NcXHF

ENDOCRINE THERAPY AND ITS EFFECT ON SEXUAL FUNCTION
0.001). 49 In conjunction with pelvic floor physical therapy,
dilator therapy appears to be most effective.
Pelvic Floor Exercises
Strengthening the pelvic floor may have restorative effects
and improve arousal. 33,50 Pelvic floor exercises, such as contraction
and relaxation of vaginal and pelvic muscles, improve
sexual function by helping pelvic muscles relax during
penetration, thereby improving dyspareunia from pain associated
with reflexively tightening. Improving blood flow to
the pelvic floor from exercises, self-stimulation, and/or vibrator
use also benefıts sexual function by using the arousal
response. 33 Pelvic floor physical therapy and/or biofeedback
may be useful for treating vaginal pain, strengthening pelvic
floor muscles, improving circulation for arousal, and providing
feedback regarding these issues. 33,50,51
Antidepressants
Women with breast cancer are frequently treated with antidepressants
for depression, anxiety, and management of
their hot flashes. Many SSRIs are extremely helpful in treating
psychologic diffıculties, but cause sexual side effects. 52,53
Therefore, a conversation about the risk and benefıts of SSRIs
should occur before prescribing these medications. A study
in patients with cancer showed that up to 79% of patients
were receiving one or more psychotropic medications. 54
SSRI-induced sexual dysfunction may improve with phosphodiesterase
type 5 inhibitor treatment, but this therapy has
never been studied in patients with cancer and the medications
are not FDA approved for this indication. 55 Bupropion
is an antidepressant that does not have the adverse sexual side
effect profıle of most SSRIs and has been shown to actually
improve overall sexual satisfaction, arousal, orgasm intensity,
and desire. 55 An effective treatment strategy is to change
a patient to bupropion from a different SSRI, if they are experiencing
sexual side effects.
Psychologic Treatment
During endocrine therapy, patients with cancer often experience
persistent sexual diffıculties (e.g., dyspareunia, diffıculty
with lubrication, decreased libido) and attention to
their effect on QoL should be an essential part of their clinical
care. Sexual function and a person’s sexual self-schema can
also be adversely affected by depression and distress that often
accompany a breast cancer diagnosis. 56,57 Therefore, it is
essential to screen for psychologic problems and intervene
early to improve a patient’s confıdence, psychologic wellbeing,
and self-perception during and after treatment. Counseling
and/or sex therapy can be effective treatment options
to help patient’s cope and adjust to changes, especially when
performed in combination with other treatment strategies.
Therapy can help a woman understand the effect of breast
cancer and its treatment on sexuality, reduce fear about
intimacy, learn strategies to address pain (i.e., intravaginal
moisturizers and dilator therapy), promote vaginal health,
increase sexual knowledge, expand the sexual repertoire, and
promote positive sexual identity. Psychologic and physical
consequences of cancer that affect sexuality and sexual function
should be addressed proactively with all patients with
cancer. Therapy can also help a patient cope with an altered
body image, decreased self-esteem, depression, anxiety, and
fatigue.
Sensate Focus is a technique used for women experiencing
dyspareunia that helps to reduce anxiety associated with sexual
touch. Sexual function for women is often multifactorial
in nature with both a physical and mental component. This is
evident when an individual overcomes sexual challenges despite
physical impairments through adaptation. For example,
a recent mindfulness intervention demonstrated improvement
in the perception of arousal, even when no physical improvements
in engorgement were noted. 58 In female patients
with cancer, decrease distress was associated with increased
sexual satisfaction. 59 Psychologic interventions appear to be
effective, but additional randomized controlled trials are necessary
to develop a standardized evidence-based approach to
treatment. 60
Hormone Replacement Therapy
The use of intravaginal estrogens, testosterone, and DHEA in
women with hormone receptor–positive breast cancer is
controversial. Several small studies have been performed and
are ongoing, but it is unlikely that a large randomized study
evaluating safety will ever be performed. 61-64 At this time, intravaginal
hormone therapy should only be considered as a
last resort after the failure of all nonhormonal options. A discussion
of the risks, benefıts, side effects, and alternatives to
hormone therapy is required before initiating treatment so
patients can make informed decisions. It is a balance between
the perceived need for treatment and concerns about the
therapy.
Investigational Treatments
Currently there are no FDA-approved medications for decreased
libido, arousal, or orgasmic diffıculties in women.
However, this is an area of active drug development by pharmaceutical
companies and both investigational nonhormonal
and hormonal treatments are being studied.
Bremelanotide or PT 141 is a promising nonhormonal agent
for female sexual interest/arousal disorder. It is a melanocortin
1 and 4 receptor agonist that binds to the melanocortin 4
receptor in the hypothalamus. Flibanserin, a 5-HT1A receptor
agonist and 5-HT2A receptor antagonist, is another nonhormonal
drug being studied for treatment of hypoactive
sexual desire disorder. The combined formulation of sildenafıl
plus testosterone, as well as buspirone plus testosterone,
are two hormonal agents that are being studied for hypoactive
sexual desire disorder, low sexual motivation, and insensitivity
to sexual cues.
CONCLUSION
As women live longer after a breast cancer diagnosis and
treatment, attention to QoL and symptoms are of increasing
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
e579