Management of Sexual Problems in Breast Cancer Survivors


Alternative Therapies Ginseng,  Ephedra equisetina (ma huang),  and Ginkgo biloba extract are alternative therapies that have been used for sexual problems (Bartlik et al.,  1999).  These agents should all be used with extreme caution in cancer patients. Ginseng may lead to agitation and may promote tumor growth. Ma huang (ephedra) may result in sympathetic activation and has been associated with serious,  even fatal,  side effects such as heart attack,  stroke,  and arrhythmias (U.S.  Food and Drug Administration, 2004). Ginkgo biloba extract is reported to improve cerebral circulation and blood flow by its inhibition of platelet-activating factor and may improve genital blood flow by the same mechanism. However, Ginkgo biloba should be used with caution when bleeding or thrombocytopenia is a concern.

Topical Treatments for Vaginal Atrophy and Dryness

Vaginal dryness should be addressed early because it is easier to prevent vaginal atrophy than to cure it. Women should start using vaginal moisturizers at the start of chemotherapy or antiestrogen therapy such as tamoxifen or an aromatase inhibitor. Vaginal moisturizers such as Replens are helpful in preventing atrophy, and water-soluble lubricants such as KY Jelly and Astroglide may make intercourse more comfortable. The woman should apply a liberal amount to her partner and to the inside and outside of her vagina before her partner attempts penetration.

The use of topical estrogen therapy is controversial in breast cancer survivors. Weisberg et al. (2005) found that a continuous estradiol-releasing vaginal ring (Estring)  and a vaginal estradiol tablet (Vagifem)  were equally safe and effective in the relief of the symptoms and signs of urogenital estrogen deficiency in postmenopausal women. 

In this study of women who were presumably well and without a history of breast cancer (this information is not specified in the methods section of the paper), estradiol and total serum estrone levels showed a small increase during treatment but still stayed within or near the normal range for postmenopausal women.

In a small study of seven postmenopausal women taking aromatase inhibitors for the treatment of early breast cancer, six experienced an increase in serum estradiol levels when they started using topical estrogen therapy (Kendall et al.,  2006).  These levels returned to the post-menopausal range by week 7-10 of topical estrogen therapy in four of these six women. Thus, one should caution breast cancer survivors taking aromatase inhibitors that the use of topical estrogen for vaginal atrophy may reduce the efficacy of the aromatase inhibitors. Kendall et al.  (2006)  suggest that for breast cancer survivors with severe atrophic vaginitis, short-term use of vaginal estrogens in combination with tamoxifen, followed by a return to the use of aromatase inhibitors, may be an option.

Dilator Use for Treatment of Dyspareunia

A gynecologist should evaluate a woman with painful intercourse if the cause is believed to be more complex than simple vaginal dryness.

A woman with a small, tight vagina may need to use a dilator. If a woman is at risk for vaginal atrophy and has sexual intercourse less than once a week, she may need to use a dilator regularly (4-5 times a week) to “practice” good vaginal health.

Karin M. E. Hahn
The University of Texas, Department of Breast Medical Oncology


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