Although sexual health is not always addressed in discussions with female cancer patients, it is of great concern to many. There are reliable tools for assessment of sexual health and interventions that can make a healthy sex life more possible, explained Jeanne Carter, PhD, Head of the Female Sexual Medicine and Women’s Health (FSMWH) program at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City.
At the 2017 Annual Meeting of the Multinational Association of Supportive Care in Cancer, Dr Carter shared research from her program at MSKCC to update attendees on current findings, newer assessment instruments, and clinical tools to identify sexual/vulvovaginal health concerns in women with cancer. She also provided excellent advice about simple interventions that can enhance sexual health and function.
The Sexual Activity Questionnaire (SAQ) was used to evaluate 500 women who sought treatment at MSKCC. Among respondents, 49% said that they were sexually active, and 44% said no. Thirty-eight percent had physical problems that made sex uncomfortable, 25% were not interested, 16% had no partner at the moment, 14% were too tired, and 14% had partner issues.
“The SAQ allows you to determine why they are not sexually active,” Dr Carter said.
Another survey given to patients in the waiting room for outpatient appointments pinpoints concerns about sexual/vaginal health. Seventy-three percent of 211 outpatients surveyed said they were “somewhat” or “very” concerned about sexual/vaginal health. Among women who were seeking help about sexuality and vaginal health at the clinic, 93% were “somewhat” or “very” concerned.
“This shows that many women are worrying about this, and maybe we are not asking them the right questions,” Dr Carter suggested.
The MSKCC researchers set out to evaluate the effectiveness of simple sexual/vaginal health promotion treatment strategies at the FSMWH program over a 2-year period. Data from clinical assessment forms were extracted from women referred to the FSMWH program during and after cancer treatment who were seen for an initial consult and followed after recommendations were made between September 2012 and October 2014.
The tools used to assess patients included the SAQ, the Female Sexual Function Index (FSFI), as well as exploratory questions regarding concerns about sexual function, vaginal health, confidence in using vaginal health promotion strategies, and managing future issues. Symptoms were assessed, including dryness and soreness. A checklist is used at physical exam that includes pain at exam, scarring, vaginal pH, moisture, elasticity, length, thickness, vulvar atrophy, and vulvar irritation. “We found over time that we also needed to keep track of the incontinence issue,” Dr Carter noted.
Women were given diagrams of the vulvovaginal area, appropriately labeled. “The vulvar area is important but forgotten. The vulva is to the vagina as Vermont is to Florida, and many people don’t know where the vestibule is, even though it is a common site of pain,” she told listeners.
Women were educated about lubricants, which are different from moisturizers. A lubricant is usually water-based with no lasting moisture, whereas a vaginal moisturizer hydrates vaginal tissues and can be applied to all external tissues. Nonhormonal moisturizers include Replens, Hyalo Gyn, and K-Y Liquibeads. Low-dose vaginal estrogen can also be used, but many cancer survivors are afraid to use hormones.
To be effective, moisturizers need to be used 3 to 5 times per week and applied both vaginally and to external tissue, but typically packages don’t mention the external tissue, Dr Carter said. About 40% of women in their study needed to use a moisturizer 5 times a week, she added.
Pelvic floor exercises may have good tissue effects that enhance arousal. Dilator therapy allows women to gain confidence and decrease anxiety about vaginal penetration, aids in the treatment of stenosis/adhesions, and increases the flexibility of vaginal tissues.
In a sample of 175 women treated at the FSMWH program, more than two-thirds were aged ≥50 years, 60% were married, and 92% were having menopausal symptoms. About 50% were breast cancer patients, one-third gynecologic cancers, and another group colorectal cancer. Eighty-three percent were currently taking endocrine therapy, and more than 50% had some prior cancer-related treatment.
Eighty-eight percent of the women were compliant with aggressive moisturizing, and with this there was significant improvement in pain on pelvic exam. Also, there were statistically significant changes in vaginal moisture, vulvar atrophy, and vulvar irritation; improvement in patient-reported symptoms of dryness and discomfort; and improvement in pleasure from sexual activity as well as a reduction in discomfort.
“Every domain on the FSFI improved, including engagement in sexual activity and confidence in sexual activity,” Dr Carter said.
An important finding is that panty liners and thin pads contribute to dryness of the external tissues. Therefore, prior to using a panty liner or pad, it is suggested that women apply a sealant type of cream to protect tissues; suggested products include Aquaphor, Balmex, Desitin, and A&D ointment. These creams also have healing properties.
Indirect benefits of interventions, including pelvic floor exercises, were improved urinary and fecal incontinence.
Patient feedback on evaluation of the program at FSMWH included the following statements: “This makes so much sense.” “It’s so simple, I can’t believe it worked.” “Why didn’t anyone tell me?”
Fixing the Knowledge Gap
“Less than 20% of cancer survivors will seek professional help, yet 39% to 72% say that they would be interested in seeking help,” Dr Carter stated.
She gave the following suggestions for healthcare providers to improve discussions with patients:
- Initiate and encourage discussions
- Normalize concerns by providing straightforward information about possible sexual consequences and treatment options to minimize them
- Give an individual or couple permission to raise issues any time during the continuum of care
- Have an open-minded attitude
- Maintain a personalized approach
- Create a safe environment for discussions
- Pay attention to psychosexual changes instead of solely clinical outcomes
Other resources include the PROMIS tool, a 1-item screening tool to identify sexual problems and concerns over the past 12 months, which can be given to patients at office visits.
The National Comprehensive Cancer Network has an adapted sexual symptom checklist for female cancer patients on their website.