Sexual Difficulties After Early-Stage Breast Cancer Treatment and Recommendations

Surgery is the standard treatment for early-stage breast cancer. However, most patients also receive endocrine treatment that suppresses female hormones to reduce the risk of cancer returning after surgery. These hormone-suppressing treatments can cause side effects such as fatigue, weakness, changes in blood sugar levels, weight fluctuations and mood changes. They can also cause sexual dysfunction, which is often overlooked and not discussed.

Sexual difficulties are often distressing for women receiving endocrine therapy and negatively affect quality of life. Although uncommon, some patients may not want to continue endocrine therapy because of sexual problems.

By assessing women's symptoms of sexual dysfunction and providing interventions, quality of life can improve.

Evidence-based interventions to support sexual well-being, such as education and counseling, physical therapy and product recommendations, may improve sexual difficulties during endocrine therapy. Routine assessment is needed to identify women with sexual problems who could benefit from these interventions.

Why Is It Important?

Aromatase inhibitors (AI), tamoxifen and suppression or ablation of ovarian function are among the treatments for hormone receptor-positive (HR+) breast cancer. These adjuvant (protective, postsurgical) endocrine therapies

• can cause vaginal dryness,
• dyspareunia (painful intercourse),
• problems with orgasm and
• loss of libido.

Radiation therapy can also negatively affect the response to sensation.

Treatments, together with body-image concerns related to breast cancer surgery, can lead to sexual dysfunction.

Women with early-stage breast cancer need routine assessment for the physical and psychological symptoms of hormone suppression. These assessments may allow earlier intervention to improve sexual function.

A Recent Study

A study was designed that enrolled 300 women with stage 0-3 breast cancer who began adjuvant endocrine therapy between March 2012 and December 2016.

Participants completed questionnaires on patient-reported symptoms during endocrine therapy at 3, 6, 12, 24, 36, 48 and 60 months. Sexual function was assessed with the Medical Outcomes Study Sexual Problems (MOS-SP) questionnaire.

Respondents were assessed in four areas of sexual function:

• lack of sexual interest
• inability to relax and enjoy sex
• difficulty becoming sexually aroused
• difficulty reaching orgasm

Participants also completed other questionnaires assessing common side effects during adjuvant endocrine therapy. Additional measures included Patient-Reported Outcomes Measurement Information System (PROMIS) forms for pain, fatigue, depression, anxiety, physical function and sleep disturbance, and the Functional Assessment of Cancer Therapy Endocrine Symptom Scale (FACT-ES).

Notable Results

The median age of the 300 participants was 62, and 84.3% were women with stage 1-2 breast cancer.

Before adjuvant endocrine therapy, 44% of the women had undergone mastectomy (surgical removal of the whole breast), 28.2% chemotherapy and 66.3% radiotherapy.

Of the treatments started, 55% were AI (aromatase inhibitor) alone, 39.7% tamoxifen alone, and 5% tamoxifen plus ovarian function suppression; one patient received AI plus ovarian suppression. Five patients switched between types of endocrine therapy, while the rest did not change.

In this prospective clinical study of women with early-stage HR+ breast cancer receiving adjuvant endocrine therapy, sexual difficulties were common, and 55% of patients reported at least one sexual problem at enrollment, while 45.7% experienced clinically significant sexual deterioration.

The findings are consistent with earlier studies showing an association between worsening endocrine side effects and sexual problems during adjuvant endocrine therapy. Hot flashes and vaginal dryness are experienced by patients during adjuvant endocrine therapy and are among the most common endocrine side effects. Vaginal dryness often leads to dyspareunia, which can cause problems in several areas, including difficulty relaxing and enjoying sex and difficulty reaching orgasm. Hot flashes, meanwhile, have been associated with mood disturbances and disrupted sleep, which may lead to sexual difficulties. In a recent large cross-sectional study, sleep problems and fatigue were associated with sexual difficulties.

The study also found that worsening physical function during adjuvant endocrine therapy was associated with worsening sexual function.

The study additionally confirmed the previously demonstrated association between mastectomy (surgical removal of the whole breast) and sexual difficulties. Patients who undergo mastectomy may experience body-image concerns that predict negative sexual health outcomes.

Overlooked

Although common and distressing for patients, sexual problems are often underreported and undertreated in routine clinical care. About 60% of breast cancer patients who have sexual difficulties and feel a need for intervention do not consult a health professional.

Common patient-reported barriers to accessing support for sexual difficulties include embarrassment or discomfort in raising sexual concerns. Many patients report wanting doctors to start these discussions, while doctors may be reluctant to do so because of time constraints, lack of knowledge and training, and concerns about offending the patient.

Various interventions have been shown by evidence to improve sexual function during hormonal therapy. Vaginal moisturizers, tablets, suppositories, gels, oils, topical vitamins D and E, and hyaluronic acid may help relieve vaginal dryness, and lubricants can be used during sexual activity for dyspareunia associated with vaginal dryness. Topical lidocaine has also been shown to improve dyspareunia in this group of patients. Local hormonal therapies, including vaginal estrogen or dehydroepiandrosterone (DHEA), may also be used; however, there are concerns about systemic absorption of estrogen, and not all patients and doctors are comfortable using these products in this setting.

In addition, pelvic floor (groin area) muscle training may improve sexual function in survivors of gynecological (women-specific) cancers, and vaginal dilators (expanders) may improve dyspareunia caused by vaginal atrophy.

Conclusion

Given the availability of evidence-based interventions for sexual difficulties, routine assessment of sexual function is critically important in breast cancer patients receiving adjuvant endocrine therapy.

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