Breast cancer is the most common malignancy in women. Some 2.5 million women in the Untied States are breast cancer survivors: the 5 year survival rate is estimated to be close to 90%. Most women will survive breast cancer and sexual health intimacy concerns are very important in their disease recovery. Twenty-five percent of new cases present before menopause and 15% present before the age of 45. Sexual concerns are distressing complications for women during their diagnostic, treatment, and survivorship phases of breast cancer. Etiological factors that contribute to sexual complaints include premature menopause, premorbid sexual dysfunction and negative self-esteem, relationship discord and underlying psychogenic anxiety and major depression.
Some sources suggest that women of Asian or African American descent may be less communicative about sexual health concerns and possibly more prone to sexual dysfunction after breast cancer, but this has yet to be conclusively determined. There is limited study on breast cancer survivors who are lesbian, bisexual or single. But false assumptions about sexual identity can act as barriers for women who wish to get help for their sexual problems.
Living with a diagnosis of breast cancer can negatively affect sexual self image and function. Common concerns include: fear of recurrence, hesitancy to start a new relationship, fear of partner rejection upon disclosure of breast cancer, stress and sadness related to changed fertility status. In addition, long term life plans and financial stability may have changed.
Research also suggests that surgical therapies used in the treatment of breast cancer can place equal or greater stressors upon a woman’s sexual life than the diagnosis of cancer itself. For example, breast surgery can dramatically change sexual body image. When nipples are removed, sexual excitement that was previously derived from nipple stimulation can become altered or absent When nipples are removed, sexual excitement that was previously derived from nipple stimulation can become altered or absent.
Although the sexual impact of excision and/or reconstruction may be most significant immediately after breast surgery and decrease with time, there may be a need to address problems related to another issue, surgical menopause, especially in younger breast cancer survivors. Up to 10% of women with breast cancer have a genetic predisposition for the development of ovarian cancer because of BRCA gene mutations and some of these women may choose to undergo a risk-reducing bilateral salpingo-oophorectomy (RRBSO). In a recent study, women who underwent a RRBSO were negatively impacted, experiencing dyspareunia and altered body image.
In addition, many women choose to undergo prophylactic mastectomy of the breast unaffected by cancer fearing bilateral involvement or another primary breast cancer. Studies of sexual function after prophylactic mastectomy are scant, but cosmetic results are not always favorable and may negatively impact sexual self esteem.
Radiation therapy may cause direct and indirect affects in terms of sexual dysfunction. Skin damage, fatigue, alopecia, diarrhea, nausea, vomiting and radiation-induced symptoms contribute to general malaise and negatively impact sexual desire and response. Limb lymphedema can contribute to limitations in arm movements that affect caressing and other forms of intimate expression.
Studies are lacking with respect to Mammocyte ®, a novel minimally invasive intramammary placement of radiation at the time of surgical intervention and its implications on female sexual function.
Chemotherapy can be associated with nausea, vomiting, alopecia and malaise. It also increases the probability of premature menopause dramatically in women over the age of 35. More than 40% of women receiving chemotherapy at the age of 40 become amenorrheic. In addition, weight gain associated with chemotherapy and hormonal manipulation has been linked to women’s feelings of lost attractiveness . Goodwin et al noted a mean overall weight gain of 1.6 kg, with an average gain of 2.5 kg, in newly diagnosed breast cancer patients receiving chemotherapy, and a 1.3-kg gain in those taking tamoxifen.
A common adjuvant hormonal treatment for breast cancer is Tamoxifen. It is a first generation selective estrogen receptor modulator (SERM), prescribed to block estrogen receptors in the breast. It also acts as a weak estrogen agonist on the uterine lining requiring monitoring for adverse endometrial effects. Although tamoxifen use may be associated with increasing vulvovaginal dryness and sexual discomfort in some women, studies that have looked at the impact of tamoxifen on sexual function have proven inconclusive.
Aromatase inhibitors (Anastrozole, Letrozole, and Exemestane) are rapidly becoming the mainstay of treatment for various stages of breast cancer. These drugs prevent the production of any estrogen and many women complain of vaginal dryness, moderate to severe dypareunia and loss of sexual desire while on AI therapy. Scientific data are limited. Management may include encouragement of nonpenetrative sex and use of nonestrogen vaginal products such as lubricants and moisturizers to ease dyspareunia.
The literature confirms that many women adapt well after they learn of a breast cancer diagnosis and treatment completion. There are, however, a subset of women who report continued anxiety, depression, and concerns regarding body image, fear of recurrence, post-traumatic stress disorder, and sexual problems well after treatment completion. Sometimes women link prior negative sexual experiences, past sexual behavior (promiscuity, extra marital affairs or acquisition of sexually transmitted diseases) to their cancer diagnosis.
Breast cancer recurrence can create substantial stress as women attempt to maintain their sexual lives. Younger and distant recurrence patients may have the greatest risk for sexual disruption. As a patient once stated, “When I had cancer I had fear of the unknown, when it came back I had fear of the known.” Data demonstrates that many forms of sexual expression (including kissing and intercourse behavior) decline after the recurrent cancer diagnosis and does not significantly improve over time.
Mechanisms for coping, the dynamics of relationships and treatment with chemotherapeutic agents are critical elements to consider when assessing sexual function. After a breast cancer diagnosis, these factors are more influential variables than hormonal levels and age in their affect on arousal, orgasm, lubrication, satisfaction and sexual pain . One study of women receiving ongoing anti-estrogen therapy involved multiple regression analysis to determine what influenced desire, arousal, orgasm, pain and satisfaction. It was found that relationship factors predicted desire and a history of chemotherapy predicted problematic arousal, lubrication, orgasm and pain. However, there was no relationship between sexual function and hormonal levels including androgen metabolites. The experience of chemotherapy rather than the resulting low hormones appeared to be highly detrimental to sexual function.
It is imperative to counsel patients concerning possible sexual remedies including treatments for vaginal dryness. Since breast cancer is often hormonally sensitive and tumor cells possess estrogen and progesterone receptors, treatment of menopausal sequelae with systemic replacement hormones is almost always contraindicated. The use of alternative medications, including serotonin reuptake inhibitors, antihypertensive medications, and environmental modifications (rhythmic breathing, acupuncture, vitamins, avoiding spicy foods and alcohol, dressing in layers) is becoming more widely accepted to help decrease the intensity and severity of menopausal symptoms, though evidence of efficacy with these modalities is limited. Sexual health resources to enhance body image (wigs, special lingere, attachable nipples etc) should be widely available to help the survivor reclaim her sexual self esteem. The use of minimally absorbed local vaginal estrogen products remains an individual decision that requires informed consent and consultation with the oncology team.
Several small reports document increased estradiol levels in women who take aromatase inhibitors and vaginal estrogen tablets. New lower dose tablets need further investigation and safety in breast cancer populations is lacking. Preliminary studies suggest that 0.5 G of Premarin vaginal cream applied locally twice weekly has no endometrial effects and is not systemically absorbed; however it remains officially contraindicated in hormonally sensitive cancer survivors. Long term safety data are lacking such that the use of local estrogens for the treatment of vaginal atrophy after breast cancer women remains experimental: the amount of escape in to the systemic circulation has the potential to interfere with aromatase inhibition.
Non hormonal water based lubricants and moisturizers remain the primary treatment. Delivery of DHEA to the vaginal tissue may allow strictly local estrogen (and androgen) action and be a preferable choice in the future for women who must be strictly systemically estrogen-deplete. A phase III RCT of 216 postmenopausal women without breast cancer, has confirmed maturation of epithelial cells and decrease in pH without significantly increasing serum estrogen or testosterone levels, with all steroid values remaining in the range seen in post menopausal women. All domains of sexual function improved.
The safety of androgen replacement in the breast cancer population has not been adequately studied. There is a concern that testosterone can be converted to estrogen, which may reactivate or promote further tumor growth. The use of androgen replacement in estrogen deficient breast cancer patients was not effective for lowered libido in a recent randomized placebo controlled crossover clinical trial. Future studies are needed to examine the safety and efficacy of androgens in this population.
*(Adapted:International Consensus Conference on Sexual Medicine July 2009)
San Diego Sexual Medicine is conveniently located on the spacious campus of Alvarado Hospital, a private, physician-owned hospital just ten miles from downtown San Diego, and is easily access by car or public transportation.