Kristin Rojas, MD, FACS, on Improving Sexual Health During Breast Cancer Treatment

At my presentation at IBC East, I discussed the most common symptoms that patients report when they present with sexual health concerns during and after breast cancer treatment. Those three most common symptoms include hot flashes, vaginal dryness and painful sex, and low desire. I also discussed ways to distinguish between evidence-based therapies for sexual dysfunction and fringe therapies that we often hear about patients receiving from other providers. When talking about hot flashes, I reviewed some non-hormonal options for patients who are on or off endocrine thera-py. Traditionally, we've thought of medications like clonidine and gabapentin being good options, but in the Sexual Health After Cancer Program that I run at University of Miami called MUSIC, which stands for Menopause Urogenital Sexual Health and Intimacy Clinic, we use low dose SNRIs, includ-ing venlafaxine among others, and we also like to use oxybutynin, specifically the XL formulation, and we dose it at night, five milligrams. That significantly decreases the severity and frequency of hot flashes, and that's been shown in a placebo controlled trial. Another common constellation of symptoms that patients report is vaginal dryness and painful sex or genitourinary syndrome of menopause. We address these concerns with four easy steps in the MUSIC Sexual Health After Cancer Program. This includes one, eliminating irritants, two, moisturize for maintenance, three, lubricants for sexual activity, and four, address the pelvic floor. The first step or eliminating irritants is an often neglected step, but we go through an inventory of every-thing that's touching the delicate tissues of the vulva and the vagina and eliminate products that have artificial fragrances that can be really irritating, or formaldehyde in toilet paper, artificial fra-grances in the detergent the patients wash their underwear with. All of these products or chemi-cals can cause an irritating reaction and potentially an allergic reaction that manifests as burning and stinging in the vulva. So for these patients, we have them really back off these products and cleanse with water only to the non hair bearing area and add single ingredient organic coconut oil, which is a great emollient for patients, to the vulva and the vagina, and it is also a natural antimicrobial and antifungal. We also have more high-tech moisturizers that have hyaluronic acid. These can be in the form of a sup-pository. There's some brand name ones out there, but also some available through CVS that are much cheaper. The second step is after moisturization, which by the way, most patients do get bet-ter if we teach them how to moisturize regularly and help them understand the difference be-tween moisturization and lubricants. Moisturizers for maintenance, just like you use under eye cream every night, this should become part of your routine. Now, when I'm talking about lubricants, for those products, we want those products to be as slip-pery as possible, and so there's water-based and silicone based. For patients that aren't using con-doms for STD or pregnancy protection, we start with silicone-based lubricants, specifically those that are paraben-free and don't have any gimmicks like warming sensations or flavors, et cetera. There's also some patients do like using oil-based products for lubricants, although they do degrade latex condoms, so it's really important to review that with patients. Now, lastly, for patients who have persistent pain with sexual activity or persistent symptoms, after using non-hormonal moisturizers regularly for a couple months, we address the potential anatomic changes that those patients may have. In the MUSIC Sexual Health After Cancer Program, we found that when we examined patients, many of whom were on estrogen suppression therapy, that many of them had shortening and narrowing in the vagina or vaginal stenosis, which can make penetra-tive intercourse completely impossible. Now, for those patients, it's really helpful to add a low dose vaginal hormone along with mechanical dilation with a dilator, and we have two options that we go to in MUSIC for patients on tamoxifen. We start with low dose vaginal estrogen. We like the estrogen cream because you can really tailor it to the area of the vulva and the vagina where pa-tients are having most pain. For example, the posterior fourchette or the posterior aspect of the vulva can be an area that loses a lot of elasticity with estrogen suppression, and that's a great place to apply a low dose estradiol cream. In the past, the studies looking at pharmacokinetics of these medications, of the vaginal applica-tions and systemic absorption, they use much higher doses than what we're using today, and they also use those applications every night. In MUSIC Sexual Health After Cancer Program, what we do is continue the non-hormonal moisturizer, but add a low dose vaginal hormone once or twice a week, and we found that this probably mitigates some of that risk of absorption. We also use low dose vaginal DAGA for our patients on aromatase inhibitors since we have Alliance trial data show-ing that it's helpful and does not increase serum estradiol. And lastly, low desire. So low desire can be more difficult to treat because it's often multifactorial. There are psychosocial issues. Patients are dealing with the trauma of a diagnosis. For patients with partner issues, we refer them to counseling. The aasect.org website is a great resource for that. We also discuss behavioral interventions for these patients, so we talk about sleep hygiene, we talk about strategies for minimizing pain. We also talk to patients about setting aside time for sexual activity and then using different resources to prepare for that, such as what we call in MUSIC, sexy podcasts or essentially audio erotica. Some of those can be Dipsea, Quinn. That's D-I-P-S-E-A or Quinn, Q-U-I-N-N. There are two FDA approved medications for patients with low desire. One is flibanserin and that's a once a day pill. We have patients take it at night. And the second is a PRN injection patients can give themselves in the abdomen prior to sexual activity. We have a lot more anecdotal experience treating patients with flibanserin. We oftentimes give it to patients on aromatase inhibitors. There was an alcohol warning when this drug was originally approved, but now we tell patients if they're going to have more than two drinks in one day, we have them skip their pill. Lastly, fringe therapies we do not recommend for addressing the sexual health concerns of cancer patients, any cancer patient really, not just breast cancer patients. Number one, things like vaginal steaming or a vaginal detox, you'd be surprised the patients that are engaging in these types of ac-tivities that they read about on TikTok or Instagram. We also avoid products like jade eggs or these pelvic floor weights that can actually make pelvic floor muscle dysfunction worse. Many patients actually have levator spasm because the pelvic floor is like a basket of muscles, and when one of those muscles is spasming, it can cause a lot of pain with sexual activity. That's why dilators are real-ly helpful or referring these patients to pelvic floor or pelvic health physical therapy. We avoid bioidentical hormones because there's no evidence that bioidentical hormones are safer or more effective. However, there are some very concerning studies showing that bioidentical hormone pharmacokinetics result in significantly elevated levels of serum estradiol and serum tes-tosterone, specifically in those patients who are using those testosterone pellets that many of us have come across. Some of those levels of testosterone in the studies that have reported these levels can be greater than 400 picograms per deciliter, and the estradiol can be greater than 1,000 picograms per milliliter. We avoid bioidentical hormones because we have FDA approved therapies where the pharmacokinetics are known that work really well. And lastly, we do not recommend vaginal energy-based devices for patients with sexual dysfunction who have a history of cancer. These CO2 lasers were never FDA approved to be used in the vagina. They were approved by a program called 510(k), which is where companies can essentially register their devices by attaching it to another preexisting device. The FDA actually never had to investi-gate whether vaginal lasers were effective or even safe. And we have taken care of many patients who have burns, vaginal stenosis, and their exams look like patients who've received vaginal brachytherapy after these energy-based devices. Because these devices rely on microscopic injury to the vagina and we're artificially suppressing the estrogen in these patients, my personal opinion is that potentially we're disrupting the healing response. And so since we have FDA approved ther-apies that are very helpful for genitourinary syndrome of menopause, we do not recommend these vaginal energy-based devices for patients. And even in 2018, the FDA asked these companies to roll back their deceptive marketing because they were concerned that women were being harmed. Keep an eye out for these advertisements in October because they tend to go in overdrive for Breast Cancer Awareness Month. They're also not effective. There are two placebo sham controlled trials showing that vaginal energy-based devices are not more effective than placebo, and those studies included both patient reported outcomes and vulvar biopsies. So that's what we discussed in my talk at IBC East where we discussed ways to manage patients with sexual health concerns. I hope that you find some of this information helpful. And our MUSIC Sexual Health After Cancer Program does have an Instagram for patients who don't have access to a program like this, and that's @music_sexaftercancer. Thank you.