Breast cancer and sexuality: what women want to know

The laser, used to treat vaginal dryness (or, more properly, genitourinary syndrome) caused by some of the more common breast cancer drugs, is safe. But it may not be more effective than a placebo. To raise the doubt is a recent clinical study published on Jama Network Open, which compared the outcome of treatments carried out with a fractional CO2 laser and with a fake laser. The trial involved 72 women operated on for breast cancer and being treated with aromatase inhibitors, drugs that inhibit the production of estrogen in menopause.

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Comparison of laser and placebo

The laser in question acts by causing small lesions on the mucosa and thus stimulating the production of collagen and a sort of remodeling. To verify the effectiveness of this treatment, researchers from the University of Barcelona divided the patients into two groups: all underwent an initial therapy with non-hormonal moisturizing creams and vaginal stimulation; half then continued with the real laser treatment and half with the sham (placebo group) for 5 months (one treatment per month).

Sexual function was assessed (measured through an index, the Female Sexual Function Index), the degree of pain during intercourse, vaginal pH and sexual health (through another index), quality of life and perception of one’s body image. In addition, other objective parameters were evaluated before and after the treatments, such as changes in the elasticity and thickness of the vaginal epithelium, and estradiol levels.

Let’s get to the results: after six months, both groups reported improvements in sexual function, but without statistically significant differences between the two. The same was also true for the other parameters considered, both subjective and objective. The interventions were well tolerated overall, but tolerance was significantly lower in the true laser group.

As the authors report, evidence of the efficacy of laser treatments for genitourinary syndrome linked to some anticancer treatments is still contradictory, and their data show that it does not seem to bring a real benefit. The conclusions are similar to those of another study conducted in Australia on postmenopausal women (non-patients), published in 2021 in Jama. The message they leave at the end of the publication is that more long-term studies and meta-analyses on this tool are needed.

Sexual disorders: a still submerged problem

As we have already reported in Salute Seno, however, the laser is only one of the possible remedies to a problem increasingly felt by patients, and which has to do as much with sexual health as with genitourinary health and with the quality of life. Doctors, however, still seem unwilling to take charge of this aspect, especially when the tumor is metastatic. Yet the patients are often young, thanks to the therapies the average survival is greatly increased and with it also the quality of life. This is underlined by MedScape, which offers clinicians an informal test to test their knowledge on this topic. And that gave us the inspiration for a little quiz on such a complex topic.

Breast cancer, it’s time to talk about sex

by Tiziana Moriconi

May 15, 2021

1) What is the sexual health-related adverse effect most often reported by patients taking tamoxifen, among the most common anti-estrogen drugs for breast cancer?

– Anorgasmia (the inability to achieve orgasm)

– Dyspareunia (pain during intercourse) and vaginal dryness

– Sexual arousal disorder (it is not the decrease in libido, but the inability to achieve arousal)

– Vaginismus (fear of penetration associated with involuntary muscle contraction)

Answer

Studies have shown that the most common symptoms are vaginal pain and dryness, followed by a decrease in sex drive.

2) Women with breast cancer should avoid some vaginal lubricants. Which of these are to be preferred?

– With parabens

– Based on petroleum derivatives (e.g. petroleum jelly)

– Based on glycerin

– Silicone based

Answer

According to the American Cancer Society (ACS), silicone-based lubes are preferred over water-based ones for comfort and effectiveness (although they should not be used in conjunction with silicone sex toys). Instead, those based on petroleum derivatives should be avoided; those containing parabens (which can pass through the skin and mimic the action of estrogen) and perfumes; those based on unnatural oils (because they can increase the risk of vaginal infections); those with cooling or heating properties, because it is not clear which substances are used to generate these sensations; those with propylene glycol, which can irritate, and glycerin, which can promote fungal infections. Some natural oils, such as coconut oil, and mineral oils can be used, but carry a risk of breaking the condom. In any case, products that are not specifically for intimate use should be avoided.

3) What sexual health concerns are most often raised by patients with metastatic breast cancer?

– Sex life has become less important due to new perspectives and implications for intimacy

– Body image is the main barrier to intimacy

– How to deal with physical limitations (eg bone pain) is often overlooked by doctors

– How to deal with vaginal dryness

Answer

A small qualitative study carried out through semi-structured interviews with 32 women aged between 35 and 77 showed that sex life continues to be a very important aspect. The main concerns relate to one’s physical limitations – frequent vaginal pain and bone pain, for example – associated with intercourse. Women report that they don’t always receive satisfactory information and that doctors tend to focus on vaginal lubricants.

4) What percentage of women with metastatic breast cancer report a decrease in sexual desire?

– 20%

– 40%

– 60%

– 80%

Answer

There are not many researches that investigate these aspects in patients with stage IV breast cancer. In a 2015 survey of about 600 women, 80% reported having no sexual desire. For more than 70%, the disease had a negative impact on the sexual sphere and anxiety about relationships was reported; 64% did not feel pleasure and for 50% it was even a source of anguish. Although over half felt they could talk to a clinician, only 20% did and just 17% sought treatment; nearly 40% said they would never have resorted to treatment, even if it was free, or requested sexology advice.

5) How should the doctor relate according to patients and partners?

– Patients should always be the first to raise the issue of sexual health

– Partners who insist on talking about sexual issues should be considered a warning sign by doctors

– Physicians should proactively provide information about potential adverse effects of treatments on sexuality, both to patients and partners

– Physicians should reject any rigid beliefs patients have about sexuality

Answer

A recent qualitative survey shows that, according to patients and their partners, doctors should be trained to address the issue of sexual health. Specifically, they should pro-actively provide information about potential adverse effects on sexuality. An open dialogue on this topic within a clinical context can in fact reduce the difficulties in reporting any problems. Clinicians should generally include the partner in the discussion, provided this is in line with the patient’s wishes. The progressive PLISSIT (Permission, Limited Information, Specific Suggestion, Intensive Therapy) model for sexology counseling has proven to be useful. The P stands for permission to discuss the problem, LI for providing some information about the problem; SS to provide suggestions and IT to refer to a therapy.