Summary of: Sexual Health in Women Affected by

Gynecologic or Breast Cancer

This section of the research paper highlights the prevalence of sexual health problems among
women affected by gynecologic or breast cancer and emphasizes the importance of understanding
the effects of cancer treatment on sexual health. It discusses practical methods for routinely
screening for sexual dysfunction, reviews treatment options, and addresses the limitations of the
current literature in addressing sexual health problems among sexually and gender minoritized
communities. The paper emphasizes the need for appropriate timing of referrals to sexual health
experts, physical therapists, and sex therapists, especially considering the increasing number of
cancer survivors and the importance of quality of life and survivorship issues. The section also
discusses the adverse effects of cancer treatment modalities on sexual function and the guidelines
for suggested treatment options and referrals for patients experiencing sexual dysfunction.
Furthermore, it points out the high prevalence of sexual dysfunction among people diagnosed with
gynecologic or breast cancer and provides strategies for evaluation and management of sexual
dysfunction.

SEXUAL AND GENDER MINORITIZED COMMUNITIES

The section on Sexual and Gender Minoritized (SGM) communities discusses the unique
considerations and limitations in understanding the experiences of individuals with non-
heterosexual orientations and non-cisgender identities in the context of cancer care and
survivorship. The literature has been noted to be predominantly heteronormative, leading to limited
understanding of the specific needs of SGM patients. Efforts are being made to address these
needs, including calls for routine collection of sexual orientation and gender identity data in
healthcare research. Moreover, organizations within oncology are recognizing and advocating for
addressing the disparities experienced by SGM individuals in cancer care. Specific to sexual
health, research findings suggest that commonly used sexual function questionnaires may not
adequately capture the experiences and priorities of SGM patients. The study's cognitive interviews
revealed perceptions that these questionnaires do not align with the diverse experiences and
priorities of SGM individuals. Thus, there is a need for further research and development to ensure
that clinical expertise in sexual health also addresses the diverse needs of SGM communities.

DEFINITION OF SEXUAL DYSFUNCTION AFFECTING WOMEN

WITH CANCER
The section discusses the classification of female sexual dysfunction according to the Diagnostic
and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR). It outlines the
three main categories of sexual dysfunction affecting women: sexual desire and arousal disorders,
orgasmic disorders, and sexual pain disorders. It also highlights the changes from the previous
DSM-5 version, notably the grouping together of desire and arousal disorders and the grouping of
dyspareunia and vaginismus. However, the section emphasizes that the sexual health of women
with cancer is often more complex than the DSM-5-TR classifications suggest. It notes that factors
such as intimacy, which are crucial in addressing sexual health problems in women with cancer,
are not included in the DSM criteria. This highlights the need for a broader, more comprehensive
approach to addressing sexual dysfunction in women with cancer.

UNDERSTANDING THE IMPORTANCE OF INTIMACY

The section emphasizes the significance of intimacy as a crucial aspect of sexuality after cancer,
distinct from sexual activity. It highlights the tendency of medical professionals to prioritize coital
relationships, potentially neglecting the importance of intimacy outside of sexual intercourse. The
author presents Basson's perspective, indicating that intimacy is experienced independently from
stimulation, arousal, desire, and satisfaction. Furthermore, Perz et al. conducted a methodological
study involving interviews with healthcare professionals in oncology, individuals with cancer, and
their partners. The study revealed that both men and women adapt sexually to cancer, with
closeness becoming more pivotal than sexual intercourse in their relationships. This suggests a
need to address and prioritize intimacy in the sexual lives of individuals after cancer.

CANCER TREATMENTS LEADING TO CHANGES IN SEXUAL

FUNCTION
The research paper highlights the prevalence of sexual function problems among women living
with or surviving cancer, especially in those with gynecologic cancers. Cancer treatments, including
surgery, chemotherapy, radiation, immunotherapy, and hormonal therapy, can contribute to sexual
health issues. Additionally, psychosocial and mental health effects of cancer can also impact
sexual function. The type of treatment, pre-cancer sexual health, coexisting disorders, medical
comorbidities, anxiety, depression, cultural concerns, and trauma history can all influence sexual
challenges. However, despite the high prevalence of sexual health problems, especially in
gynecologic and breast cancer survivors, these issues are often not adequately addressed. The
paper emphasizes the importance of physicians regularly inquiring about sexual issues and
underscores the need to understand the effects of cancer diagnosis and treatments on sexual
health to effectively address these concerns.

Radical Hysterectomy
Radical hysterectomy is the primary treatment for early-stage cervical cancer and is sometimes
used for endometrial and ovarian cancers. Short-term effects of the procedure may include
difficulty with orgasm, vaginal shortening, dyspareunia, lymphedema, genital numbness, and
sexual dissatisfaction. Long-term consequences can involve a lack of sexual interest, lymphedema,
genital numbness, and insufficient vaginal lubrication. The procedure may also impact bowel and
bladder function, indirectly affecting sexual function. The disruption of the hypogastric and
splanchnic nerve plexuses during surgery could be the underlying cause. However, nerve-sparing
radical hysterectomy has shown improvements in bowel and bladder function, as well as sexual
function in both the short-term and long-term, while maintaining comparable oncologic outcomes to
traditional radical hysterectomy.

Oophorectomy
The research paper discusses the impact of oophorectomy in patients undergoing surgery for
ovarian and endometrial cancer. Even in postmenopausal patients, the removal of the ovaries can
lead to hormonal changes, resulting in decreased sexual desire and menopausal symptoms. Pre-
menopausal patients are at the highest risk for severe onset of menopausal symptoms and
experience less sexual pleasure post-surgery. The paper also addresses the impact of vulvar
surgery on sexual function and psychological well-being, highlighting that the removal of a portion
of the vulva can lead to body image issues, pain during intercourse, vaginal narrowing, and
numbness along the scar. Additionally, the study reports that patients who were not sexually active
after radical vulvectomy cited genital complications from their surgery as the reason for abstinence.
Furthermore, it discusses the association between lymphedema following groin dissections and
decreased quality of life and sexual function, emphasizing the importance of early identification and
treatment of lymphedema symptoms.

Breast Surgery
The research paper discusses the impact of breast cancer surgery on sexuality and body image. It
highlights the importance of the breast as a sexual organ for stimulation, arousal, and positive body
image. The study by Gass et al. surveyed women after breast cancer treatment and found that
regardless of the surgical procedure, 80-90% of patients considered the chest or breast as
important for sex and intimacy. However, after surgery, the importance decreased to 74% for
patients who underwent lumpectomy, 77% for those who underwent mastectomy with
reconstruction, and 47% for those who underwent mastectomy without reconstruction. These
findings indicate that breast cancer surgery has significant effects on breast-specific sensuality and
emphasize the need to consider the impact on sexuality and body image when planning and
undergoing breast cancer surgery.

Sexual Dysfunction After Radiation Therapy

The section on sexual dysfunction after radiation therapy (RT) highlights the various adverse
effects that RT to the pelvis can have on sexual function in women with cervical, endometrial, and
vulvar cancers. These effects include vaginal stenosis, vaginitis, ulceration, scarring, atrophy, and
premature menopause, leading to dyspareunia. Compared with chemotherapy, RT has a more
significant negative impact on body image, sexual dysfunction, and loss of sexual interest. Vaginal
stenosis, a subacute-to-late effect of RT, can lead to permanent changes in the vagina, such as
adhesion formation and vaginal shortening. The secondary effects of RT, related to tissue repair
mechanisms, can cause vaginal wall thickening and narrowing of the vaginal canal. These late
effects may occur up to 20 years after RT, with the incidence of vaginal stenosis increasing over
time. The findings suggest that women undergoing pelvic RT may experience significant long-term
sexual dysfunction and vaginal changes that can affect their quality of life.

Sexual Dysfunction After Chemotherapy

Chemotherapy is commonly used in the treatment of gynecologic malignancies and breast cancer,
and it is associated with high rates of sexual dysfunction. Despite this, there has been limited
research on sexual function problems in women actively undergoing chemotherapy. A study by
Kulkarni et al. found that only 49% of patients receiving systemic therapy for gynecologic cancers
were sexually active in the prior year, with just 24% being sexually active in the prior month. Sexual
dysfunction was prevalent, affecting 62% of patients in the upfront treatment group and 72% in the
recurrent treatment group. Despite the high rates of sexual inactivity and dysfunction, the majority
of patients (67%) expressed a desire for sexual activity in the future. Bukovi c et al. investigated
sexual function among women with ovarian cancer and found that sexual satisfaction decreased in
all patients after treatment, with more pronounced effects in those receiving chemotherapy. The
research demonstrates the significant impact of chemotherapy on sexual dysfunction in this patient
population.

SCREENING FOR SEXUAL DYSFUNCTION

The research paper discusses the guidelines issued by Cancer Care Ontario regarding addressing
sexual health by the healthcare team at the time of cancer diagnosis and at designated follow-up
intervals, which have been endorsed by ASCO. It highlights that despite these guidelines, the
majority of cancer patients have not been asked about sexual dysfunction during their care due to
various barriers. These barriers include patient fears and misconceptions, as well as clinician-
driven factors such as lack of time, training, and resources. The paper advocates for standardized,
routine screening for sexual dysfunction among all cancer patients, not just during survivorship,
using screening tools like the Brief Sexual Symptom Checklist for Women, ASEX, FSFI, and
others. It also emphasizes the need for inclusive assessment tools that consider patients' diverse
cultural, religious, and sexual orientation backgrounds. The paper concludes by recommending the
use of brief and simple screeners to assess sexual health problems in a busy clinical setting,
ensuring that the topic is inclusive and sensitive to individual differences.

TREATMENT CHOICES FOR SEXUAL DYSFUNCTION Moisturizers

The research paper discusses the use of vaginal moisturizers in the management of vaginal
atrophy and related symptoms. Cancer Care Ontario recommends their daily use for comfort and
pelvic examinations. The American Society of Clinical Oncology suggests applying vaginal
moisturizers three to five times per week in the vagina, at the vaginal opening, and on the external
folds of the vulva to improve vulvovaginal tissue quality. Vaginal moisturizers are intended for long-
term relief of vaginal dryness and are classified as class IIa medical devices by the Medicines and
Healthcare products Regulatory Agency. Although there are concerns about the potential
association of plant-based oils with urinary tract infections, they are often recommended due to
their natural formulation. It is suggested to use moisturizers five times per week with an applicator,
1 hour before planned penetrative activities, and to avoid douching and other vaginal washes.
Vaginal estrogen can be considered if symptoms do not respond to nonhormonal approaches.

Lubricants
The section on lubricants discusses their role in providing short-term relief for vaginal dryness and
discomfort during sexual activity, differing from moisturizers in this regard. Commercially available
lubricants come in different base materials, including water, silicone, mineral oil, and plant oil. Each
type has its advantages; water-based lubricants are non-staining and less irritating, but may require
reapplication. Mineral oil and plant oil-based lubricants last longer and cause less irritation, but may
increase the risk of urinary tract infections and render condoms ineffective. It is important to advise
against using flavored, scented, or warming lubricants, as they can cause irritation. The paper
emphasizes the importance of counseling patients on the various types of lubricants available and
their potential impacts on sexual activity and health.

Dilator Therapy
Vaginal dilator therapy is often used to prevent vaginal stenosis after radiation therapy (RT), which
can lead to decreased sexual function. A prospective study by Quinn et al found that using vaginal
dilators after RT was associated with maintaining vaginal length for all patients and improving
sexual function. While multiple studies have shown similar improvements in sexual function and
decreased vaginal stenosis with dilator use in women who received RT, there are some conflicting
results. Additionally, vaginal dilators can benefit women who have not had pelvic RT by managing
vaginismus, vaginal stenosis, and dyspareunia. Future studies to evaluate the role of vaginal
dilators in improving dyspareunia in cancer patients without prior pelvic RT are recommended.
Dilator therapy is most effective when initiated early, used regularly, and ideally at least three times
per week to prevent vaginal stenosis. Counseling and guidance about expectations can promote
adherence to dilator therapy and improve outcomes.

Hormone Therapy in Women with Gynecologic and Breast Cancers

The section on Hormone Therapy (HT) in women with gynecologic and breast cancers evaluates
the risks and benefits of vaginal and systemic HT in treating menopausal symptoms. Vaginal
estrogen is effective for genitourinary symptoms, while systemic HT has associated risks such as
coronary artery disease, stroke, venous thromboembolism, and increased risk of breast cancer.
The use of HT is recommended for women younger than 60 years within 10 years of menopause,
while caution is advised for older individuals. Patients with gynecologic and breast cancers,
particularly those diagnosed before menopause, may experience more severe menopause
symptoms due to cancer treatments. Although limited high-quality data exists, shared decision-
making is recommended for offering HT to these patients, taking into account the cancer type. The
guidance for HT use in women with a history of gynecologic or breast cancer is based on available
evidence and clinical experience, with an emphasis on minimizing risks.

Endometrial Cancer
The majority of endometrial carcinomas are of endometrioid histology and are estrogen-dependent
and most often low-grade. The standard treatment is total hysterectomy and bilateral salpingo-
oophorectomy (BSO) with lymph node evaluation. Studies on the safety of systemic hormone
therapy (HT) in patients with early-stage endometrial cancer show no increase in recurrence risk or
impact on overall survival for those with low-grade cancer. Data for HT use in high-risk endometrial
cancer patients are limited. In contrast, patients with epithelial ovarian cancer who received HT
after treatment did not show a significant increase in recurrence risk or impact on overall survival.
For patients with BRCA1 or BRCA2 pathogenic variants, risk-reducing BSO is recommended, and
HT is not shown to increase the risk of breast cancer. Cervical cancer is not thought to be
hormonally driven, and HT is reasonable for young survivors of cervical cancer. However, systemic
HT is generally not recommended for individuals with a history of breast cancer due to concerns
about increased risk of cancer recurrence, but low-dose vaginal estrogen can be considered after
shared decision making and communication between sexual health and oncology clinicians.

EXPERT REFERRALS FOR THE MANAGEMENT OF SEXUAL

DYSFUNCTION Pelvic Floor Physical Therapy
The section outlines the impact of cancer treatment on sexual function, particularly in women, and
highlights pelvic floor physical therapy as a recommended first-line treatment for pelvic floor
symptoms affecting sexual function. Pelvic floor physical therapy includes massage, strengthening,
and relaxation exercises, with evidence suggesting improvements in sexual health and quality of
life for gynecologic cancer patients. The role of desire in the sexual response cycle is discussed,
highlighting physical, hormonal, emotional, and medical factors that can affect libido. The paper
recommends a multimodal approach, including psychosocial counseling and psychotherapy, for
addressing decreased libido. Additionally, it discusses the FDA-approved drug flibanserin for
hypoactive sexual desire disorder and the positive impact of multidisciplinary clinics and experts,
such as physicians, psychologists, and physical therapists, in managing sexual symptoms in
cancer patients. The paper emphasizes the importance of addressing these issues and provides
valuable insights for healthcare professionals in managing sexual dysfunction in cancer survivors.

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