“Breast Cancer and Sexuality: Multi-modal Treatment Options”
Michael L. Krychman, MD and Anne Katz, RN, PhD
December 7, 2011 – The Journal of Sexual Medicine
Women who have had breast cancer can face a number of sexual issues. Often, there are body image concerns, regardless of whether a woman has had reconstructive surgery. A patient may experience changes in sexual self-esteem and self-efficacy. Chemotherapy and adjuvant hormone therapy may cause vulvovaginal atrophy with subsequent dyspareunia and decrease in sex drive.
Sexuality for women who have had breast cancer is an important issue, but few widely-accepted treatments have been evaluated for efficacy and safety. This article looks at available multimodal treatments that may help, including pharmacologic, nonpharmacologic, and psychosocial interventions.
Traditional Hormonal Treatments
Breast cancer tumor cells often have both estrogen and progesterone receptors. For this reason, using hormone replacement therapy to treat menopausal symptoms is contraindicated.
However, some healthcare providers are prescribing off-label minimally absorbed local vaginal estrogen products, depending on the individual patient’s situation since some patients still complain of vaginal issues after trying non-hormonal treatments.There is no data showing their long-term safety. Experts are concerned that small amounts of hormones may escape into systemic circulation and impair aromatase inhibitors action. Prescriptions of minimally absorbed local vaginal estrogen products are not FDA approved for women with breast cancer. Patients undergoing this type of treatment should be counseled and provide their explicit consent.
Alternative Hormonal Treatments
Because hormonal treatments for vulvovaginal atrophy are not recommended for breast cancer patients, researchers are investigating options that won’t raise hormone levels, such as intravaginal tamoxifen and ospemifene tablets.
Dehydropiandrosterone (DHEA) vaginal ovules are another possibility. Trials of this drug were still in phase III when this article was drafted and studies have not been done for women with a history of malignancy. The drug is not FDA approved and remains experimental. However, it has shown some promise in treating vaginal atrophy without raising hormone levels. It may also help in treating hypoactive sexual desire disorder.
Intravaginal testosterone gel has been found to help dyspareunia and vaginal dryness without increasing estradiol. More study is needed to determine whether it will benefit breast cancer patients. Few studies have shown that androgen therapy is especially helpful for breast cancer patients. Experts are also concerned about the aromatization of androgens to estrogen, so more research is necessary. Systemic testosterone therapy for breast cancer patients remains controversial.
Some women take selective serotonin reuptake inhibitors (SSRIs) for hot flashes and other menopausal symptoms. These drugs may have negative l side effects on sexuality.
For some women, the antidepressant bupropion increases sexual desire and satisfaction. But this drug has not been studied with breast cancer patients and many sexual medicine providers do not prescribe it.
Some interaction between tamoxifen and specific SSRIs that inhibit the cytochrome P450 2D6 (CYP2D6) enzyme has been reported. More study is needed, but providers should be cautious.
Adjuvant Use of Phosphodiesterase Type 5 Inhibitors (PDE5)
Researchers have studied sildenafil (a type of PDE5 inhibitor) use for sexual dysfunction caused by SSRIs. Overall, data on PDE5s have not consistently shown benefits and it is unknown whether their use is safe for breast cancer survivors and those at risk for breast cancer.
PT 141 (bremelanotide) is a nonhormonal drug being studied for use with premenopausal women with female sexual arousal disorder (FSAD) and hypoactive sexual desire disorder (HSDD). So far, results appear promising. If they are confirmed, this treatment may be suitable for breast cancer patients with sexual dysfunction.
Many women with breast cancer find that nonhormonal vaginal moisturizers and water-based lubricants help vulvar and vaginal dryness as well as dyspareunia. These products can be purchased over-the-counter and are easy to use, making them a popular choice.
Some products contain additives, such as warming agents, perfumes, and artificial colors and flavors. These additives can be irritative of a mucosa that is already sensitive or atrophied. A variety of lubricants are available. Water-based lubricants are “compatible” with latex. Petroleum-based products are another option, but they should not be used with condoms, diaphragms, and cervical caps. Natural oils, such as avocado, olive, peanut, and corn, can also be used as lubricants. “Natural” and herbal products have been helpful for some women, although they should be used cautiously. Vibrators and self-stimulators are other treatment options.
Regular sexual activity is also helpful for vaginal atrophy.
Many couples experience sexual and relationship issues after breast cancer. A multimodal approach is commonly taken, including couples counseling, cognitive behavioral therapy, and interventions for specific issues like coping with changes in body image.
In many cases, interventions that focus on the couple are more beneficial than those that focus on the woman alone. Some examples are education on breast cancer diagnosis and treatment, fostering mutual support, sex therapy, and developing problem-solving skills and coping strategies. Sensate focus has also been helpful, as it helps a woman “relearn her body as a source of pleasure instead of pain” and allows couples alternative ways to feel sexually satisfied. Couples counseling can also help with a woman’s perception of body image, as her partner’s response to her body can play an important role.
Individual Interventions for the Woman
Several studies have looked at ways individual counseling can benefit women with breast cancer.
One study found that a 6-week psychoeducational intervention helped with relationship and communication issues.
In another study, women who attended two weekly 2-hour sessions reported greater sexual satisfaction, but no significant changes in the areas of marital intimacy, body image, or sexual dysfunction. Researchers suggested that including the partners in these sessions would have yielded better results.
Currently, researchers are investigating whether a combination of cognitive behavioral therapy and exercise will help with menopausal symptoms, including issues with body image and sexual function.
Mindfulness-based meditation has been studied with various groups, but no studies have yet investigated sexuality, body image, or relationship problems. Still, such interventions have helped people with non-specific cancers cope with anxiety, depression, stress, and fatigue.
Preliminary results of another study have shown that mindfulness meditation has helped women with arousal disorder and women with gynecological cancer.
While study results are encouraging, more evidence is needed to address sexual functioning.
This review has shown that for breast cancer survivors facing sexual issues, “..the evidence is sparse for all kinds of treatments, in particular those at the psychosocial level.” However, many studies are currently investigating medications and psychosocial interventions that may help this population. Further studies are needed.