Sexual dysfunction due to breast cancer care improves with nonhormonal treatments

Safe and effective treatments are available for women who experience sexual dysfunction because of breast cancer care, according to a presentation during the NAMS Annual Meeting.

“More and more cancer patients are being cured of their disease, and most breast cancer patients will be survivors,” Shari B. Goldfarb, MD, medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, said during her presentation.

Shari B. Goldfarb

“Therefore, increased attention to quality of life and symptoms is very important both in the short term while patients are undergoing treatment and in the long term throughout their survivorship,” Goldfarb said.

Three-quarters of the women who are in treatment or who are survivors in Goldfarb’s practice have experienced some type of sexual dysfunction, she said, including more than half of her patients who have reported decreased libido. Orgasm problems, dyspareunia and body image concerns are common as well.

“Endocrine therapy can really impact sexual function,” Goldfarb said.

Tamoxifen can cause vaginal dryness and discharge. Aromatase inhibitors also cause vaginal dryness in addition to pain with intercourse, vulvar atrophy, vulvar changes and vaginal atrophy.

“The problem is that we’re putting more and more women on these medications, so we need better treatments for their symptoms,” Goldfarb said.

ACOG recommends that patients with estrogen receptor positive (ER+) breast cancers or endometrial cancers begin treatment with nonhormonal approaches, though this may not be adequate for everyone, Goldfarb said.

“The key is for patients with a history of estrogen-dependent breast cancer to have informed decision-making discussions about risk-benefit ratios,” she said.

Memorial Sloan Kettering conducted a study examining the use of nonhormonal moisturizers among its patients. It included 58 women with ER+ breast cancer on aromatase inhibitors and 43 postmenopausal endometrial cancer patients who received and used an intervaginal hyaluronic acid moisturizer internally and externally three times a week.

Patients were evaluated at 12 weeks for improvements in vaginal and vulvar symptoms and in vaginal pH. According to Goldfarb, 75% of the patients had not responded to therapy at the 12-week mark, so they were instructed to increase their moisturizing frequency to five times a week.

After 24 weeks, Goldfarb said, the study yielded a statistically significant mean increase of 4 points in Female Sexual Function Index.

“So, 25% of the patients improve with just using high allergen or hyaluronic acid moisturizer three times a week, and then out of the 75% that did not initially respond, 80% of those responded without using intervaginal estrogen,” Goldfarb said, adding that those patients who did not respond probably need more intensive or intervaginal estrogen therapy.

In another study, postmenopausal women on astrozole or letrozole received 10 µg of estradiol nightly for 2 weeks and then twice weekly for 24 weeks. There was no significant elevation in estradiol, but patients did see statistically significant improvements in desire, pain, lubrication, orgasm and satisfaction.

DHEA, another option for treating vulvovaginal atrophy, is inserted intravaginally once a day at bedtime. It decreases vaginal pH, parabasal cells and moderate-to-severe vaginal dryness while improving sexual activity, Goldfarb said, though she also noted that it should be used with caution because it may stimulate androgen receptors found in triple-negative and ER+ cancers.

Finally, disease stage plays a key role in determining who should receive treatment, Goldfarb said.

“You look at the grade of disease. The lower-grade diseases make you feel a little bit more comfortable,” she said, recommending nonhormonal treatment for patients with no lymph node involvement, triple-negative diagnoses, tamoxifen usage, low risk of recurrence, remote time since diagnosis and severe symptoms that impair quality of life.

“If they have failed nonhormonal options,” she continued, “we tend to recommend local intervaginal estrogen therapy.”

References:

• Carter J, et al. Gynecol Oncol. 2020;doi:10.1016/j.ygyno.2020.05.025.
• Carter J, et al. Support Care Cancer. 2021;doi:10.1007/s00520-020-05472-3.