Leslie R. Schover, PhD
Preventive sexual counseling can be effective in reducing sexual dysfunction resulting from the treatment of breast cancer patients with aromatase inhibitors (AIs); however, that intervention should be provided early in treatment and supported by encouragement from providers, Leslie R. Schover, PhD, said in a presentation at the 2017 Miami Breast Cancer Conference.
Schover is the founder of Will2Love, an online resource to help guide cancer survivors in sexual wellness and parenthood. She was previously a professor of behavioral science at The University of Texas MD Anderson Cancer Center, where she created and evaluated innovative treatment programs for cancer and sexual health. She has also served as a staff psychologist at the Cleveland Clinic Foundation.
The importance of AIs and their effect on sexuality is growing as more women are being prescribed this treatment. In addition, there is potential for the course of these drugs to be extended from 5 years up to 10 years, and vaginal/vulva adverse events (AEs) grow worse the longer patients stay on AIs. These sexual issues are often overlooked or underestimated. Schover said this is because many American women over the age of 50 are no longer sexually active and because study questionnaires on sexual health are inadequate.AIs and Sexual Dysfunction
Schover led a survey study of 139 women within the Department of Breast Medical Oncology at MD Anderson Cancer Center with localized breast cancer.1
Ninety-three percent of the women reported some level of sexual dysfunction after using AIs as adjuvant therapy after 18 to 24 months. Additionally, 75% of the women reported being distressed about the effects AIs had on their sexual health, whereas one-quarter of the women stopped all partner sex due to severe genital pain and dryness. About 70% of women attributed sexual problems to the initiation of AI therapy. The main issues, Schover explained, were vaginal dryness and dyspareunia.
That survey provided a benchmark for a follow-up investigation: a randomized pilot trial designed to evaluate the effect of early intervention on sexual dysfunction during the first year on AIs.2
The study also sought to compare efficacy of prebiotic and hyaluronic-acid, over-the-counter, estrogen-free vaginal moisturizers.
The MD Anderson study enrolled 57 postmenopausal women with early-stage breast cancer who started AIs as first-time endocrine therapy. All of the patients received a detailed handout covering the management of AEs from AIs as well as follow-up questionnaires after 6 months and 1 year on treatment. In addition, half of the study participants received a kit of products to help treat sexual dysfunction. This included the vaginal moisturizer, water-based lubricant, a vaginal dilator, and instructions on how to use everything. This active treatment group was also given access to an online information resource and coaching over the phone. Within this active treatment group, half received the prebiotic over-the-counter vaginal moisturizer and half received the hyaluronic-acid product.
Included in the instructions that all participants received was an explanation about the importance of adhering to AI treatment. “Usually, only maybe 50% of women finish the 5 years of an aromatase inhibitor, or of tamoxifen,” Schover explained. This nonadherence is usually a result of the side effects AEs that women experience from these drugs, including sexual dysfunction. The aim was to use these interventions on a preventative basis, to stop the sexual problems that occur when starting on an AI.
Of the findings from this study, Schover said, “What we had trouble demonstrating, except on a couple of measures, was that the active treatment groups were better than the usual care. They both were in far better shape in a year than the women in our benchmark survey.” Compared with the 24% of patients who stopped having partner sex completely in the benchmark study, only 9% stopped in this study. Sexual dysfunction was also not as prevalent in this study as it was in the benchmark study. Overall, the patients’ sexual function over the study period was fairly stable. Schover expected a sharp decline, based on the earlier data.
Schover listed several limitations, including the size of the study and the likelihood of undertreatment. The recommended frequency for the vaginal moisturizer is 5 to 7 times a week. “We told them to use it 2 to 3 times a week,” Schover explained. “And when we looked at how often women actually used it, it was an average of about twice a week.”
There was also a regression between the 6-month outcomes and the 12-month outcomes. Schover attributes this to the limited 6-month supply that the researchers gave women. “A lot of them didn’t go out on their own and buy more,” she said.