“Sexual and intimacy issues are the white elephant in the room for women with breast cancer,” stated Susan W. Rafte, of the Pink Ribbons Project, Houston, Texas. Rafte, an 18-year survivor of metastatic breast cancer, introduced an expert in sexuality to discuss approaches to sexual problems in breast cancer patients at the first session to be planned and moderated by a patient advocate (herself) at the San Antonio Breast Cancer Symposium.1
“Intimacy is vital for the breast cancer survivor, and she needs comprehensive sexual care that involves communication with the team of health care providers who treat the patient,” stated Michael Krychman, MD, executive director of the Southern California Cancer Center for Sexual Health and Survivorship Medicine in Newport Beach, California.2 “We do a disservice when we don’t address sexual care,” he added.
“The foremost issue is breaking the silence. If you don’t see sexual problems in your practice, you are not asking the right questions. Ninety percent of breast cancer survivors have some sort of sexual complaint, either immediate or long-lasting,” he continued.
Sexual issues need to be addressed in the context of patients’ ethnicity and choice of partners—whether gay or straight, he continued. Also, overall health and wellness should be addressed.
Several nonpharmacologic interventions can improve sexual health. “Data support that the Mediterranean diet can improve indices of sexual health function. Body mass index [BMI] and BMI maintenance is vital for overall general health and for sexual health as well. Mindfulness has been found effective for sexual desire and arousal disorders as part of a larger treatment program. Meditation can improve response and decrease sexual distress,” Krychman said.
Vulvovaginal atrophy (VVA) is a common problem that affects sexual function in sexually active postmenopausal women and breast cancer survivors, and reducing symptoms of VVA may help sexual function, he said.
Lubricants and moisturizers can be used. There is a difference between these 2 products; lubricants are used at the time of sexual intercourse and moisturizers promote long-term relief of VVA. Over-the-counter lubricants include K-Y Jelly, Astroglide, olive oil, and other types of oils. Moisturizers, such as Replens, need to be used consistently to help improve plasticity of the vaginal lining.
“A woman with VVA should be prescribed vaginal dilators to increase the circumference of the vagina. They come in sets and require instruction and monitoring. We see patients every 4 weeks to increase compliance. They need constant encouragement to use these dilators, but this helps the woman increase her sexual self-esteem,” he said.
Turning to pharmacologic approaches, the use of estrogen preparations to manage VVA is controversial for breast cancer survivors, because estrogen fuels some breast cancers. Some newer versions of these preparations have less estrogen.
“I tread cautiously about advising use of minimally absorbed local estrogen for breast cancer survivors,” Krychman said. “The vagina is not cement. The vaginal epithelium does have some absorption. It is important to emphasize that the effects of minimally absorbed local estrogen remain to be elucidated in breast cancer patients,” he stated.
Several nonhormonal products are in development for VVA and will be suitable for breast cancer survivors if approved by the US Food and Drug Administration (FDA). These include intravaginal testosterone (no systemic increase in estradiol levels, he said) and intravaginal dehydroepiandrosterone (DHEA; suppositories given daily with no increase in systemic estradiol levels, under review at the FDA).
Ospemifene (a vaginal receptor agonist, or selective estrogen receptor modulator [SERM]) just completed phase 3 clinical trials and is under review by the FDA. This is a first-in-class oral agent that targets the vaginal epithelium, Krychman said, which “may be interesting for the breast cancer population. I think it is very exciting. Oncology teams are more comfortable using SERMs than local estrogens,” he commented.
In Europe, Vagitocin (intravaginal oxytocin) is in phase 2 testing for VVA, while estriol, a weak endogenous estrogen, has been used for many years. Estriol is safe for the endometrium and reverses VVA, Krychman added. However, “These 2 products are not FDA approved. Some of my colleagues are using estriol in a compounded formulation. This has not been studied in breast cancer survivors,” he stated.
“The approach to the breast cancer survivor with VVA should always begin with nonpharmacologic strategies. Alternatives should be tried first. Document all discussions with patients, and get informed consent. Consider following estradiol levels and tailor the treatment regimen accordingly. See your patients regularly,” he advised.
Potential off-label approaches to treatment of sexual dysfunction include bupropion (an antidepressant with prosexual effects) and flibanserin, a nonhormonal serotonin modulator. In studies of more than 10,000 women, flibanserin improved sexual interest and was very well tolerated. A study by Katz and colleagues called BEGONIA is in press in the Journal of Sexual Medicine, he added.
Other compounds in clinical trials include a nonhormonal vulvar soothing cream called cellular lysate cream; Femprox (alprostadil), a topical cream that improves blood flow to the clitoris and response; Lybrido (testosterone with a phosphodiesterase inhibitor); Lybridos (testosterone with a 5-HT1A agonist); and bremelanotide (a melanocortin receptor agonist).
1. Rafte SW. Navigating the obstacles and risks of survivorship. Presented at: 2012 CTRC-AACR San Antonio Breast Cancer Symposium; December 4-8, 2012; San Antonio, TX.
2. Krychman M. Emerging sexual pharmacology for the breast cancer survivor. Presented at: 2012 CTRC-AACR San Antonio Breast Cancer Symposium; December 4-8, 2012; San Antonio, TX.