Why Aren’t We Addressing Sexual Concerns in Women Who Have Survived Cancer?

Key points

• A study involving cancer patients reported changes in sexual function in 87% of patients.
• Female patients were found to be less likely than male patients to be asked about sexual health.
• Cancer treatment can cause various side effects that impair women’s sexual function, such as vaginal dryness, pain during intercourse and low libido.
• Oncologists are well placed to address female patients’ sexual health concerns following treatment. They can recommend vaginal moisturizers, lubricants and vaginal estrogen, and refer patients to work with a sex therapist and a pelvic floor therapist when needed.

Sexual problems are extremely common in women after a cancer diagnosis and treatment; yet most women are never asked by their oncologists about these distressing symptoms and concerns.

As part of a series of tweets about sexual health in women with cancer, Dr. Laila S. Agrawal conducted an informal Twitter poll asking whether they had been asked about sexual health problems. Eighty percent of the 497 responses were “no.”

Agrawal said, “I was alarmed by this answer, but I should not have been surprised. I see patients in a sexual health program for women at a state-run cancer center. I know that after cancer treatment, women cannot have sex and grieve the loss of their healthy sex lives. I often hear that these women were ‘blindsided’ by sexual changes and felt completely unprepared for these changes in their bodies.”

Professionals, patients and their loved ones all fail to discuss sexual problems.

Sexual dysfunction is known to be a common and distressing problem after cancer treatment. Symptoms are reported by 70% of women with breast cancer, women with gynecologic (female-specific) cancers, of whom 65% to 90% report symptoms, and women with colorectal cancer, of whom 60% report symptoms.

Comprehensive guidelines for treating sexual health problems in cancer patients were published by the US National Comprehensive Cancer Network in 2016 and ASCO in 2018. The question is: “Why do we still not consistently address sexuality in practice, and instead leave our patients to ‘suffer in silence’ ?”

Medical professionals reported that, regarding sexual life in cancer, they

• were insufficiently trained,
• felt embarrassed,
• had insufficient time, and
• had limited awareness of treatment.

Oncologists tend to raise the issue when sexual concerns are very important to a patient. However, this is not usually what happens. Patients overwhelmingly do not ask for help with sexual concerns, even when they want treatment for this issue. The responsibility for asking patients about sexual health problems lies with the oncologist.

Gender Inequality

There is a marked gender inequality in addressing sexual health problems in people with cancer, and women are less likely than men to have their sexual function assessed.

A study involving cancer patients reported that 87% had changes in sexual function, but female patients were less likely than male patients to be asked about sexual health (53% of men and 22% of women; P < .001). Similarly, an earlier study reported that 80% of patients with prostate cancer received information about changes in sexual health, but only 33% of patients with breast cancer received this information.

Although disappointing, this striking difference in medical care between men and women is to be expected. In traditional medical education, women’s lack of pleasure during intercourse has not been considered a valid medical concern. Dr. Laila S. Agrawal said, “As a medical student, I was taught to obtain a woman’s sexual history relating to pregnancies, miscarriages, abortions, contraceptive use, number of sexual partners and infection risks—essentially focusing only on the childbearing aspects of their sexuality. However, we were not taught to ask women whether sex was painful or pleasurable. We were not trained to ask whether she had low libido that bothered her or concerns about having an orgasm. It is time for medicine to recognize that female sexuality is an important medical issue.”

Effects of Cancer Treatment on Women’s Sexual Life

Sexual function is influenced by physical,, psychological and social factors, and a cancer diagnosis and treatment can affect all three pillars of health. Chemotherapy, removal of the ovaries and pelvic (groin-region) radiotherapy can all cause early menopause. Women may experience vaginal dryness, reduced lubrication, pain during intercourse and urinary symptoms, as well as systemic symptoms such as low libido, hot flashes, joint pain, sleep disturbances and mood changes.

Postmenopausal women receiving hormone-blocking treatments such as aromatase inhibitors may also experience these symptoms. For women with breast cancer, breast surgery such as mastectomy can lead to loss of nipple and breast sensation, which is associated with sexual arousal, pleasure and orgasm for many women. Surgery for gynecologic cancers may cause loss of clitoral sensation or scarring of vulvar or vaginal tissue. Pelvic radiotherapy can often cause vaginal narrowing and shortening. This not only affects vaginal sexual activity but may also make medical pelvic examinations extremely painful, impossible or traumatic.

Vaginal Dryness

Treatment for vaginal dryness and reduced lubrication includes vaginal moisturizers, lubricants and local vaginal hormone therapy (see the table below). For women with hormone-sensitive cancers, such as estrogen receptor-positive breast cancer, guidelines recommend first-line use of vaginal moisturizers three or more times a week. While vaginal moisturizers are used regularly to maintain vaginal tissue, water- and silicone-based lubricants are used to reduce friction-related discomfort during sexual activity.

 Table: Potential Treatment Options for Vaginal Dryness

For patients whose symptoms and concerns do not improve with vaginal moisturizers and lubricants, local vaginal hormone therapy may be used, as included in guidelines from ASCO, the American College of Obstetricians and Gynecologists and the North American Menopause Society. Studies have shown no increased risk of developing breast or uterine cancer in women using vaginal estrogen. For women with breast cancer taking aromatase inhibitors, some research has shown slight increases in serum estradiol levels; however, this is not linked to any clinical outcome such as cancer recurrence.

Painful Intercourse

Dyspareunia, or pain during intercourse, is unfortunately a common concern after cancer treatment and may result from vaginal narrowing caused by pelvic radiotherapy. Treatment may include progressive vaginal dilators (expanders) and pelvic floor physiotherapy. Some women feel pain at the entrance or opening of the vagina. A study showed that 4% aqueous lidocaine (diluted local anesthesia) applied to the vestibule before sexual activity reduced symptoms of dyspareunia. Pelvic floor dysfunction can also cause dyspareunia; working with a pelvic floor therapist and using treatments such as biofeedback, manual therapy, exercise and vaginal dilator therapy may be effective.

Low Libido

Low libido is a common and often distressing concern for women after cancer treatment. If a woman experiences low libido that she finds distressing, treatment should be offered. Psychosexual counseling, exercise, mindfulness and sensate focus may help. Several commonly prescribed drugs, including some antidepressants such as selective serotonin reuptake inhibitors, may adversely affect libido. A recent study found that bupropion was no better than placebo at improving sexual function. One limitation of this study was that other sexual problems, such as painful sex, vaginal dryness and reduced lubrication, may not have been addressed with participants. There are 2 drugs approved by the FDA (US Food and Drug Administration) for treating low libido in premenopausal women with hypoactive sexual desire disorder not caused by medications or medical effects: flibanserin and bremelanotide. An ongoing study of flibanserin in women with breast cancer (study code: NCT03707340) is seeking to understand the effectiveness of these drugs for treating women with low libido after a cancer diagnosis, and additional studies are needed.

In conclusion, as oncology professionals, we are uniquely placed to understand the effects of cancer and its treatment on women’s sexual function, assess our patients’ concerns, recommend basic interventions and refer them for specialized care. I would like to personally invite all oncology medical professionals reading this article to ask each of your patients about sexual function. By doing so, we can move closer to addressing sexuality as a fundamental quality-of-life issue for people who have completed cancer treatment.