Management of Sexual Problems in Breast Cancer Survivors
Andrey Nailor, M.D.·Published 24 June 2008·7 min read
Key points
According to Basson (2006), the management of sexual desire and arousal disorders in women includes psychological and pharmacologic interventions.
There are a number of different psychological interventions that may be helpful for breast cancer survivors with sexual desire and arousal disorders.
Estrogen In the United States, the only medication approved by the Food and Drug Administration for the treatment of sexual dysfunction in women is estrogen (Basson, 2006).
Vaginal dryness should be addressed early because it is easier to prevent vaginal atrophy than to cure it.
According to Basson (2006), the management of sexual desire and arousal disorders in women includes psychological and pharmacologic interventions.
Psychological Interventions
There are a number of different psychological interventions that may be helpful for breast cancer survivors with sexual desire and arousal disorders.
Cognitive behavioral therapy is used to identify and modify factors contributing to sexual dysfunction. Such factors may include maladaptive thoughts, unreasonable expectations, and insufficient nongenital physical stimulation. These sessions vary in number and usually include both partners in order to work on strategies to improve the couple's emotional closeness and communication and to improve erotic stimulation (Basson, 2006).
Sexual therapy is similar to cognitive behavioral therapy but includes sensate focus techniques that are used to change the focus from a performance goal-that is, orgasm-to giving pleasure through touch. Although one study reported that women treated with a combination of behavioral and sexual therapy had improved sexual and marital satisfaction (Trudel et al., 2001), there are few data on the efficacy of such interventions among breast cancer survivors.
Short-term psychotherapy could be utilized to explore poor sexual selfimage and nonsexual experiences in childhood that could affect current sexual function. There are, however, few data to support the benefit of this therapy (Heiman, 2002).
If the breast cancer survivor with sexual dysfunction is known or thought to have a mood disorder such as depression or anxiety, we engage our colleagues in the Department of Psychiatry to ensure that the disorder is appropriately managed. They review the woman's medications to ensure that they are not contributing to sexual dysfunction. A small, short-term study of bupropion (Wellbutrin) in nondepressed, premenopausal women found an increase in arousability and sexual response but not in initial desire (Segraves et al., 2004). {pagebreak}
Systemic Pharmacologic Interventions
Estrogen In the United States, the only medication approved by the Food and Drug Administration for the treatment of sexual dysfunction in women is estrogen (Basson, 2006). Systemic estrogen can decrease vasomotor symptoms and insomnia as well as dyspareunia secondary to vaginal atrophy and thus may improve sexual motivation, although this premise has not been rigorously tested (Basson, 2006). However, the use of systemic estrogen in breast cancer survivors, particularly those who had hormone-sensitive tumors, is controversial.
In a small clinical trial conducted at M. D. Anderson, menopausal women with a history of stage I or II breast cancer with a disease-free interval of at least 2 years (for estrogen receptor-negative tumors) or at least 10 years (for tumors with unknown estrogen receptor status) were given estrogen replacement therapy (ERT) (Vassilopoulou-Sellin et al., 2002). Of the 56 breast cancer survivors who received ERT, 30 took ERT for more than 5 years, 20 took ERT for 2-5 years, and 6 took ERT for less than 2 years.
Written and revised by
Andrey Nailor, M.D.
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Although ERT did not appear to compromise disease-free survival in this highly selected patient population, the authors concluded that larger randomized trials were needed to confirm the safety of ERT in breast cancer survivors. At M. D. Anderson, we do not routinely recommend hormone replacement therapy for our breast cancer survivors.
Given that desire and orgasm are mediated by testosterone, estrogen-deficient women can experience desire and can get pleasure from masturbating or being touched.
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There was no difference in sexual satisfaction between the estrogen-plus-progestin and placebo groups of the Women's Health Initiative trial, which examined exogenous hormone use in postmenopausal women (Hays et al., 2003). However, sexual dysfunction was not a primary end point of this trial, and there is concern that the assessment tool used was inadequate (Basson, 2006).
Testosterone Basson has reviewed the recent randomized, controlled clinical trials that investigated the impact of testosterone supplementation on a number of outcomes, including sexual responsiveness, level of desire, and the number of sexually satisfying events (Lobo et al., 2003; Braunstein et al., 2005; Buster et al., 2005; Simon et al., 2005; Basson, 2006; Davis et al., 2006). In the five trials discussed in Basson's review, post-menopausal women were treated with systemic estrogen therapy combined with either methyltestosterone (Lobo et al., 2003) or testosterone (Braunstein et al., 2005; Buster et al., 2005; Simon et al., 2005; Davis et al., 2006).
When the data from the four estrogen-combined-with-testosterone trials were combined, women receiving estrogen and testosterone reported 1.9 more sexually satisfying events per month than they had at baseline, while women receiving placebo reported 0.9 more such events (Braunstein et al., 2005; Buster et al., 2005; Simon et al., 2005; Davis et al., 2006). These trials did not address the long-term implications of the use of this combination therapy.
No safety or efficacy data are available for testosterone supplementation for estrogen-deficient women (Basson, 2006). Not surprisingly, the use of testosterone in breast cancer survivors is controversial. At M. D. Anderson, we do not routinely prescribe testosterone therapy for our breast cancer survivors with sexual dysfunction.
Phosphodiesterase Inhibitors Sildenafil (Viagra) is a selective inhibitor of phosphodiesterase type 5, an enzyme responsible for degrading cyclic guanosine monophosphate in the corpus cavernosum of the penis. By diminishing the effect of phosphodiesterase type 5, sildenafil facilitates the effect of nitric oxide during sexual stimulation: cyclic guanosine monophosphate levels increase, smooth muscle relaxes, and blood flows into the corpus cavernosum, producing an erection in men (Sildenafil, 2007).
However, in two large randomized trials of women with arousal and desire disorders, sildenafil did not improve sexual desire, sensation, lubrication, or satisfaction (Basson et al., 2002). In a small laboratory-based, randomized trial, some women with genital arousal disorder appeared to respond to a single dose of sildenafil (Basson and Brotto, 2003). Clearly, further studies are needed on the safety and efficacy of these drugs in women with sexual dysfunction, including breast cancer survivors. {pagebreak}
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.
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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.
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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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