Sexual health best practices for physicians of female patients with cancer

A brief outline of techniques to use with female patients who have or had cancer.

Sexual health is important for any adult’s well-being, but patients with cancer face a new set of challenges when it comes to sexuality. Laila S. Agrawal, M.D., breast cancer oncologist with Norton Cancer Institute, is spearheading efforts to develop a sexual health clinic at Norton Healthcare.

“The World Health Organization says that sexual health is fundamental to the overall health and well-being of individuals, couples and families, and that this is relevant throughout the individual’s lifespan, not only in reproductive years,” she said.

Dr. Agrawal has recently has been giving virtual continuing medical education sessions on the subject. This article is an overview of her material.

Cancer’s effects on sexual health

“When we are thinking about sexual health and sexual dysfunction, we look at it in the context of the bio-psycho-social model,” Dr. Agrawal said. “So many domains affect the body’s sexual function. From hormonal changes, loss of sensation and mastectomies, to changes in body image and low libido, female cancer patients face myriad symptoms and experiences.”

Sexual health is the third most common concern for cancer survivors and issues are associated with poor quality of life and mood disorders.

“Sexual health issues caused by cancer and treatments do not magically disappear on their own,” Dr. Agrawal said. “The more I talked to my patients about this, the more I learned. This is a medical issue we need to address.”

Best practices for our patients

Ask about sexual health and acknowledge its importance

Despite being such a prevalent and important issue, it is often not discussed in the clinic.  This is perhaps the most important takeaway: The recommendations that follow are only useful if someone starts the conversation.

“I want doctors to understand the importance of the medical provider asking about sexual health,” Dr. Agrawal said.  This legitimizes sexual health as a relevant and treatable medical condition.

In a 2020 survey of over 400 cancer patients (most of them female), 87% of patients said cancer treatment impacted sexual function and/or desire, including dyspareunia or pain with sex, body image distortion and the inability to achieve orgasm. Only 28% had been asked by a medical provider about sexual health and female patients were less likely to be asked than male patients.

Questions to ask in the clinic

  • Initiate with a question: “Do you have any concerns about your sexual health, such as interest in sex, vaginal dryness or pain with sex?”
  • Ubiquity Statement: “Many patients with cancer have changes in their sexual health. Do you have any concerns?” Follow up with specific questions.
  • Ask in context of relationship: “Are you in a relationship? Are you sexually active? If so, do you have any concerns? If not, do you have any concerns that may have caused you not to be sexually active?
  • Basic assessment: Add to review of symptoms or assessment of side effects.

Self-reporting checklists

A number of checklists have been developed for use in cancer clinics. Patients can use these to self-assess and begin a conversation with you. These are short surveys, typically beginning with a general question such as “Are you satisfied with your sexual function?”

These checklists may be more comfortable for the patient and more useful for the physician when opening a dialogue about sexual health.

Understand sexual dysfunction

Once you have made a commitment to ask your cancer patients about sexual health, you must understand the scope of sexual dysfunction and have at your disposal an array of solutions to the issues. These conditions can cause pain, embarrassment or a host of other discomforts to the patient, but they can be mitigated or even relieved entirely with appropriate treatment. It’s important to remember these symptoms and their causes can overlap and vary in intensity, based on the patient. Treatments also overlap and can be used to address variations on each symptom.

Genitourinary Syndrome of Menopause: Includes the effects of estrogen deprivation on the female genitourinary tract such as genital dryness, burning, irritation, urinary symptoms, and sexual symptoms of pain and decreased lubrication.

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In pre-menopausal cancer patients, it can be caused by premature menopause after chemotherapy, surgery, pelvic radiation, or the effects of estrogen blockers or oophorectomy. In post-menopausal cancer patients, it can be exacerbated by anti-estrogen medication.

Treatment: Education around vaginal moisturizers and lubricants and their respective differences and uses is key. Vaginal estrogen therapy is not contraindicated in cancer patients and can be considered after a risk benefit discussion with the patient when symptoms persist after the use of non-hormonal treatments (link to ASCO guidelines).

Insertional Dyspareunia: Pain felt at the entrance of the vagina during penetration.

Treatment: Studies show the administration of topical 4% aqueous lidocaine to the vestibule about three minutes before penetration can significantly reduce insertional dyspareunia.

Pelvic floor dysfunction: The pelvic floor is a group of muscles that help lift and support the pelvic organs including bladder, vagina and rectum. An overactive pelvic floor is common cause of pain with sex.

Treatment: Referral to a pelvic floor physical therapist can identify the source of dysfunction in the musculature. Manual therapies including stretching, yoga or trigger point release are beneficial in releasing muscle tension. Tools in varying sizes such as vibrators, vaginal wands and vaginal dilators are another option.

Sexual Response:   Female sexual response includes desire/interest in sex, mental and physical arousal, and orgasm.

“The female sexual response is not a linear process,” Dr. Agrawal said. “Sexual stimuli including biological and psychological factors can lead to arousal, as can the spontaneous sex drive.”

Treatments: The American Society of Clinical Oncology (ASCO) suggests that psychosocial or psychosexual counseling is beneficial to patients experiencing sexual response issues.

Since the issue is biopsychosocial, it’s important to consider how those domains interact to create this issue.  Many medications commonly prescribed to cancer patients can negatively impact sexual response, including SSRIs, SNRIs, tricyclics and antipsychotics, to name a few.

Low desire/hypoactive sexual desire disorder (HSDD): From a biological standpoint, many neurotransmitters and hormones affect sexual function, including estrogen, melanocortins and dopamine. The first step is to assess the patient’s current medication use and determine if any may be the culprit of low desire. Additionally, stress, diet, exercise, and alcohol play a role in sexual health and desire.

Treatments: Education about self-stimulation and use of vibrators, different types and techniques for orgasm, and the female anatomy are important. There are two new medications approved for female hypoactive sexual desire disorder — flibanserin and bremelanotide, however these have not been studied in cancer patients.

Psychosocial aspects such as body image and relationship: Body image involves perception, cognition, behaviors, and emotions related to ones body.  It is a common concern in cancer patients as cancer and treatment can cause physical changes such as loss of a body part, hair loss, weight changes, and scarring.

Treatment: “We should directly ask our patients about this and refer them to appropriate counseling,” Dr. Agrawal said.

Changes in Epic

The NCI Sexual Health Smart Set has been created in Epic based on ASCO recommendations to simplify the process for providers to treat sexual health concerns.  It includes diagnosis codes, commonly prescribed medications, information sheets for vaginal moisturizers and lubricants, and referrals for pelvic floor physical therapy, psychosocial counseling, and sex therapy.

“We have made changes in the review of systems within Epic [electronic medical records], so that female sexual health specifically can be documented,” Dr. Agrawal said.

This allows physicians who use that as part of their routine encounters to formalize and track sexual health concerns.

Notes on using EPIC

The EPIC build associated with this new program includes the addition of Sexual Health Concerns to the existing ROS for female patients of any age, an AMB Referral to the Sexual Health Program, a new Chief Complaint of Sexual Health Concern, and a new Sexual Health Smart Set. To review the EPIC communication on these additions, go to your NCI Learning Home Dashboard by clicking on the ROCKET ICON  and selecting the NCI Sexual Health Program link located under What’s New.


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