Many women (and some men, too) find that a breast cancer diagnosis and treatment seriously disrupts their sex lives. Physical changes, fatigue, lingering nausea and pain, body image issues, and emotional exhaustion all can affect your desire for and ability to have sex. Studies estimate that 40% to 100% of people diagnosed with cancer report some sort of sexual difficulty. At the same time, both patients and their doctors are reluctant to talk about cancer- and treatment-related sexual problems.
Sexual health and function are important components of quality of life for everyone, no matter their age. People who have sexual problems after cancer treatment are more likely to have poor quality of life and other issues, such as depression and lack of self-esteem.
To help doctors help their patients, the American Society of Clinical Oncology (ASCO) has issued guidelines on interventions to address sexual problems in people with cancer.
The guidelines were published in the February 2018 issue of the Journal of Clinical Oncology. Read "Interventions to Address Sexual Problems in People With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaption of Cancer Care Ontario Guideline."
ASCO is a national organization of oncologists and other cancer care providers. ASCO guidelines give doctors recommendations for treatments and testing that are supported by much credible research and experience.
To create the guidelines, a panel of experts reviewed recommendations from Cancer Care Ontario to make sure that they were based on the most relevant scientific evidence. Patricia Ganz, M.D., medical oncologist and professor in the schools of Medicine and Public Health at UCLA and member of the Breastcancer.org Professional Advisory Board, was on the panel of experts.
The guidelines recommend:
- For all people diagnosed with cancer, a member of the patient’s healthcare team should initiate a discussion on sexual health and any sexual problems caused by the cancer or its treatment. The conversation could include the patient’s partner, but ONLY if the patient would like the partner to be part of the discussion. The discussion should first start when the patient is diagnosed and continue to take place periodically throughout treatment and follow-up.
- For women with cancer who are having problems with sexual response, including desire, arousal, or orgasm, doctors should offer psychosocial and/or psychosexual counseling. For premenopausal women, doctors may suggest Addyi (chemical name: flibanserin), though the panel noted that Addyi has not been tested in women with a history of cancer or women taking hormonal therapy, so the risk/benefit analysis of this medicine for women who’ve been diagnosed with cancer is unclear. The expert panel also said that any kind of regular stimulation, including masturbation, would likely improve sexual response, no matter which type of stimulation is used.
- For women with cancer who have body image issues, doctors should offer psychosocial counseling. If a woman has a partner, studies show that couples therapy offers more benefits than usual care. Doctors should talk to women early and often about body image and should take into account cultural and/or religious beliefs.
- For women with cancer who are having difficulty with intimacy or relationships. doctors should offer psychosocial counseling. If a woman has a partner, studies show that couples therapy offers more benefits than usual care.
- For women with cancer who have problems with overall sexual functioning and satisfaction, doctors should offer psychosocial counseling -- either one-on-one or group counseling -- for the woman or the woman and her partner. Exercise or pelvic floor physiotherapy also may be helpful.
- All women should be offered information and ways to manage symptoms based on the individual woman’s diagnosis. For women with persistent physical issues, a gynecologic exam may be helpful. For any woman continuing to have relationship issues and/or distress, mental health counseling should be an option.
- For women experiencing hot flashes and/or night sweats, hormone replacement therapy is considered the most effective treatment. NOTE: Women who have been diagnosed with breast cancer should NOT take hormone replacement therapy. If a woman can’t take hormone replacement therapy, antidepressants such as Paxil (chemical name: paroxetine), Effexor (chemical name: venlafaxine), or Prozac (chemical name: fluoxetine); nerve pain medicines such as gabapentin; and high blood pressure medicines such as clonidine can be alternatives. It’s also important to know that women taking tamoxifen should not take Paxil or Prozac.
- Cognitive behavioral therapy and/or hypnosis also may help ease hot flashes.
- Doctors should discuss all treatment options for hot flashes, including non-medicinal options, with women and talk about the risk and benefits of each option.
- For women having vaginal or vulvar dryness, doctors should recommend lubricants for all sexual activity or touch, along with vaginal moisturizers to improve tissue quality as a first step. Moisturizers may need to be applied more frequently -- 3 to 5 times per week -- in the vagina, at the vaginal opening, and on the external folds of the vulva to help ease symptoms in women who have been diagnosed with cancer.
- For women who don’t respond to the first step for vaginal dryness, or who have more severe symptoms, low-dose vaginal estrogen can be used as a next step. For women diagnosed with hormone-receptor-positive breast cancer who are not responding to lubricants and moisturizers, low-dose vaginal estrogen may be considered after a thorough discussion of the risks and benefits of this treatment.
- Doctors may recommend lidocaine for women who have persistent pain during sex.
- Doctors may recommend vaginal DHEA (dehydroepiandosterone) for women experiencing vaginal dryness who have been diagnosed with hormone-receptor-positive breast cancer who are currently taking an aromatase inhibitor and have not responded to previous treatments. DHEA is a hormone produced by the adrenal gland that helps produce other hormones, including testosterone and estrogen.
- Doctors also should offer pain medicine to women taking an aromatase inhibitor who are having joint/bone pain that interferes with sexual function.
- Doctors may offer vaginal dilators to women having vaginismus and/or vaginal stenosis. When a woman has vaginismus, her vagina’s muscles squeeze or spasm when something is entering it, such as a penis or a tampon. For many women, it is extremely painful. Vaginal stenosis is the narrowing or loss of flexibility of the vagina; it also makes intercourse painful. Ideally, the benefit of vaginal dilators is the greatest when started early. Vaginal dilators should not be recommended based on sexual activity or sexual orientation. Instead, vaginal dilators should be recommended to all women at risk for vaginal changes so they can be proactive in their sexual and vulvovaginal health.
- Doctors may recommend cognitive behavioral therapy and pelvic floor (Kegel) exercise to help decrease sexual anxiety and discomfort.