Abstract
Background
Sexual dysfunction is common in patients with serious illness. Up to 90% of patients with cancer (especially gynecological and breast cancers) experience sexual dysfunction from the underlying illness or treatment-related side effects.1,2 Many patients with serious illnesses want to discuss their sexual health with their clinicians since sexual symptoms negatively impact relationships, their partner, and their mental health.3,4 Genitourinary symptoms of menopause (GSM) and decreased libido are two common sexual symptoms in patients with serious illness. 5 This Fast Fact assimilates the published evidence to provide guidance to clinicians for managing GSM and decreased libido. 5
Definitions and Etiology
GSM is a constellation of symptoms caused by a hypoestrogenic state, resulting in changes in urogenital tissues. The hypoestrogenic state is due to the ovaries no longer producing adequate estrogen and progesterone. This condition can result from natural menopause but can also be a result of surgical menopause, chemotherapy, or radiation.6,7 Low libido, or decreased sexual desire, or arousal, is often caused by many factors, including medical conditions, psychological factors, dyspareunia, medications, substance use, stress, and/or relationship difficulties.
GSM symptoms are divided into three categories:
Genital (often due to vulvovaginal atrophy): vaginal dryness, irritation, burning, itching, or discharge. Urinary: urgency, frequency, incontinence, recurrent urinary tract infections, and discomfort with urination. Sexual: lack of lubrication, low libido, decreased arousal, and dyspareunia (painful intercourse).6,7
GSM treatment options: Most of the therapies below can be prescribed by all clinicians. For the less commonly utilized therapies, refractory symptoms, or simply if the clinician ever needs help, referral to a sexual health clinic is recommended. The International Society for the Study of Women’s Sexual Health also has a website (https://www.isswsh.org/) endorsing certain clinicians for GSM care.
Psychotherapy and sex therapy are essential components of GSM treatment not just for the patient, but for their significant other too. It is first-line treatment for low libido and involves a referral to a licensed sex therapist, psychologist, or licensed clinical social worker.
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It can decrease negative emotional responses to sexual stimulation, improve partner communication, and improve menopause awareness.
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Unfortunately, it is not always covered by insurance. Vaginal moisturizers treat daily dryness. They are affordable and include coconut oil or Replense®. Vaginal lubricants treat dryness with sexual activity. Water-based lubricants are easy to clean and do not damage condoms or sex toys but require frequent application and may increase yeast infection risk. Silicone-based lubricants are more slippery and longer lasting and do not damage condoms but are harder to clean and cannot be used with silicone sex toys. Oil-based are less expensive but difficult to clean and can damage both silicone sex toys and condoms. Avoid petroleum jelly or baby oil. Vaginal estrogen can treat essentially all GSM symptoms. It increases blood supply, improves tone, enhances lubrication, normalizes genital pH, and prevents UTIs.
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There are a wide range of preparations, including creams (Estrace, Premarin), rings (Femring), tablets, and inserts.7,10 Of note: low-dose preparations (e.g., Vagifem oral tablets or Estring vaginal rings) may not raise estrogen levels more than placebo.
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Collaborate closely with the patient’s oncologist in patients with hormonally sensitive cancers. Caution is advised for patients on aromatase inhibitors.
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Vaginal DHEA (Prasterone 6.5 mg daily vaginal insert) is a precursor to estrogen and androgens. When placed intravaginally, it improves GSM symptoms by increasing local estrogen and androgen levels.
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Abnormal vaginal discharge is a rare side effect. It is more expensive than vaginal estrogen, and its safety and efficacy have not been directly compared with vaginal estrogen.
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Pelvic floor physical therapy (PT): Patients with dyspareunia naturally tighten their pelvic floor musculature, resulting in muscle hypertrophy and perpetuation of the pain cycle. Pelvic floor PT aids in relaxing and retraining the pelvic floor.
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PTs with specialized training in GSM conditions are available in most communities. The number and type of treatment sessions vary and include biofeedback, manual therapy (including massage and dilator therapy), and trigger point treatment. Additionally, self-massage of the perineum can be taught to improve perineal elasticity and break down scar tissue. Vaginal dilators or vibrators may be recommended 2–3 times/week after pelvic surgery or vaginal radiation to break down scar tissue and allow for pelvic examination and penetrative vaginal intercourse. Over-the-counter devices like the Ohnut ring (typically less than $100) reduce pain by limiting the depth of penetration. Ospemifene (60 mg daily) is a prescribed selective estrogen receptor agonist/antagonist medication approved for vaginal dryness and dyspareunia. It may decrease the risk of recurrent UTIs too.
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Vasomotor side effects are common.
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The FDA recommends against its use in patients with known or suspected breast cancer.
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The usual cost is around $300 per month. Hormone replacement therapy (HRT): The risk-to-benefit profile of HRT for GSM is complicated and evolving. It is even more so in patients with hormonally sensitive cancer. Consider a referral to a sexual health specialist to weigh HRT risks and benefits in close collaboration with oncology. Medications for low libido demonstrate minimal to modest benefits. Their cost can range from $900–$1400 per month and is associated with significant side effects. They are only FDA approved in premenopausal women and include:
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Flibanserin (100 mg at bedtime): Serotonin agonist/antagonist. FDA black box warning for CYP3A4 inhibitors, hepatic impairment, and >1–2 alcoholic drinks within two hours of use.16–17
Bremelanotide (1.75 mg subcutaneous injection): taken 45 minutes prior to sexual activity.18,19 Many contraindications (e.g., heart disease, naltrexone, uncontrolled hypertension). Off-label use of testosterone, bupropion, and buspirone has demonstrated benefit in sexual desire and satisfying sexual events, but long-term safety and efficacy are unknown.
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Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.