Anticipate Sexual Dysfunction in Patients on Aromatase Inhibitors

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Outside of clinical trials, about half of women don’t complete the recommended 5 years of treatment with an aromatase inhibitor.
— Leslie R. Schover, PhD

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For patients with breast cancer starting on aromatase inhibitors, sexual dysfunction is commonly reported. Early intervention may lessen its impact—but it’s not an easy fix, says a specialist in this area, Leslie R. Schover, PhD.

Dr. Schover is Founder of Will2Love, an online sexual health program for cancer survivors. She retired in 2016 from her position as Professor of Behavioral Science at The University of Texas MD Anderson Cancer Center, Houston. She described sexual dysfunction related to aromatase inhibitors in a talk at the 2017 Miami Breast Cancer Conference.1

“Outside of clinical trials, about half of women don’t complete the recommended 5 years of treatment with an aromatase inhibitor,” she said. While myalgia is mostly to blame for this, she believes the risk of sexual dysfunction has been underestimated. Many trials don’t measure sexual dysfunction, she explained, or they use brief, inadequate instruments. Sexually active women are more likely to be distressed about sexual problems, which applies even more to a population increasingly being prescribed aromatase inhibitors—ie, premenopausal women.

Sexual Counseling Helps

Dr. Schover led studies that first aimed to benchmark the problem, and then, to determine whether early intervention—within 1 month of starting an aromatase inhibitor—could lessen sexual dysfunction.

The work started with a survey of consecutive women enrolled in MD Anderson’s breast medical oncology registry, all postmenopausal and receiving an aromatase inhibitor as first-line adjuvant therapy.2 There were 129 responders (44% response rate), of whom 93% scored in the sexually dysfunctional range on the Female Sexual Function Index. On a separate questionnaire, 75% reported being “distressed” about sexual issues.

Only 52% were sexually active at baseline, but 79% of these women reported new sexual problems after starting treatment. Approximately half the women took measures to solve the problem, including eliminating sex with a partner to avoid pain (24%) and changing hormonal therapy (13%).

Dr. Schover’s Recommendations

  • In women on aromatase inhibitors who may develop sexual dysfunction, educate preventively and prescribe moisturizers, lubricants, and dilators with explicit instructions for use.
  • Preventive measures include use of a hyaluronic acid-based moisturizer five to seven times a week; use of water-based or silicone-based lubricant by both partners for sexual activity; stretching the vagina two to three times per week via dilator or intercourse.
  • In some women who continue to experience pain with intercourse, a very low-dose estrogen may need to be considered.

This served as background for a pilot intervention study that enrolled postmenopausal women with localized disease within 4 weeks of starting an aromatase inhibitor.3 All received a handout on managing sexual and other side effects and received a home vaginal pH test kit.

The usual-care group received no additional therapy. The active treatment group received a 6-month supply of a vaginal moisturizer (randomized to a hyaluronic acid–based product [Hyalo-Gyn] or a prebiotic), a water-based vaginal lubricant and dilator, plus access to an educational website and phone coaching. They completed 4 different questionnaires/instruments at baseline and at 6 and 12 months (querying about sexual function and satisfaction, sexual distress, physical symptoms, coping strategies, adherence).

Accrual proved difficult, with only 80 women expressing interest and 57 (mean age 59, mostly white and educated) ultimately participating. Retention, however, was good: 86% at 6 months and 78% at 12 months.

Improvements With Intervention

Most women entered the study with some sexual dysfunction. At baseline, sexual dysfunction was reported by 76% of the usual-care group, 81% of the prebiotic treatment group and 71% of the hyaluronic acid–based treatment group. Over time, sexual function improved or remained stable for the group as a whole, and only 9% stopped all partner sex, compared to 24% in the benchmark survey, Dr. Schover reported.

Compared to the benchmark sexual dysfunction rate of 93% in the previous survey, the 12-month sexual dysfunction rate was lower with intervention: 71% in the usual-care group, 78% in the active treatment prebiotic group and 64% in the active treatment hyaluronic acid–based group.

Controlling for age and education as covariates, the Female Sexual Function Index total score at 12 months was significantly higher for the combined active treatment group (19.95) and usual-care group (20.15) compared to the score for sexually active women in the benchmark survey (13.05, P = .002). Compared to the usual-care group, the combined active treatment group had less dyspareunia (P = .07) and sexual distress (P = .02) at 6 months.

“Active treatment appeared to have some small benefits, especially at 6 months, which may be the optimal time for assessment since women still have a supply of moisturizer,” she commented.

What Worked Best?

At 6 months, women using the hyaluronic based–based moisturizer had improved significantly more on the Female Sexual Function Index than those using the prebiotic (P = .04). None of this group reported stopping all partner sex, compared to 30% of the prebiotic arm and 5% of the usual-care group.

At 12 months—when the moisturizer supplies had run out—participants used less moisturizer and more lubricant. “I’m assuming that’s because moisturizers are expensive to purchase and harder to find than the ubiquitous lubricants,” Dr. Schover suggested.

Participants were instructed to use the moisturizer at bedtime, daily for the first week, then 2 or 3 times a week. They reported a mean use of twice a week. “But it may work better to use this particular kind of moisturizer daily for women with severe dryness,” she said. “We may have been undertreating to some extent.”

The women were also instructed to use the vaginal dilator or have sexual intercourse twice a week. They reported a mean use of 0.38 times weekly. “We don’t really even know if stretching makes a major difference, but we do know that in this study, patients did not use [the vaginal dilator] often, despite our encouragement,” she said.

No significant differences were observed in vaginal pH at any point; all measurements were in the postmenopausal range.

Adherence to Endocrine Therapy

Adherence to aromatase inhibitors was better in this study than in the pilot trial, where 12% discontinued endocrine therapy and 3% switched to tamoxifen. In this study, only 7% stopped all endocrine therapy and 14% switched to tamoxifen (9% specifically because of sexual problems).

Participants were encouraged to discuss options with their providers, which may have made this small difference, she said. In addition, 2%, all in the usual-care group, began vaginal estrogen, “which can be a concern,” she added.

Dr. Schover’s Advice

“It makes perfect sense to educate women preventively—not after they have had problems for 6 months and given up on sex—and to prescribe moisturizers, lubricants, and dilators with explicit instructions,” Dr. Schover emphasized.

She advocated the following: use of a hyaluronic acid–based moisturizer five to seven times a week; additional use of water-based or silicone-based lubricant (by both partners) for sexual activity (oil-based products can be considered); and stretching the vagina two to three times per week (via dilator or intercourse).

“For some women, sex continues to be painful,” she acknowledged. Very low–dose estrogen or the [estradiol vaginal ring (Estring)] may need to be considered. ■

Disclosure: Dr. Schover is the founder of a digital health startup company, Will2Love, which offers online help for cancer-related sexual dysfunction. Will2Love offers free content but also paid services.


1. Schover LR: Preventing sexual dysfunction in women on aromatase inhibitors. 2017 Miami Breast Cancer Conference. Presented March 11, 2017.

2. Schover LR, Baum GP, Fuson LA, et al: Sexual problems during the first 2 years of adjuvant treatment with aromatase inhibitors. J Sex Med 11:3102-3111, 2014.

3. Advani P, Brewster AM, Baum GP, et al: A pilot randomized trial to prevent sexual dysfunction in postmenopausal breast cancer survivors starting adjuvant aromatase inhibitor therapy. J Cancer Surviv. February 22, 2017 (early release online).