What to do about Sexual Dysfunction CAGPO Annual Meeting Recent Advances in Oncology Care Oct 20, 2012

Transcription

1 An Update on SURVIVORSHIP: What to do about Sexual Dysfunction 2012 CAGPO Annual Meeting Recent Advances in Oncology Care Oct 20, 2012 Elaine E. Jolly, OC, MD, FRCS(C) Professor of Obstetrics & Gynecology University of Ottawa

2 Conflict of Interest Speaking Honourarium Merck Pfizer Ferring Amgen Novo Nordisk Boheringer Ingelheim Advisory Boards Merck Pfizer Ferring Novo Nordisk Astra Zenica Servier Research Pfizer BoheringerB h i Ingelheim Bio Santé Eli Lilly Proctor Gamble

3 Objectives An Update on Survivorship Introduction Ovarian Failure Vasomotor Osteoporosis Urogenital Ageing g Follow up Tamoxifen Patients Breast Cancer and Sexuality

4 Impact of cancer diagnosis Fear of: death pain or discomfort related to the illness and or treatment becoming dependent or disabled using hormone replacement therapy cancer returning or developing a new cancer hopelessness and uncertainty about the future after cancer treatments Overwhelmed with lack of information or information overload Concerns about body image or loss of a body part or organ Apprehension about sexual function, intimacy, and relationships (fear of rejection) Feelings of guilt about family members having to deal with the illness Anger about getting cancer

5 What are the Medical Needs of Breast Cancer Survivors? Quality of life: well being, vigor, day-to-day interests, sleep, sex life, satisfaction with role and relationships Health: Maintain excellent function of all systems for optimal physical and mental performance Avoid / manage chronic diseases (arthritis etc) and prevent health crises: cancer, MI, stroke

6 Our role in helping women attain these goals Review each woman s concerns Evaluate her risks based on population data, family history, and personal profile (Hx, Px and lab) Educate her about unrecognized risks Advise re: optimal lifestyle choices Enquire about alternative therapies that she may be using and discuss appropriateness p Provide information about medical options for improving quality of life, health promotion, and disease prevention

7 First Line Health Promotion/ Disease Prevention Measures Exercise Smoking Cessation Calcium Vitamin D Moderation of Alcohol Intake

8 Ovarian failure Develops within one year of therapy in 63%-96% of perimenopausal women, receiving chemotherapy It is in many cases definitive iti Burstein, et al. N Engl J Med 2000; 343:

9 Estrogen deficiency after Breast Cancer Vasomotor symptoms Vaginal dryness Osteoporosis

10 Up to 20% of patients with breast cancer consider stopping or actually cease endocrine treatment because of menopausal symptoms. Fellowes et al 2001.

11 Hot flashes: treatment options Lifestyle modifications Dress in layers Fans, cold showers Cool liquids Exercise / paced respiration Acupuncture Avoid triggers (coffee, alcohol) Non-hormonal medications Web Resource

12 Managing sleep Complete history to rule out co-morbidities Ensure proper symptom management strategies t Avoid nicotine, alcohol, decongestants, eating at bedtime Principles of good sleep hygiene Regular bed and waking time Dark, quiet, comfortable and cool sleep environment Comfortable mattress and pillows Use bedroom only for sleep and sex Web Resource

13 Management Non Hormonal Rx of Hot Flushes SSRI s + SNRI s Clonidine Bellergal l Gabapentin

14 Oral Clonidine in Postmenopausal Patients with Breast Cancer experiencing Tamoxifen-induced induced Hot Flashes Double-blind, placebo-controlled: 194 using Tamoxifen Oral Clonidine hydrochloride, 0.1 mg/d/placebo for 8 weeks Hot flash: 37% Clonidine group 20% Placebo group Clonidine more difficulty sleeping (41% vs 21%; P=0.02) 02) Quality of life score (+0.3 points: Clonidine vs points Placebo; P = 002) 0.02) at t8 weeks, although the median difference was 0 in both groups Pandya et al Ann Intern Med. May 2000

15 Management Antidepressants Effective for Hot Flushes Venlafaxine 1 Effexor 37.5 to 150mg OD Fluoxetine 2 Prozac 20mg OD Sertraline 3 Zoloft 25 to 50mg OD Paroxetine 4 Paxil 10 to 20mg OD Desvenlafaxine Pi Pristiq 50 to 100mg OD 1 Loprinzi CL Lancet 2000; 356: Loprinzi, CL. Lancet 2000; 356: Loprinzi, CL. Breast Cancer Res Treat 1999;57: Trott, EA. Del Med Jrn 1997;69(9): Stearns, V. Breast Cancer Res Treat 1997; 46:23-33.

16 Venlafexine in Management of Hot Flashes in Survivors of Breast Cancer Loprinzi, CL. Lancet 2000; 356:

17 Desvenlafaxine Efficacy in Severe HFs as Early as Day 1 and Persisting Benefit mg Placebo Number of severe HF 4 * 2 ****** *** *** *** *** Days Daily Number of Severe Hot Flushes Week 1

18 Paroxetine Controlled Release in the Treatment of Menopausal Hot Flashes: Randomized control trial. Stearns V, et al JAMA 2003; 289:

19 Antidepressants & P450 Enzyme CYP2D6 Some antidepressants inhibit Cytochrome P450 enzyme CYP2D6 which is needed to metabolise Tamoxifen to Endoxifen. Paroxetine, to a lesser extent Fluoxetine Sertraline but not Venlafaxine. Loprinzi et al Lancet Oncology 2008

20 Gabapentin for Hot Flashes Anticonvulsant Also used for: chronic pain syndromes migraine prophylaxis May act directly upon temperature regulatory centers Dose range 200mg to 400mg QID Tablets 100 and 300mg Improvement seen from 1 to 3 days Side effects: blurred vision, drowsiness, nausea, (infrequent) tremor, lack of muscular coordination Guttuso T. Neurology 2000;54:2161:63

21 Gabapentin for Hot Flashes in 420 women with Breast Cancer: A randomized double-blind placebo-controlled trial Pandya Lancet 2005

22 Systematic Review & Meta Analysis Gabapentin for Hot Flashes in women with natural or tamoxifen-induced menopause. Toulis et al Clin Ther. 2009

23 Alternative Non-Prescription Therapies: Concerns Aggressive marketing generates inquiries and use In % of midlife US women had used CAM in the previous year (Brett 2007) Side effects and drug interactions are not well known but clearly occur (Ang-Lee 2001, Mills 2005, Singh 2007) Lack long-term safety and efficacy data

24 Low Estrogen Levels Increase Relative Fracture Risk

25 Prevalence of Vertebral Fracture in Women with Non-metastatic Breast Cancer X5 Vertebral fracture risk is markedly increased in women with Breast cancer. Kanis et al Br J Cancer. 1999

26 Bone Density changes with Tamoxifen and AI s Gnant M et al Lancet Oncol Sep;9(9):840-9

27 Aromatase Inhibitor-Associated Arthralgia Syndrome Reason for discontinuation of AI treatment. Possible mechanisms: immune cells and cytokines, modulating pain sensitivity. Detailed patient symptoms, inflammatory and rheumatologic markers. Treatment: non-steroidal anti-inflammatory drugs (limited help). Research: high-dose vitamin D and new-targeted therapies to inhibit bone loss. Burstein HJ. Breast. 2007

28 Urogenital Ageing Bladder Urgency Frequency Recurrent UTI Vagina Dryness Painful intercourse Recurrent infection

29 Vulvovaginal AtrophyTreatment Smoking cessation Continued vaginal stimulation provides protection by increasing blood flow ( dilators, vibrators, partner) Avoid antihistamines Vaginal lubricants Vaginal moisturizers Vaginal moisturizers (KY Moisture Beads, Replens, Vitamin E)

30 Urogenital Atrophy Quality of Life Moisturization 1 Replens (polycarbophil gel) Estrogen Ring Tabs Cream Lubrication KY Silk E Astroglide Gyne Moistrin Lubrin Utilization 2 Regular intercourse maintains vaginal blood flow 1 Van der Laak, J. Clin Path 2002; 55(6): Leiblum et al, JAMA, 1983; 249(16):

31 Safety Vaginal Estrogens Quality of Life CEE Cream 1 03mg 0.3 mean E 2 12 pg/ml Estradiol Ring 2 2 mg Ring E 2 /day 5-10 g (Estring) Estradiol tab 3 10 g E 2 /day < 4 g (Vagifem) 1 Mandel et al. J.C.E.M. 1983; 57: Smith et al. Maturitas 1993; 16: Manorai et al. J. Obst. Gynec. Res. 2001; 27(5):

32 Follow up Tamoxifen Patients Premenopausal Postmenopausal Dysfunctional Uterine Blg Postmenopausal Bleeding Endometrial Polyps Endometrial Polyps Endometrial Hyperplasia Endometrial Hyperplasia Endometrial Cancer Endometrial Cancer Ovarian Cysts Ovarian Cysts Endometriosis / Fibroids Subendometrial Osteoporosis YES Pseudocysts VTE Osteoporosis NO VTE

33 Endometrial and Uterine Effects of AI vs TAM 1 st -line Rx: 3 months TAM Endometrial thickness No change Uterine Volume No change Endometrial pathology Cysts, polyps No change 2 nd -line Rx with AI after TAM: Endometrial thickness Uterine volume AI TVUS: Transvaginal ultrasonography Morales et al. SABCS 2003.

34 Follow up Gynecologist / Family Doctor Annual exam REASSURANCE? Vaginal US? CA 125? Colorectal screening stools s for occult blood barium enema sigmoidoscopy colonoscopy

35 Quality of Life Depression Anxiety Psychosociocultural Poor Concentration Memory Loss (short term) Inability to cope Libido Sexuality

36 Impact of Breast Cancer on Relationships and Sex Sexuality is the least discussed subject following breast cancer diagnosis Doctor s frequently do not bring this subject up Women find sex hard to talk about Common to have difficulty with sex and intimacy Practical changes impacting on sexuality Induced menopause

37 Sexual Assessment Guidelines Ensure patient comfort and privacy Ensure confidentiality Address sexual concerns early and throughout treatment Determine patient goals Avoid overreaction Refer patient for complex problems

38 Understanding Assessment Barriers Physician or Nurse does not initiate discussion Time constraints Lack of training in this area Personal discomfort Fear of offending the patient t Not familiar with treatment options

39 Classification: Female Sexual Disorders Sexual Desire Disorders - Hypoactive Sexual Desire Disorder (HSDD) - Sexual Aversion Disorder Sexual Arousal Disorder Orgasmic Disorder Sexual Pain Disorders - Dyspareunia - Vaginismus - Other sexual pain disorders

40 Sexual Assessment Initiate the discussion ask your patient if she is having any difficulty with sexuality Identify nature of the problem(s) Establish whether problem is associated with menopause, cancer diagnosis Assess if problem is causing distress Ask if interested in getting help This is NOT a five minute discussion

41 The 7 H s of Sexuality Health Head Home Hormones o Honey Heart Habits

42 Approach to treatment: Health Other Medical Conditions Long term side effects of surgery and radiation Long term side effects of chemotherapy Energy level Stress management

43 Medications which cause Sexual Difficulties Hormonal Preparations Antiestrogens Tamoxifen/Aromatase Inhibitors Psychoactive Medications Cardiovascular and Antihypertensives Other: Antihistamines SSRI s & SNRI s Indocid Ketoconazole Phenytoin Sodium

44 Approach to treatment: Head The Brain is the BIGGEST sex organ in the human body Emotional well-being Mood instability Self-Image o Cancer / Chronic Illness o Body weight o Body shape Attitude towards sex Sexual satisfaction

45 Psychological Factors Patients relationship with her partner Number of years in present relationship Past negative sexual experiences - rape or sexual abuse Low sexual self image Poor body image Lack of feelings of safety Any negative emotions associated with arousal Stress Fatigue Depression or anxiety disorders

46 Approach to treatment: t t Home Create personal time Create couple time Create a sensual environment Make time for Intimacy, love, and sex

47 Approach to treatment: Hormones Decreasing Estrogen Level Decreasing Testosterone Level Thyroid dysfunction

48 Approach to treatment: Honey Proactively P l raising i sexuality issues Encourage communication The partners involvement in the decision-making process, hospital visitation, early viewing of scars, and early resumption of sexual activity were important for couples to function optimally Counselling can be important in preventing serious problems

49 Approach to treatment: Heart Emotional closeness to partner Length of relationship with partner Communication with partner Availability of partner

50 Approach to Treatment: Habits Do you make time for intimacy? Do you initiate sexual activity? Do you express your feelings? Do you communicate your needs? Do you indulge in creative sex? Do you experience pain during sex?

51 Options for Decreased Sexual Interest Physical exam to identify physical causes More time for manual or oral stimulation Experimentation with erotic materials Sensual massage or warm bath Change in sexual routine Non-coital sexual activity Increased communication

52 Psychosocial Issues MD Patient Knowledge Compassion Sensitivity Reasonable Hopeful Supported Sad Despondent Alone Empathy Resolved Angry Patience Concerned Afraid

53 Management I care about you! I need information! I need reassurance!

54 Thank you!