Female orgasmic disorder (FOD)
(1) A marked delay in, marked infrequency of, or absence of orgasm and/or (2) a markedly reduced intensity of orgasmic sensations
Female sexual interest/arousal disorder (FSIAD)
Requires at least three of the following (in any combination): (1) absent/reduced interest in sexual activity, (2) absent/reduced sexual/erotic thoughts or fantasies, (3) no or reduced initiation of sexual activity and being unreceptive to a partner’s attempts to initiate sex, (4) absent or reduced sexual excitement/pleasure during sex in all or almost all (approximately 75–100 %) of sexual encounters, (5) absent or reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., verbal, visual), and (6) absent or reduced genital or nongenital sensations during sexual activity during sex in almost all or all (approximately 75–100 %) of sexual encounters
Genito-pelvic pain/penetration disorder (GPPPD)
Persistent or recurrent difficulties with one or more of (1) vaginal penetration during intercourse; (2) marked vulvovaginal or pelvic pain during intercourse or penetration attempts; (3) marked fear of anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration; and (4) marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration
Female Sexual Interest/Arousal Disorder (FSIAD)
The diagnosis of female sexual interest/arousal disorder is characterized by a lack of or significantly reduced sexual interest/arousal. It must be manifested by at least three of the following (in any combination): (1) absent/reduced interest in sexual activity, (2) absent/reduced sexual/erotic thoughts or fantasies, (3) no or reduced initiation of sexual activity and being unreceptive to a partner’s attempts to initiate sex, (4) absent or reduced sexual excitement/pleasure during sex in all or almost all (approximately 75–100 %) of sexual encounters, (5) absent or reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., verbal, visual), and (6) absent or reduced genital or nongenital sensations during sexual activity during sex in almost all or all (approximately 75–100 %) of sexual encounters.
Female Orgasmic Disorder
The diagnosis of female orgasmic disorder (FOD) requires the presence of (1) a marked delay in, marked infrequency of, or absence of orgasm and/or (2) a markedly reduced intensity of orgasmic sensations.
Genito-pelvic Pain/Penetration Disorder (GPPPD)
The diagnosis of genito-pelvic pain/penetration disorder (GPPPD) requires persistent or recurrent difficulties with one or more of (1) vaginal penetration during intercourse; (2) marked vulvovaginal or pelvic pain during intercourse or penetration attempts; (3) marked fear of anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration; and (4) marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
The DSM-5 requires that a woman must have symptoms 75–100 % of the time to make a diagnosis of sexual disorder, except when there is a substance or medication-induced disorder. The symptoms have to be present for at least 6 months and should not be better explained by a nonsexual mental disorder, a consequence of severe relationship distress (e.g., partner violence) or other significant stressors.
Each of the sexual dysfunction categories can be further described by using specifiers such as “lifelong versus acquired “and “generalized versus situational.” The severity of the problem should also be documented—specifically, whether it is mild, moderate, or severe. Finally, associated features should be noted, including the presence of (1) partner factors (partner sexual problem and/or health status); (2) relationship factors (difficult communication, differences in desire for sexual activity); (3) individual vulnerability factors (poor body image, history of sexual or emotional abuse), psychiatric comorbidity (depression and/or anxiety), or stressors (job loss, bereavement); (4) cultural or religious factors (attitudes about sexuality); and (5) medical factors relevant to prognosis, course, or treatment.
Screening and Assessment
The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) provide evidence-based recommendations for screening and management of late effects of cancer treatment, including psychosexual dysfunction .
It has been recommended that sexual health status in women cancer survivors should be assessed at regular intervals and at least annually [29, 30] as well as anytime a woman voices a sexual concern. To facilitate screening and assessment, office intake forms can include screening questions that prompt patients to provide information about sexual functioning. There are a number of screening instruments that can be used in an office setting that will allow quick identification, some of which have been developed and/or validated for use in cancer survivors [31–33]. Simply asking the patient about her sexual function and activity validates that it is an important part of overall health.
When introducing the topic of sexual functioning, it is important to communicate with the patient in a comfortable, nonjudgmental manner. Some providers find it is helpful to “normalize” the presence of sexual concerns, which lets the patient know that she is not the only person experiencing her problem. Questions should start as open ended and become more directed. No assumptions should be made about her sexuality or sexual behaviors (i.e., assuming sexual orientation or practice of monogamy).
A complete history should be elicited with special emphasis on the gynecologic and sexual history. Medication should be thoroughly reviewed, as many can have negative effects on sexual function . The physical examination should include a thorough pelvic examination . Both external and internal genitalia should be evaluated for abnormalities, such as atrophy, scarring, and strictures. Laboratory evaluation (such as sex hormones and thyroid function tests) can be added as indicated.
Although the focus of this article is on sexual functioning of adolescent and young adult female cancer survivors, it is imperative that other aspects of sexual health are discussed. Discussions about pregnancy and STI prevention are particularly important in this population, as they are vulnerable to reproductive health complications as it relates to immune compromise, incompatibility between desired contraception methods and treatment, and pregnancy complications .
Some specialty cancer centers have recognized that women with a history of cancer have unique needs with regard to sexual functioning and have developed supportive services that can help patients anticipate and manage sexual issues before, during, and after cancer treatment. Often, these expert teams are multidisciplinary and may include gynecologists, reproductive psychologists, sex therapists, and pelvic floor physical therapists who can assess patients and provide a comprehensive treatment plan to optimize sexual functioning.
Treatment plans should be tailored to the individual patient and focus on the physical, psychological, and social factors that contribute to her sexual problem . While there are few FDA-approved treatments for sexual dysfunction in women, there are still a considerable number of treatments that can be utilized to improve women’s sexual satisfaction and well-being.
Education and Setting of Expectations
Healthcare providers can play a major role in helping women with sexual concerns or sexual dysfunction by providing accurate, unbiased sexual health education. Women who were diagnosed at a very young age might have some educational deficits in this area. It is not uncommon for some to have erroneous knowledge and beliefs about sex, including basic anatomy and physiology. Furthermore, societal influences of what “normal” sex and sexuality are can promote unrealistic expectations about how an individual woman’s sex life should be. It is imperative to educate women that “normal” sexual functioning is variable between women and even throughout an individual woman’s life. It should also be emphasized that the overall goal of healthy sexual functioning should be the achievement of sexual satisfaction and that she should be encouraged to define what that means for her as an individual and as part of a couple.
Lifestyle modification should be encouraged, as overall well-being influences sexual functioning. Women should be counseled to adopt healthy lifestyle behaviors, such as smoking cessation, limiting alcohol consumption, exercising most days of the week, getting adequate sleep, eating a healthy diet, and reducing stress as much as possible. The conditions surrounding sexual experiences should be optimized as well. Women should be informed of the importance of adequate sexual stimulation and arousal, which can be achieved with prolonged foreplay and the use of sexual aids. If patients experience difficulty with sexual intercourse, they should be encouraged to explore alternative means of expressing sexual intimacy and incorporate sexual activities that don’t require intercourse. If intercourse is desired, the use of vaginal lubricants and moisturizers can make sexual activity easier and more comfortable.
Significant improvements in sexual function after intervention with traditional sex therapy and/or cognitive-behavioral therapy have been observed . Traditional sex therapy is a behavioral treatment that aims to improve an individual/couple’s erotic experiences while reducing anxiety and self-consciousness about sexual activity . Cognitive-behavioral sex therapy includes traditional behavioral sex therapy components but places a greater emphasis on modifying thought patterns or beliefs that interfere with intimacy and sexual pleasure . Directed masturbation has been demonstrated to be efficacious in the treatment of orgasmic disorders [38–40]. Mindfulness-based cognitive-behavioral treatments have also shown excellent promise for sexual desire problems . Brotto et al. demonstrated that a brief mindfulness-based cognitive-behavioral intervention was successful in improving sexual desire and arousal problems in gynecologic cancer survivors . Finally, a two-session counseling intervention that included education and support regarding cancer and reproductive issues was found to lessen anxiety about sexual and romantic relationships in adolescents and young adults with cancer .
Pelvic floor therapy is a type of physical therapy that can help strengthen the muscles of the pelvic floor and increase blood supply and innervation to the pelvic floor muscles. A pelvic floor exercise program has been shown to improve pelvic floor strength and sexual functioning in survivors of gynecologic cancers . Dilator therapy is often recommended to selected patients for the prevention of vaginal stenosis in patients who received pelvic radiotherapy ; however, evidence that it prevents vaginal stenosis or improves quality of life is mixed . Adherence to long-term use is often poor . Data on the use of dilators for the treatment of sexual dysfunction in the adolescent population and younger is nonexistent.
For women who are prematurely postmenopausal as a result of their cancer treatment, hormonal replacement therapy can restore the normal hormonal milieu. However, only conjugated equine estrogen and ospemifene are FDA approved for the specific treatment of female sexual dysfunction. Vaginal estrogen can be prescribed in a variety of forms and is effective in the treatment of vulvovaginal atrophy (VVA), a common cause of painful intercourse. However, the use of estrogen in any form in patients with a history of hormone-sensitive cancer is controversial. Ospemifene is a selective estrogen receptor modulator that acts directly on the vulvovaginal tissues to reverse atrophy without exerting estrogenic effects on the uterus and breast; however, it has not been specifically studied in cancer survivors . Finally, vaginal dehydroepiandrosterone has been used for the treatment of VVA; its use is associated with lower levels of systemic estrogen and testosterone, but its long-term safety profile is unknown .
The role of testosterone therapy for the treatment of female sexual dysfunction is even more controversial. Although it is not FDA approved for this indication, it is frequently prescribed off label. Testosterone has been shown to improve sexual satisfaction, general well-being, and mood ; however, safety concerns such as potential development of breast cancer and negative effects on cardiovascular health have limited its use .
Bupropion is a mild dopamine and norepinephrine reuptake inhibitor/nicotinic acetylcholine receptor antagonist that is used as an antidepressant and smoking cessation aid. Prior studies have shown that it is also useful in treated low desire in women , including those with SSRI-induced low desire [50, 51], and women receiving adjuvant hormonal therapy for breast cancer . Flibanserin is a 5-HT1A receptor agonist/5-HT2 receptor antagonist that was recently approved by the FDA for the treatment of premenopausal women with hypoactive sexual desire disorder (HSDD) [53, 54]. However, there are no data on its use in cancer survivors.
There are multiple sexual enhancement products that are available over the counter. While most have not been rigorously tested for efficacy and safety, many women with a history of cancer express interest in their use . Most pharmacologic interventions for the treatment of sexual dysfunction have not been tested in cancer survivors , highlighting the importance of more research in this area.
When to Refer
Complex cases warrant referral to professionals who have specialized training in sexual health and medicine. Organizations such as the International Society for the Study of Women’s Sexual Health (www.ISSWSH.org); the American Association of Sexuality Educators, Counselors and Therapists (www.AASECT.org); and the Society for Sex Therapy and Research (www.SSTARNET.Org) have online tools that can assist with locating healthcare providers that specialize in sexual health issues.