Your Sexual Health as a Cancer Survivor

Many survivors experience sexual side effects due to cancer treatments, but there are steps they can take to improve the health and safety of their sexual encounters, says Dr. Mindy Goldman from the Gyn Center for Cancer Survivors and At-Risk Women from UCSF.

“I am really happy to be here today and talk about an issue that I think is really important and many times doesn’t get discussed enough in oncology visits and follow ups,” says Dr. Goldman, at the CURE 2020 Women’s Cancers Summit.

Cancer survivors often have sexual side effects as a result of their treatments. Surgeries can cause pain and body image issues, while radiation can cause scaring, pain and decreased lubrication. Chemotherapy causes a decreased sensation and impaired arousals, in addition to hot flashes and virginal dryness. Those who have received hormonal therapies can also experience vaginal dryness, pain and decreased desire.

Dr. Goldman says we see so many sexual side effects in breast cancer survivors because two out of three breast cancer diagnoses are hormone sensitive, meaning they are sensitive to estrogen or progestogen or both. She makes it clear, however, that hormones do not cause breast cancer.

“When we’re talking about sexuality and cancer, it’s important for us as providers to realize that the priorities are not the same for all women. For some women, they are thinking about their sexuality, others arousal, sexual identity, and for some fertility,” says Dr. Goldman, “But my general approach is to fix what you can.”

If patients are experiencing hot flashes, it is important to remember some different lifestyle interventions such as wearing loose clothing, not smoking, not consuming caffeine, alcohol or spicy foods. Exercising regularly and lowering room temperatures also works. The most successful way for treating the hot flashes are menopausal hormones, but if those aren’t an option, she gives the following other options:

• Low-dose antidepressants
• Antihypertensive clonidine
• Gabapentin and pregabalin
• Vitamin E
• Soy supplements
• Herbal products, the best studied is Black Cohosh
• Integrative therapies, like cognitive behavioral therapy, mindfulness, acupuncture, stellate ganglion blocks, relaxation techniques

For those experiencing vaginal dryness they can try hormones and the following local estrogens:

1. Vagifem-10mcg nightly for two weeks then two times a week
2. Imvexxy- 4 and 10 mcg dosing, nightly for two weeks then two times a week
3. Estring- 2 mg Estradiol q 3 months

She also offers the following over-the-counter options for vaginal dryness:

1. Vaginal moisturizers that retain water and provide longer-term relief
2. Oils penetrate thin tissue and soothe
3. Topical vitamins, including D or E
4. pH-balanced gels with hyaluronic acid
5. Soothing agents for vaginal or vulvar pain
6. Topical anesthetics for introital discomfort
7. Lubricant for sexual activity
8. Vaginal dilators, which helps to stretch the tissue and figure out what hurts and doesn’t hurt in a non-sexual setting

Lasers and energy devices have also been treating vaginal dryness such as the Micro ablative CO2 laser or the “Mona Lisa.” It improves collagen production, and was FDA approved for skin resurfacing, not for vaginal dryness, they also put out a warning for potential statements. It requires three treatments and is not covered by insurance. There are still many trials going on.

Other types of devices that could help are FemLift, Fem Touch, ThermiVa and vSculpt, but none are FDA approved for vaginal dryness, sexual dysfunction or vaginal rejuvenation.

For survivors experiencing painful sex, Dr. Goldman recommends Osphena (ospemifene), which was FDA approved in 2013 for painful sex. There is also Intrarosa (prasterone), which was FDA approved in 2016 for painful sex, though it has not had trials on safety or efficacy in breast cancer patients on aromatase inhibitors.

Dr. Goldman stresses it is important treat your vaginal dryness and then your low sex drive after. Some drugs she recommends for low desires are Addyi (fibanserin), FDA approved in 2015 to trat Hypoactive sexual desire disorder in premenopausal women. She also recommends Vylessi (bremelanotide), which was FDA approved in 2019 for hypoactive sexual desire disorder in premenopausal women.

Other lifestyle changes that can also help with experiencing sexual side effects. Treating stress, fatigue, underlying mood or anxiety disorder, “you want to address pain, because it’s hard to feel sexual when you’re having pain.” Treating your sleep, “it’s hard to feel sexual when you’re chronically overtired.” In addition to treating vaginal dryness, regular exercise, healthy diet, and working on relationship issues if there are any.

“You want to set goals and work as a team. Make sure you’re providing education. Open communication is important for both partners, alter sexual behavior as needed to accommodate some physical, emotional and social changes,” Dr. Goldman concludes, “A big push for utilizing specialists in sex therapy if needed.”

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