR CANCER
Sexual health condition that
ame cat egor i e a #emal e
exual dy#unction in the general
"o"ulation. .he *merican Pychiatric
*ociation de#ine the #ollo-ing #emale
exual di order7 exual
i nt eret 8 aroual , orgamic, and
genito"el'ic "ain8"enetration 395.
Cancer and it treatment can directly
caue all o# thee condition.
Surgical treatment can reult in
ditortion o# #emale anatomy, "articu2
larly #or "atient -ith breat or gyneco2
logic cancer. In addition, the remo'al
o# t he o'ar i e i n "r emeno"au al
-omen lead to "remature meno"aue
-ith reultant hormonal and "hyical
change that can alter e'eral domain
o# exual #unction. Surgical treatment
can reult in exual dy#unction #or
-omen diagnoed -ith other tumor
a -ell! a an exam"le, exual dy#unc2
t i on i occur i n +=> and ?@> o#
-omen treated #or early tage rectal
cancer 3;5.
Chemotherapy can result in sys-
temic efects that dampen both sexual
desire and arousal. In addition, chemo-
afect a "atien
t
el#2"erce"tion o# exual attracti'ene, and
oue treatment may caue 'aginal or rectal mucoal toxicity
3,5. For "atient treated -ith high2doe chemothera"y a "art o#
a tem cell tran"lantation "rotocol, the additional toxicity may
induce 'ul'o'aginal gra#t2versus-host disease 3%AHD5. Be i
kno-n about the effects of chemotherapy on the #emale
genital tract other than, the ovaries, although women may
ex"erience a persistent vaginal discharge after chemothera"y,
-hich likely re"reent 'aginal mucoiti! alo, there i ome
e'idence that chemothera"y contribute to 'ul'odynia 3?5. In
addition, the ex"erience o# cancer diagnosis and treatment may
profoundly afect a woman's body image and sense of
sexuality (6).
Radiation therapy (RT) can also impact sexual #unction in
-omen. For exam"le. &. #or breat cancer induce local kin
i&ening, conuacture, andior change in texture and color.
a" may result m chronic breast pain, an) of which can a##ect a
v s body unage or ability to enjoy sexual activity.
V!" fdtas# away result from $% to the pelvis with
re&ailaat vaginal fibrosisor stenosis that limits a woman's
capacity for vaginal intercourse as well as affects her genital
pelvic and clitoral sensitivity during sexual acti'ity. .hee
changes last long after $% has been com"leted. For exam"le,
-omen treated #or cer'ical cancer ha'e re"orted exual
dy#unction u" to ? year later 3<5.
ADDRESSING SEXUAL HEALTH IN CANCER
SURVIVORS
.he general a""roach to exual health iue aociated
-ith cancer treatment. like many condition, in'ol'e
"atient edmcafio(# screening, diagmmis. and management
%oo often, =W ad aae
)

*
are %he only goat of the
oncolog+ and, in the context of a busy practice,
survivorship iue including exual health are relegated to
other "ro'ider uch a ocial -orker or "rimary care
"ro'ider. 0ithout an ex"licit undertanding o# ho- the care o#
the cancer ur'i'or i coordinated, iue uch a exualit y
are o#ten le#t unattended. * an exam"le, 0iggin et al.
3=5 conducted a ur'ey o# gynecologic oncologit and #ound
that le than hal# made it a "ractice to take a exual
hitory in ne- "atient and =:> did not #eel there -a
u##icient time to de'ote to ex"loring exual iue. $nl y
9:> #elt they had u##icient time to "eak to their
"atient about thee iue, -hich -a the entiment o#
both male 3=?>5 and #emale 3<;>5 re"ondent.
Approaching Patients beore Treat!ent
Ideally, antici"atory guidance regarding exual health
iue hould be a key element o# "atient education be#ore
treatment #or cancer, but many -omen -ho ex"erience exual
ad'ere effects complain that they were not informed
in
advance. %he typical se,uence ofcvvnb that accompanies
ancer diagnosis and treatment re,uires the complete
attention o# the "atient and her medical team, and thi
o#ten doe not allo- #or "roacti'ely addreing
"ottreatment /uality o# li#e iue. .here#ore, the
"erti#it$ an% Steri#it$&
' $ne a""roach that ha -orked for
"
ine oncology darts
i to re'ie- the ty"ical coure o# "atient care and counseling
for a particular tumor ite. .he team can ther, identi#ythe
mot a""ro"riate time to counel "atient about the "otential
#or exual health iue.
Approaching Patients ater Treat!ent
$nce acti'e cancer treatment ha been com"leted,
"atient hould be creened #or exual health iue.
Sexual health concern are common among thoe
com"leting treatment and -hile mot com"laint can be
treated, o""ortunitie to addre t hem are o#t en
mied. In one tudy o# "ati ent follow-up observation
after pelvic radiation, exual iue were addressed in
only 9?> o# 'iit 3@5.
)arrier t o addressing sexual healt h iue exi t ,
including time contraint or a reluctance to e'en
bring u" exual health iue on the "art o# clinician,
and the ene that many -omen #eel embarraed to ak
about thee iue or may be una-are that treatment i a'ailable
3+:5. In addition, ome "atient may be concerned that their
oncologit -ill "ercei'e that thee iue are tri'ial or that
the "atient i ungrate#ul #or their care. Ho-e'er, /uerie
about exual health can be made 2in a -ay that i2
com#ortableC #or "at i ent , and /uet i on can be
i ncor"orat ed i nt o a routine "ottreat ment re'ie- o#
ytem. In addition to aking thee /uetion, it i
im"ortant to enure that reource are a'ailable locally #or
"atient -ho -ih to "urue #urther treatment.
0hen addreing exual #unction, it i eential that
aum"tion not be made regarding exual orientation or ex2
ual "ractice 3++5. .he "atient hould be aked o"en2ended
,uestions that allow her to feel com#ortable haring in#orma2
tion that is pertinent to her e'aluation and management. For
exam"le, 'aginal intercoure may not be the mot im"ortant
com"onent o# exual acti'ity #or many -omen, including
thoe -ho ha'e ex -ith other -omen.
DIAGNOSIS
.he diagnoi o# exual health iue re/uire a hitory o#
the exual com"laint and a "ertinent medical hitory,
including an oncologic and exual hitory. * medication
hitory hould alo be re'ie-ed becaue o# their im"act on
exual #unction, including the ue o# antide"reant and
endocrine thera"ie. It i im"ortant to ae the a"ect o#
exual dy#unction that are botherome to the "atient,
including -hether concomitant ym"tom o# anxiet y or
de"reion are "reent 3+9, +;5. Detailed diagnoi and
treatment o# exual deire, aroual, and orgam iue i
beyond the co"e o# thi article, but many re'ie- o#
thee to"ic can be #ound in the literature 3+,2+D5.
E'aluat ion and t reat ment o# t hee iue may
necessitate referral to a behavioral health "ecialit or sex
therapist.
It i im"ortant to dicu the interaction bet-een the
) 13 1 VOL. 100 NO. 4 / OCTOBER 2013
1 917
VIEWS AND REVIEWS
.he e'aluation hould include a "el'ic, examination, in
-hich the 'ul'a and 'agina are examined #or the "reence
and e'eri t y o# at ro"hy, change i n 'agi nal l engt h or
caliber due to urgery or "el'
i
c radiation, or adheion.
Care houl d be t aken t o communi cat e -i t h t he "at ient
regarding her ability to tolerate the examination! di##iculty
may be ym"tomatic o# dy"areunia. For thee -omen, the
ue o# a narro- Pederon or "ediatric "eculum may be
better tolerated. (e o# a lubricating gel increae com#ort
and generall y doe not i nt er#ere -i th cer'i cal am"l e
3+<, +=5.
TREAT(ENT
Treatment
must
be individualized
in
kee"ing -ith the
patient's goals. Although the o'erall goal o# management i
to enable -omen to be com#ortable -ith their ex li#e, the
ob1ecti'e may di##er tc, include achie'ement o#
orgam, decreaed "ain -ith "enetration, orim"ro'ed exual
deire. Such goal may di##er bet-een the "atient and her
"artner, -hich may re/uire re#erral #or cou"le thera"y or
ex thera"y. In addition, not all -omen ha'e a current exual
"artner, and thee "atient may re/uet an e'aluation to
enure their exual health #or the #uture.
Dyspareunia
D
y
"areunia i the mot common exual com"laint among
female cancer ur'i'or. .he mot common caue o#
dyspareunia in this population is vulvovaginal atrophy
resulting from bypoestrogenism (19). This may be due to
menopause induced by urgery, chemothera"y, or "el'ic
radiation or may be caued by endocrine thera"y, mainly
#or breat cancer 3e.g., aromatae inhibitor, tamoxi#en5.
Aul'o'aginal atro"hy i characterized by dryne, thinning
o# the e"it heli al l ining, and i n#lammat ion. .hi lo o#
lubrication and elaticit y along -ith the thinning o#
the epithelium leads to an increase in discomfort or pain
either on a daily basis or during vulvovagmal contact.
Women with atrophy often develop small lacerations with
sexual contact, particularly at the vaginal fourchette where
the labia majors converge. This often results in postcoital
bleeding, which is self-limited but may result in anxiety
about sexual
Wfvity
2
Dyspanvnia is also an important quality of life issue. This '.
as demonstrated most notably among breast cancer
survivors (A* In one study, dyspareunia was reported by
563% of women taking aromatase inhibitors and 31.3% of
dxxw UWmg tamoxifen (21).
The frst-line treatment for vaginal atro"hy i the
nonhormonal a""roach o# uing 'aginal moiturizer and
lubricant. Moiturizer hould be ued regularly e'eral
time a -eek to ameliorate daily 'aginal dryne. Bubricant
a
r
e intended #or ue during exual acti'ity. .hee "roduct are
a'ailable o'er the counter, and there are many di##erent
brand. 0omen uually try e'eral "roduct to #ind the one
they prefer. In general, water- or ilicone2baed "roduct
rizer i com"arable to 'aginal etrogen thcro"l', but
n.2.2any -omen #ind 'aginal moiturizer and lubrican2.

inu##icient, in -hich cae greater im"ro'ement can

ty"icall
y
be achie'ed -ith 'aginal etrogen thera"y 39;, 9,5.
Aaginal etrogen thera"y i more e##ecti'e #or treating
'ul'o'aginal atro"hy than ytemic etrogen thera"y
39?5. Aagi nal et rogen t her a"y i e##ect i 'e i n
t r eat i ng t he ym"tom o# 'ul'o'aginal atro"hy in =:
:
+:
to @:> o# -omen and can be adminitered a an etradiol
tablet 3Aagi#em! Fo'o Fordik FemCare *%5 or a lo-2
doe ring uch a Etring 3P#izer5 or Femring 30arner
Chilcott, a 'aginal ring that deli'er a ytemic doe o#
etrogen5, or an etradiol cream 3Etrace! 0arner
Chilcott5 or con1ugated etrogen cream 3Premarin!
P#izer5 3;, 9D5. Bo-2doe 'aginal etrogen thera"y reult in
ome ytemic abor"tion, the le'el de"ending on the
doe and the condition o# the 'aginal e"ithelium! the
degree o# abor"tion a""ear to decreae a the
e"ithelium comitie in re"one to etrogen timulation.
For the etradiol tablet 3Aagi#em, +: ug t-ice -eekl y5
in -omen a#ter natural meno"aue 3a""roximately ? "g8mB5
39<, 9=5. .he doe i more di##icult to control in etrogen222
cream becaue o# uer 'ariability, and the erum etrogen
doe i di##icult to meaure in -omen uing con1ugated
e/uine etrogen cream becaue it contain more than 9::
com"ound.
.he ue o# 'aginal etrogen thera"y in -omen -ith
etrogen2eniti'e cancer i a ub1ect o# debate. .hi
i "articularly an iue in -omen -ith breat cancer,
although it may alo be an iue o# concern in -omen -ith
ad'anced endometrial cancer or ot her hormone
rece"t or2"oit i 'e mal i gnanci e 39@2;+5. .he ue o#
'agi nal et rogen i n -omen -ith etrogen2rece"tor2
"oiti'e breat cancer ha not been -ell tudied. Fo
increae in the rik o# recurrence -a #ound in a
"ro"ecti'e cohort tudy o# -omen -ith breast
cancer that included D@ -omen treated -ith 'aginal etrogen
#or an a'erage o# + year 3range7 :.+2?. : year5 3;95. *
concern ha been raied that 'aginal etrogen may
inter#ere -ith the e##icacy o# aromatae inhibitor
thera"y. .-o tudie o# 10 or #e-er -omen ha'e #ound
that ue o# 'aginal etrogen thera"y in -omen on
aromatae inhibitor i ncreae erum et radi ol and
de"ree gonadot ro"i n levels (33, 34). *
"ro"ecti'e tudy o# D: "atient on aromatae inhibitor
treated -ith 'aginal etradiol tablet i ongoing 3;?5.
Mot "hyi ci an ue an i ndi 'i dual i zed a""roach
t o 'agi nal et rogen u""l ement at i on i n cancer
ur'i 'or, coni t ent -i t h t he "o i t i on o# t he
For t h *mer i can Meno"aue Soci et yGnamel y, t hat
ome -omen i n t hi "o"ulation -ith ym"tomatic
'aginal atro"hy unre"oni'e to nonhormonal thera"ie
may -ant to dicu the rik and bene#it2, o# thi
thera"y, but other may -ih to a'oid any thera"y
aociated -ith "otential rik 3;D5.
For -omen -ho decline 'aginal etrogen thera"y
918 1 VOL. 100 NO. 4 / OCTOBER 2013
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