The Sexual Lives of Breast Cancer Patients Receiving Hormonal Treatment

Cancer recurrence (relapse) risk reduction is the purpose of endocrine (hormonal) treatment , and most breast cancer patients receiving it have long reported adverse effects on sexual function. New studies have shown that this is much more widespread and affects almost all these patients in the population.

Held in San Francisco, USA, the 2019 Supportive Care in Oncology Symposiumwas where Jeanne Carter, head of the Sexual Health and Women’s Health Department at Memorial Sloan Kettering Cancer Center, presented the study results.

Almost all postmenopausal women in the study had low Female Sexual Function Index (FSFI) scores. This shows that patients experience substantial sexual dysfunction and various problems including vulvovaginal dryness and painful intercourse (dyspareunia). These problems are most frequently reported by postmenopausal women initially started on tamoxifen and then switched to aromatase inhibitors . In the study, sexual function index scores were worse among patients using aromatase inhibitors than among those using tamoxifen. The group with the lowest average sexual function index score had been exposed to endocrine treatment for the longest time. This suggests these unwanted conditions result from the cumulative effects of treatment.

During the symposium discussion, Mayo Clinic medical oncologist Dr. Charles Loprinzi emphasized important lessons: clinicians should actively listen to patients’ sexual-life complaints during consultations, and even when patients themselves raise no complaints on this subject , questions should be asked to assess sexual health. Patients also need referral to the appropriate specialist to receive suitable and sufficient support. Insufficient discussion of sexual function may be attributed to the many other problems patients and physicians already need to solve and have on their minds.

The substantial burden of sexual problems

The study included 446 women evaluated in the Female Sexual Medicine & Women’s Health Program at Memorial Sloan Kettering Cancer Center. Among these women with breast cancer, 77% were postmenopausal, 7% were undergoing active ovarian suppression and 16% were peri/premenopausal (during or before menopause).

Patients were receiving different treatment regimens: among postmenopausal women, aromatase inhibitors alone (30%), tamoxifen followed by aromatase inhibitors (22%), tamoxifen alone (16%) and no endocrine treatment (16%); among pre/perimenopausal women, tamoxifen alone (9%) and no endocrine treatment (5%).

Postmenopausal women using tamoxifen tended to be less sexually active than other groups. Women undergoing ovarian suppression and pre/perimenopausal women had a shorter interval since treatment completion than postmenopausal women. Postmenopausal patients were, on average, 13,25 years older than women undergoing ovarian suppression and using tamoxifen. The average time since initial diagnosis was 6,25 years in the postmenopausal group, 4 years in the ovarian suppression group and 2,5 years in the pre/perimenopausal group.

The initial assessment took place an average of 3,3 years after treatment in the postmenopausal group and 1,8 years in younger groups.

- Related topic: Preserving and Rebuilding Sexuality in Women and Men with Cancer

• Vaginal assessment showed that markedly elevated pH was most common in postmenopausal women or women who initially received tamoxifen and subsequently underwent ovarian suppression. Thin vaginal tissues were generally observed across all age groups receiving endocrine treatment. It is emphasized that prolonged endocrine treatment may cause vaginal stenosis (narrowing) in some women.
• Vulvar assessment showed that atrophy (weakening-wasting) was more common in postmenopausal women and those undergoing ovarian suppression than in pre/perimenopausal women (18%). Vulvar irritation without atrophy was more frequent in pre/perimenopausal women using tamoxifen (44%) than in women of the same age receiving no endocrine treatment (19%). Managing vulvar atrophy is important in postmenopausal women and women undergoing ovarian suppression; intervention should therefore not be delayed. Vestibular irritation was present in all groups, at rates ranging from 53% to 70%. Vestibular irritation is particularly associated with pain on penetration during intercourse.
• Level of concern about sexual function and vulvovaginal health was assessed, and most women reported substantial concern. This was found particularly in pre/perimenopausal women, regardless of tamoxifen use. When asked about their views on their future sexual lives, participants ranging from 46% to 76% reported lacking confidence about their future sexual lives.

Finally, patients were asked about vulvovaginal tissue quality. This patient-reported assessment covers their views on their own tissue quality (e.g. whether they experience vaginal dryness, vulvar dryness, insertional pain or pain from external stimuli). All groups reported vulvar symptoms more frequently than vaginal symptoms. Vulvar symptoms were particularly common in the active ovarian suppression group, probably related to greater sexual activity in these younger patients.

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Below are some terms relating to female genital / sexual anatomy frequently mentioned in this article: