Noël Arring, PhD, DNP, RN, and Debra L. Barton, PhD, RN, FAAN, FASCO, discuss clinical strategies to address sexual dysfunction in female cancer survivors.
When it comes to cancer survivorship, sexual health is a topic that is often left on the backburner. However, there are researchers seeking to clarify best practices in helping patients navigate cancer-related sexual dysfunction.
Noël Arring, PhD, DNP, RN, and Debra L. Barton, PhD, RN, FAAN, FASCO, recently published an article in the Journal of Clinical Oncology, in which they highlighted clinical strategies to address sexual health in female cancer survivors.
Arring is an associate professor at the University of Tennessee with a research interest in symptom management. She has been an oncology RN for over 20 years. Barton is a research professor at the University of Tennessee. In addition to being an oncology nurse for the past 37 years, she has been working in symptom management research for over 20.
To better understand their research, Oncology Nursing News met with the experts to discuss the current evidence and what oncology nurses should know about helping survivors manage this reality.
Many female cancer survivors describe feeling low sexual desire, the cause of which is often multifold and not well understood.
As Arring explained, there are not many pharmacologic interventions available to help women manage low sexual desire following cancer. Although the FDA has approved 2 pharmacologic agents, flibanserin (Addyi) and bremelanotide (Vyleesi), to help improve sexual desire in premenopausal women, the researcher explained that cancer survivors have unique needs.
“In terms of medications or drugs, there really aren't any for cancer survivors,” she said. “There is a difference between the needs for female cancer survivors, as opposed to women who are diagnosed with hypoactive sexual desire disorder, or HSDD. There are medications for HSDD. However, their [benefit] does not necessarily translate to women with a history of cancer.”
Further, as Barton noted, these agents are approved for women who are premenopausal.
“The medication approved for HSDD is actually approved for pre-menopausal women,” Barton said. “That is obviously a very different population than cancer survivors—who are not all premenopausal. In the breast cancer arena, and other gynecologic cancers, they are [often] postmenopausal and severely hormone depleted.”
For these pharmacologic agents to be fully utilized in practice, both researchers agreed that they need to be tested in this specific population. Until then, their full value remains unknown.
As of now, psychosexual counseling holds the potential to help survivors manage low desire, Arring said; however, more data are also needed in this arena.
“We are working on mind-body interventions for sexual desire as well as body image,” she said. “These are promising, but there is not a lot of evidence to support them at this time.”
During active treatment, many patients will undergo chemotherapy, radiation therapy, or estrogen deprivation—which can lead to vaginal shortening and tissue atrophy.
To combat this, clinicians might prescribe patients polycarbophil-based vaginal moisturizers and hyaluronic acid (HA)-based moisturizers. Unfortunately, in clinical trials, moisturizers are often used as the control regimen against pharmacologic interventions, and not studied as the intervention itself. Although there have not been many good placebo-controlled, randomized-controlled trials for HA-based and other moisturizers, Barton still recommends this approach.
“Most of the evidence for moisturizers and HA are [as] the comparative arms for low dose, topical, hormone-related treatments and many of these studies have shown equivalent benefit,” Barton said. “We do not really have good, placebo controlled-randomized controlled trials for HA or for moisturizers.”
“Anecdotally, from my experience, and from a colleague who runs a sexual health clinic’s experience, HA does seem to be very helpful for some women,” she said. “It seems like if you're moisturizing the vulvovaginal area in some way, you're going to benefit.”
She also noted that sex, if possible, can also be beneficial in helping keep the cells healthy.
“If you are able to have penetrative intercourse or even a sexual activity that increases blood flow to the vagina, you're going to be helping the cells because that's what they need; they need blood flow to bring the needed chemicals to the cells,” she said.
One study has demonstrated that 4% lidocaine has shown some effectiveness in reducing pain and boosting arousal in patients experiencing penetrative dyspareunia. This method may be a quick strategy to alleviate penetrative pain but is unlikely to help with other vaginal issues.
“Lidocaine kind of ’deadens things,’ so it makes the pain of penetration less [severe],” Barton explained, noting that in the study assessing this intervention, both arms used a lubricant. “There was lubrication involved in both arms, so it is hard to know what the 4% lidocaine actually [improved].”
Arring and Barton stressed that penetrative pain is one component of larger issues at play, and that, therefore, lidocaine is not going to solver the larger problem. However, this strategy can be useful when used in combination with other interventions.
“If somebody is having really bad pain with penetration, using lidocaine, in addition to taking care of the vulvovaginal atrophy with a moisturizer, could be helpful,” Barton said.
Moving forward, randomized clinical trials are needed to properly assess the efficacy of these various approaches. The challenge, according to the researchers, is recognizing that multi-faceted approaches are needed and writing that into the trial designs. In the meantime, standardizing how these approaches are implemented remains a key area of focus.
“We need to standardize the treatments that we are already using,” Arring explained.“[For example,] psychosexual counseling looks to be effective, but it is not standardized in how we have been implementing it.
“We need comparative studies that are looking at the different types of treatments that we're using, [and asking] not only which one works better, but at what time points and what would maintenance therapy look like,” Arring said.
“Sexual health is multi-component. It's complex,” added Barton. “We have to be able to do practical research that really addresses problems from that perspective.”