353Sexual Function, Fertility, and Cancer

SEXUAL DYSFUNCTION

Sexual dysfunction is common in patients who undergoing diagnosis of and treatment for gynecologic malignancies. This is due to pain, discomfort, bleeding, and/or psychological stress that may make intimacy difficult. Sexual disorders are typically not screened for effectively, thus masking the problem. Even for patients in whom sexual dysfunction is identified, there is little support to manage the problem. Comprehensive screening questionnaires have been validated as effective screening tools for different sexual disorders (1). Sexual disorders can be classified into four disorders: desire disorder, arousal disorder; orgasm disorder; pain disorder.

•   Pre-treatment Workup:

        Evaluate for which category of sexual disorder.

        Discuss concerns related to specific cancer therapies: examples—surgical pain or altered anatomy; radiation induced vaginal stenosis; menopausal symptoms related to either or from chemotherapy.

        Consider evaluation with the Female Sexual Function Index (SFSI) or the PROMIS Sexual Function Instrument.

        Perform a physical exam: note points of tenderness, vaginal atrophy, and anatomic changes associated with cancer surgeries or treatments. It is important to biopsy any suspicious lesions.

•   Management: guide treatment based on type of sexual disorder:

        Desire:

             Chronic medical conditions such as hypertension, diabetes, anxiety, and depression can have a negative impact on desire and should be addressed.

             Surgical disfigurement may also be a factor in desire. For women with ostomies, the four P’s approach has been applied: prepare (adjust diet in preparation for intimacy to reduce gastrointestinal problems), pouch (pouch covers are available in multiple different fabrics, including lace or silk), position (avoid positions that cause pressure on ostomy to prevent compression or spillage), and pleasure (communicate with the partner that the goal is pleasurable intimacy) (2).

        Arousal and Orgasm: treatment-induced menopause and altered gonadal function from XRT or chemotherapy are among factors that may contribute. In most hormonally sensitive cancers, systemic estrogen therapy has generally been contraindicated. However, for lower risk patients, topical estrogens have been found to be effective and relatively safe for the treatment of vaginal symptoms after menopause. Other nonhormonal therapies include vaginal moisturizers and lubricants. With regard to arousal, the prescription device EROS-CVD can be used to create gentle suction over the clitoris and has been proven beneficial in women with female arousal disorders, including those who have undergone treatment for cancer.

        Pain: patients can experience pain during intercourse from vaginal fore-shortening either due to surgery or XRT, or dryness from use of aromatase inhibitors (AIs). Patients may benefit from:

             The use of vaginal dilators along with the use of lubricants and possibly estrogen products, in order to lengthen and dilate the vagina.

             One method to minimize dyspareunia may be positional changes.

             Lidocaine 2% topical jelly applied to the vulva or vagina may reduce vulvodynia and dyspareunia.

             Antidepressants and neuromodulators (gabapentin) can mitigate some pain symptoms, but caution should be used as they may also cause some arousal disorders.

             Consider ospemifene for dyspareunia if the primary cancer was a nonhormone sensitive cancer.

        Encourage partner communication: consider psychotherapy or sexual/couples counseling.

•   Brief sexual symptom checklist for women:

        Are you satisfied with your sexual function?

        How long have you been dissatisfied?

        The problem(s) with your sexual function is:

             Little or no interest in sex

             Decreased genital sensation

             Decreased vaginal lubrication

             Difficulty obtaining orgasm

             Pain during sex

             Other

        Which problem is the most bothersome?

        Would you like to discuss it with your physician?

OVARIAN PROTECTION DURING CHEMOTHERAPY

Ovarian protection during chemotherapy has been investigated. Primary outcomes are resumption of menstruation and prevention of chemotherapy-induced ovarian failure; with pregnancy as a secondary outcome, if desired. Ovarian reserve is assessed by drawing follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) laboratories. Gonadal suppression with gonadotropin-releasing hormone (GnRH) agonist treatment has not been shown to significantly protect ovarian function or resumption of menses after completion of chemotherapy; no protective effect was seen based on age, type of chemotherapy, type of malignancy, or GnRH analog type. There was no evidence that gonadal suppression protected any ovarian reserve parameters including FSH, antra follicle count, or AMH levels (3).

FERTILITY PRESERVATION

•   It is important to discuss the risk of infertility and fertility preservation options in those patients anticipating cancer treatment. Address fertility preservation as early as possible before treatment starts. Document the discussion in the medical record (Table 6.1).

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