For women diagnosed and subsequently treated for breast cancer, concerns related to sexual health and intimacy are well documented. These concerns may be related to all aspects of breast cancer treatment, from issues related to body image as a result of surgery and/or radiation therapy to the toxic effects of chemotherapy and endocrine treatment.
For women, the impact of sexual health is rarely limited to one concern; rather, it is usually a conglomeration of issues spanning the physical and psychosocial realms, including the negative impact on one’s body image, perceived or real change in interest from partners, a reduction in the sense of femininity, changes in sexual appetite, and difficulty achieving and reduction in the intensity of orgasm, and pain with attempts at penetrative intercourse.
Surgery on the breast and axilla can result in disfigurement for women, even if the breast is spared. Symmetry may be negatively impacted and scars that remain may serve as a constant reminder of the cancer diagnosed. In addition, for women in whom their breasts were a sensual organ, work by Gass and colleagues at Women & Infants’ Hospital of Rhode Island suggest that almost 90% of women viewed chest play as a part of their sexuality prior to surgery; this dropped by over 10% post-surgery with the greatest decline in those women who had a modified radical mastectomy. In addition, following surgery, approximately 20% reported that touching their breast or chest wall after surgery elicited unpleasant sensations. Fortunately with emerging data suggesting that a full axillary dissection is not necessary in the vast majority of women with early-stage breast cancer, less women are undergoing an axillary node dissection. However, for those women who undergo this procedure, complications may extend beyond the postoperative period and include long-term risks for lymphedema as well as musculoskeletal complaints such as restricted range of motion or anesthesia of the skin. For those experiencing lymphedema, complications include pain, decreased mobility and an increased infection risk.
For young women with a hormone-receptor positive breast cancer and either a known BRCA-mutation associated breast cancer or are otherwise deemed to be at a higher risk of recurrence, removal or silencing of the ovaries (with surgery or medication, respectively) may be a part of breast cancer treatment. This will result in a premature menopause in women, and the resultant low estrogen state results in symptoms such as thinning of the vulva and vagina, vaginal dryness, and painful intercourse, as well as systemic symptoms such as hot flashes.
While surgery can have effects on sexual health, adjuvant treatment is perhaps the single most important risk factor for sexual dysfunction. For women who are premenopausal, cytotoxic chemotherapy can induce early menopause and lead to some of the menopausal sexual side effects. Chemotherapy is also associated with systemic side effections, including nausea, vomiting, hair loss, neuropathy, and diarrhea, all of which can reduce a woman’s desire. Finally, endocrine therapies such as tamoxifen and the aromatase inhibitors are notoriously associated with sexual side effects, including vaginal dryness, pain with intercourse and sexual dissatisfaction. As an example, one study showed that of women taking an AI, 20%, 60%, and 57% reported the presence of personally distressing low interest in sex, insufficient lubrication, or painful penetration, respectively.
The use of radiation therapy for breast cancer is associated with both short and long-term toxicities. Short term side effects include skin sensitivity, skin burns or breakdown, pain with touch or hypersensitivity. Longer term toxicity may include thickening of the skin, fibrosis on the chest wall, and a very rare risk of a breast sarcoma.
So what can we do to better identify and treat sexual health concerns. It has to begin with discussing the issue more openly and as part of the routine medical visit. Unfortunately, sexual health is a topic not often brought up by clinicians. While time constrictions are often cited as a barrier by clinicians (“We have so much more to talk about- like, what the status is of the breast cancer”), oncologists may feel that are not equipped to discuss let alone treat issue related to sexual function.
Still, women (and men) who are facing issues such as the change to their sexual life during or after treatment should never accept “At least you are alive” as a response to their concerns. Interventions are available to help make sense of the changes to sexuality that can often occur as a result of the breast cancer experience. Perhaps the most important is education- education about sexual function in women and recognizing that arousal and intimacy are not viewed similarly between women and men. For women, the Basson model of female sexual health incorporates the importance of both physical and psychosocial domains, including intimacy, stimulation, arousal, desire and satisfaction. Recognizing that cancer and its treatment can impact each of these areas may be the first step in understanding one’s post-cancer sexuality. Such knowledge is important because it allows women to feel less isolated or that they are the “only one” who experiences such issues.
Beyond education, treatments are available and the goals of any care plan can be tailored to meet the objectives of each individual patient or couple. These include vaginal moisturizers (for issues related to vaginal thinning or dryness), lubricants (for painful intercourse or chafing with penile thrusting), dilators (for pain related to penetration), and even lidocaine (for pain experienced at the point of penile entry). Pelvic physical therapy can also be helpful in dyspareunia and vulvodynia. There is data to suggest that increasing awareness of vaginal muscles and learning to control them can help alieviate pain. The point is, we can help. And for the woman experiencing symptoms, it is the most important point we can make.