Sex, Health, and Cancer: Female Patients Deserve Better

When it comes to treatments for sexual health issues caused by cancer treatments, women are vastly underserved.¹ Sexual dysfunction—including low libido, vaginal tightness, and vaginal dryness—is a prevalent adverse event, yet few effective treatments are available. Sonal Sura, MD, a radiation oncologist with GenesisCare in Naples, Florida, addresses the cause of this gap and outlines steps physicians can take to improve patient care for women.

Discrepancies: Women vs Men

The status of women’s sexual health, especially when they are affected by cancer, is where mental health was not too long ago. Many patients don’t feel comfortable speaking up about symptoms, and most physicians don’t have the training or tools to have meaningful conversations with patients. Further, pharmaceutical companies have not invested significant research dollars into treatments centered around women’s sexual health during and after a cancer diagnosis.

When men experience cancer treatments that could affect their sexual activity, an open discussion occurs with their physician. Most physicians receive training on how to speak to men about prostate cancer. Physicians are comfortable talking to a man about radiation vs surgery and what the effect on their sexual health might be. This is not always true for women.

That is not to say that sexual health is not being discussed in oncology. There is a difference between male and female patients who receive treatments affecting sexual health and what has been studied or what is discussed. Whenever patients receive high doses of radiation to the genital area, there’s a chance it can decrease sexual function and/or drive, regardless of whether they’re male or female.

Women feel sexual health issues are important but we, as a society, tend to undervalue women’s sexuality, and that’s perhaps even truer in the medical field. As health care providers, we may not emphasize the severity of symptoms like vaginal dryness, vaginal tightness, pain during intercourse, or loss of libido related to women’s sexual wellbeing during and after treatments.

Unfortunately, many patients are reluctant to talk about these issues, even with female physicians. They may feel that being concerned about sexual desire while undergoing cancer treatment is somehow shameful. Often, they are reluctant to discuss these types of issues when their partner is in the room with them. The partner is trying to be supportive by coming to appointments with them, but it can prevent an open discussion. Also, many patients with cancer are in their 70s or 80s and feel incredibly uncomfortable talking about their symptoms.

Addressing Women’s Sexual Health Issues In the long term, we need more research in this area. Physicians need to get involved in helping develop clinical trials, especially regarding potential treatments for hypoactive sexual desire disorder (HSDD). There are no FDA-approved medications specifically for women with HSDD secondary to cancer or its treatment.² When you think about the number of TV advertisements we’ve all seen for sildenafil citrate (Viagra) and tadalafil (Cialis), you start to understand the gap in care.

We also need a more standardized way to assess women’s sexual health issues. We have the Sexual Health Inventory for Men to help us rate how happy a patient is with their ability to have and maintain an erection. There isn’t a widely used tool for women, so we don’t have an academic way for women to rate things like their ability to get aroused, their level of dryness, etc.

But there are several things we in oncology can do in the meantime; some are quite simple.

First, if we sense that the patient is uncomfortable talking about their symptoms with their partner present, we can politely ask them to step out of the room for part of the visit.

Second, it’s essential to keep the conversation light. When we use medical jargon, it can be difficult for patients to understand and open up. For example, when I talk about using a cylindrical dilator as part of treatment for a gynecologic cancer, if they don’t seem to understand, I’ll explain that it’s similar to a dildo; they get it and start laughing. I think when we speak more like normal humans, patients begin to feel more comfortable and they begin to open up.

Third, oncologists can educate themselves about treatment risks concerning women’s sexual health and prepare themselves to ask patients difficult questions. If we get to the point where a patient feels comfortable enough to answer particular questions, we can help them figure out what’s going on. For example, are you physically not able to have an orgasm? How do you have orgasms?

Many of these questions should be discussed as part of a typical oncology consult. And if we ask the right questions, we may be able to discover whether the issue is more physiological or psychological/emotional.

Fourth, it’s crucial to have an open mind regarding treatment recommendations. For example, we don’t have good choices for pharmaceuticals for HSDD, but we know that over-the-counter herbal remedies like ashwagandha can relax patients with low libido to the point where they are “in the mood.” Similarly, patients may not realize the effectiveness of lubricants and that there are some all-natural products available now. Another pathway could be antidepressants if we can determine that the issue is psychological rather than physical.

Need for More Sexual Health Medical Professionals

The biggest problem is that not one specific clinician often manages this aspect of cancer care for women’s sexual health. If a male patient has poor sexual function after radiation, he can be referred to a urologist who is familiar with information on erectile dysfunction medications, penile implants, and other treatments. That person doesn’t exist for female patients—yet.

Gynecologists are not necessarily equipped to deal with issues like libido or vaginal tightness due to radiation. I take that role on with my patients by, for example, educating them on utilizing a vaginal dilator, prescribing the device, and having them come back every few months to check in.

But as more women survive breast and gynecologic cancers, we should continue to develop more survivorship programs and raise awareness about women’s sexual health issues going forward. In these survivorship programs, physicians can dedicate more time and resources to address these specific concerns and can advocate for women’s sexual health.

_REFERENCES:

_{1. Del Pup L, Villa P, Amar ID, Bottoni C, Scambia G. Approach to sexual dysfunction in women with cancer. Int J Gynecol Cancer. 2019;0:1-5. doi:10.1136/ijgc-2018-000096}

_{2. Study shows positive preliminary results of flibanserin in breast cancer patients suffering from low libido. News release. Sprout Pharmaceuticals. March 15, 2022. Accessed June 24, 2022. https://prn. to/3yivedb}