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Women’s Sexual Health
Near total alopecia due to some agents such as anthracyclines and general physical and genital examination, and a psychological as well as
taxanes can also affect one’s perception of sexual attractiveness. Finally, psychosexual examination. For women, this also includes a comprehensive
the systemic side effects of chemotherapy, which may include nausea or and detailed gynecological evaluation. Many patients often have other
vomiting, fatigue, and insomnia, may cause a woman to withdraw or underlying medical conditions and illnesses that directly impact sexual health
avoid intimate or sexual encounters. and the sexual response cycle. Chronic illnesses, such as uncontrolled
hypertension, hypercholesterolemia, anemia, or an underlying thyroid
Endocrine Therapy dysfunction, should be identified and treated. Arthritis may impact mobility
Breast cancer is often treated by disrupting hormonal pathways. The aromatase and limit comfortable sexual positioning. Uncontrolled diabetes may impede
inhibitors (letrozole, anastrozole, and exemestane) and the selective estrogen neural and/or vascular function in the genital pelvic region and may impact
receptor modulators (tamoxifen) block the conversion of testosterone to blood flood and vasocongestion and pelvic engorgement or excitement.
estrogen, and significantly lower levels of circulating estradiol. Often the Underlying genital infections such as candida (yeast), bacterial vaginosis, and
objective for breast cancer therapy, these treatments can aggravate trichomoniasis should also be treated. Screening of complete blood profile
menopausal symptoms and can cause osteopenia and osteoporosis. Research examinations including complete blood counts to rule out underlying anemia
examining the effects of tamoxifen on sexual function in women is conflicting and chronic fatigue, lipid profiles, and prolactin levels can be helpful. Most
and inconclusive. The Breast Cancer Prevention Trial states that minor drug classes can affect the female sexual response cycle and cause sexual
differences in sexual functioning were observed among tamoxifen users versus problems. Many antidepressants and antihypertensive medications can
those not on the medication.
7
In contrast, Mortimer demonstrated no changes change sexual desire, arousal, and orgasm.
in any phase of the sexual response cycle for women on tamoxifen.
8
The sexual
ramifications of the aromatase inhibitors are yet to be fully elucidated. If sexual concerns are discovered and physicians are unsure what to do,
referral to a sexual medicine clinic, sexual psychiatrist or psychologist, or
Sexuality at the End of Treatment other specialized professional for both initial evaluation and follow-up
Patients may experience sadness, melancholy, or depressive symptoms surveillance should be considered. Since the etiology of sexual dysfunction
concerning body image, fears of recurrence, and sexual problems even after is often complex and multidimensional, treatment should involve a
they are successful treated for their cancers and have been free of disease. In multimodal approach, which frequently includes the partner.
one study, Andersen sought to characterize the incidence of sexual problems in
gynecological cancer survivors. A series of interviews with 47 women survivors Treatment Options for Sexual Dysfunction
of early disease were conducted and compared with 18 women previously Patients with sexual complaints are always encouraged to make lifestyle
diagnosed with benign disease and 57 healthy women who served as controls.
9
modifications and changes in their behavior that will enhance and improve
At one-year follow-up approximately 50% of women cancer survivors were quality of life. A well-balanced, nutritious diet combined with an active
diagnosed with at least one sexual problem, and all sexual problems (inhibition aerobic exercise plan, stopping the use of tobacco and illicit drugs, and
of desire, problems with excitement, lack of orgasm, or dyspareunia) were minimizing alcohol consumption are all encouraged. If fatigue is a problem,
significantly higher in this group compared with the other two. frequent naps and plans for sexual intimacy scheduled around times when
one is well rested can be very helpful.
Evaluation of Patients for Sexual Dysfunction
Many healthcare providers wrongly assume that their cancer patients are Arousal Disorders
involved in heterosexual relationships. Bisexual and same-sex relationships can Women are often unsure about the relationship between their own genital
also be impacted by cancer, and sexuality is as important to this group of anatomy and sexual responsiveness and may not realize there is a normal
people as to those in more traditional relationships. Healthcare providers should physiological response to sexual stimuli and arousal. To this end, literature and
be sensitive to the sexual issues that women who have sex with women may education is an important means of self-awareness. There is a US Food and
be experiencing, and intake office forms should be generic and unassuming. Drug Administration (FDA)-approved device for the treatment of sexual
complaints that can be prescribed for women. This device, known as the EROS
One of the difficulties with addressing sexual dysfunction is the lack of CSD, is battery-operated and has a vacuum suction that attaches to the clitoral
recognition that it is a problem. Too often, cure and control are the only goals area. It is presumed to help facilitate vasocongestion in the clitoral tissue. In a
of the oncologist, and in the context of a busy practice other issues such as pilot trial of 13 women treated for cervical cancer, Schroder demonstrated that
sexuality, fertility, and routine medical follow-up are relegated to other at three months there were statistically significant improvements in sexual
providers, such as social workers or primary care providers. Without an explicit function compared with baseline, as measured by the Female Sexual Function
understanding of how the care of the cancer survivor is co-ordinated, issues Index.
11
These improvements were associated with an improvement in the
such as sexuality are often left unattended. In a survey of gynecological mucosal color and moisture of the vagina, and with decreased bleeding and
oncologists in practice in New England, fewer than half made it a practice to ulceration. The EROS-CSD remains a costly maneuver and there have been no
take a sexual history in new patients and 80% did not feel there was sufficient randomized controlled studies comparing it with hand-held self-stimulators.
time to devote to exploring sexual issues.
10
Only 20% felt they had sufficient
time to speak to their patients about these issues, which was the sentiment of Dyspareunia
both male (85%) and female (73%) respondents. Estrogen is one of many hormones necessary for sexual function in females.
Estrogen replacement is key in the management of female sexual arousal and
The approach to the evaluation for sexual dysfunction must be tailored to the relief of dyspareunia. Central arousal, peripheral sexual response, and pelvic
individual, but begins with a detailed medical history, a comprehensive sexual response are dependent on estrogen and, in some instances,
22 US OBSTETRICS & GYNECOLOGY
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