Leslie R. Schover, PhD Department of Behavioral Science

Transcription

1 Causes and Treatments of Low Sexual Desire in Breast Cancer Survivors Leslie R. Schover, PhD Department of Behavioral Science

2 IMPORTANCE OF SEX TO BREAST CANCER SURVIVORS Livestrong 2006 Post-Treatment Cancer Survivors Survey, N=2,307, 85% <age 55 at diagnosis, 2/3 female, most 1-5 years post-tx: Sexual function was 3 rd ranked physical concern, reported by 46% (after energy & concentration) Cancer Support Community s M.A.P. Breast Cancer Registry, N=1,043, mean age 55, mean 6 years posttx (recruited over internet) Sexuality a top source of distress, reported by 21% (22% fatigue, 18% sleep disturbance, 18% weight gain)

3 BREAST CANCER-RELATED SEXUAL DYSFUNCTION Low sexual desire Genital dryness and pain during sexual activity Orgasm problems tend to be secondary to above issues

4 LOW SEXUAL DESIRE: A MULTIFACTORIAL PROBLEM Loss of desire is the most complex and difficult sexual problem to treat Need to assess each contributing factor and address it Unlikely that a pill will reverse desire Sexual desire after breast cancer (or in menopausal women) is not correlated with serum free or total testosterone

5 INCREASED RISK OF SEXUAL PROBLEMS WITH ESTROGEN DEPRIVATION Premenopausal women who have abrupt ovarian failure after chemotherapy Postmenopausal women who D/C estrogen replacement after cancer Postmenopausal women taking aromatase inhibitors BRCA gene mutation carriers who have risk-reducing oophorectomy

6 DYSPAREUNIA AND SEXUAL DESIRE Who wants sex if it hurts? Over 50% of menopausal women without breast cancer have problems with vaginal dryness 59% enjoy sex less, 55% avoid sex Sexual dysfunction in postmenopausal breast cancer survivors at least as severe, exacerbated by AIs (24% stopped sex in our recent survey)

7 DYSPAREUNIA CAN BE TREATED Conservative approach using vaginal moisturizers, lubricants, and pelvic floor muscle awareness works for many Low-dose vaginal estrogens may not be safe post hormone-positive tumor New SERMs, ospemifene and lasofoxifene may prevent breast cancer and treat vulvovaginal atrophy

8 ROLE OF ANDROGEN DEPRIVATION Theory that androgen levels are key to female desire for sex If postmenopausal, gradual 50% drop in circulating androgens More sudden if abrupt ovarian failure

9 ARE ANDROGENS THE KEY TO DESIRE? Pharma hopes to make huge profits: 43% of women rate their desire as low, tho <20% distressed about it In women, high androgens associated with metabolic syndrome After natural menopause or breast cancer, endogenous T does not correlate with sexual desire or function Androgen replacement only works at doses that are supraphysiologic Very large placebo effect in all randomized trials of T patches Can women tell drug from placebo? Failure to assess invalidates all trials Most assays unreliable for free T in women

10 ANDROGENS AND BREAST CANCER RISK Endogenous androgen levels increase breast cancer risk both before and after menopause In women with localized breast cancer, those with highest T had highest risk of recurrence The more androgenic an HRT regimen, and the greater the exposure, the higher the risk of breast cancer (LIBERATE trial) My opinion: Androgens should not be prescribed to women who have had breast cancer or are at risk of breast cancer as 2nd malignancy (Hodgkin, osteosarcoma)

11 BODY IMAGE ISSUES Type of breast treatment has little impact on staying sexually active or functional, tho loss of erotic sensation Breast reconstruction prolongs the stress of treatment, usually chosen to feel whole, not for sexual issues Younger women, those invested in beauty more distressed about changes Weight gain from chemo major issue

12 BODY IMAGE TREATMENT Can facilitate getting used to looking at changes in body, desensitize Use sensate focus to introduce changes to partner, minimizing distraction during sex Promote healthy diet and exercise during and after breast cancer treatment

13 COMORBIDITIES AND MEDICATIONS Other chronic illnesses affect women s sexual function At least half of women over age 50 do not have functional sexual partner Very high percentage of breast cancer survivors take medications that blunt desire: opiate pain meds, antidepressants, anti-anxiety medication

14 DEALING WITH HEALTH ISSUES Be aware that a sexual history is important: do not assume problems are related to breast cancer Evaluate current medications and see if it is possible to D/C some that were prescribed at diagnosis, change category, or decrease dosage

15 DEPRESSION, LIFE STRESS, CHRONIC FATIGUE Menopausal symptoms may be more severe after breast cancer Sleep deprivation from hot flashes can contribute to post-treatment fatigue New survey suggests it is mild depression, rather than fatigue, that interferes with sexual desire Depression and life stress clearly linked to loss of desire at midlife

16 TREATING DEPRESSION AND FATIGUE Cognitive behavioral therapy can treat depression without medication s double-edged sword effect on sexuality Fatigue and life stress often improve with exercise programs Need for peer support, normalizing the problems

17 SUBSTANCE ABUSE Abuse of alcohol or opioid pain medication both have severe consequences for sexual desire Substance abuse may be overlooked in oncology settings Crucial to assess and treat

18 RELATIONSHIP CONFLICT Rates of divorce do not rise after breast cancer in mainstream US May be abandonment in traditional societies (Nigeria is example) However, pre-existing conflict may be exacerbated by the stress of illness Resentment and alienation are major factors in women s desire for sex Refer for individual or couple therapy

19 HISTORY OF SEXUAL TRAUMA AND DYSFUNCTION History of sexual trauma (childhood abuse or adult rape) is major antecedent of sexual dysfunction in women Women may attribute cancer to past trauma, or simply may lack good coping skills Diagnosis may trigger PTSD symptoms History of trauma should be red flag for referral to mental health professional

20 TECHNIQUES TO ENHANCE DESIRE Promote activities that increase desire: Physical sports or dance Intimate talks, cuddling, romance Erotic stories, videos, fantasies Encourage pleasurable body experiences, such as massage, makeovers Improve sexual communication & pleasure No magic bullet exists

21 Encouraging Sexual Activity Counsel partners together whenever possible Emphasize goals of maintaining intimacy and pleasure vs. sexual performance Educate about possible benefits of regular promotion of genital blood flow Explore and debunk myths about sex and cancer

22 COMMUNITY REFERRALS Know the mental health professionals who can help with complex cases, sex and marital therapy Know gynecologists and menopause experts who treat low desire, vaginal atrophy and dyspareunia