Sexual Health after a Breast Cancer Diagnosis: Addressing a Forgotten Aspect of Survivorship

Breast cancer is the most common cancer in women. The life expectancy after a breast cancer diagnosis is improving steadily, leaving many more persons with the long-term consequences of treatment. Sexual problems are a common concern for breast cancer survivors yet remain overlooked in both the clinical setting and the research literature. Factors that contribute to sexual health concerns in breast cancer survivors are biopsychosocial, as are the barriers to addressing and treating these health concerns. Sexual health needs and treatment may vary by anatomy and gender. Multidisciplinary management may comprise lifestyle modifications, medications, sexual health aids such as vibrators, counseling, and referrals to pelvic health physical therapy and specialty care. In this article, we review the contributing factors, screening, and management of sexual difficulties in cisgender female breast cancer survivors. More information is needed to better address the sexual health of breast cancer survivors whose sexual/gender identity differs from that of cisgender women.

Sexual function is complex and is affected by biological, psychosocial, and sociocultural factors that may promote or inhibit sexual response [ 19 ]. Among the components of the sexual response cycle are desire, arousal, and orgasm. Sexual desire, or libido, is influenced in multifaceted ways: by the physical and psychological health of the patient, past sexual experiences, sex education, relationship concerns (if partnered), personal beliefs about sex, and many other factors. Arousal is a neurovascular response to desire or sexual stimulation resulting in vascular congestion of the nipples/areolae and genitals. Arousal may produce an orgasm, a marked feeling of sexual release followed by rhythmic contractions in the pelvic musculature. For breast cancer survivors, it is notable that nipple-areolar sensation can be an essential component of arousal and orgasm [ 20 , 21 ]. Assessing sexual difficulties includes evaluating the patient’s sexual response and pain. Sexual pain may occur with stimulation of the vulva and clitoris, with initial or deep vaginal penetration, or with both [ 22 ]. Sexual pain can also result from conditions such as genitourinary syndrome of menopause (GSM, previously termed vulvovaginal atrophy), pelvic floor dysfunction, or chronic pelvic pain syndrome, to name a few.

Treatment-related sexual adverse effects are one of the most prevalent and distressing aspects of cancer therapy. Surgical treatments, systemic therapies, and radiation therapy all can lead to sexual health problems. Patients who have received multimodal breast cancer treatments are at high risk for sexual function problems [ 31 ]. A summary of how breast cancer treatments can affect sexuality appears in Table 1 . 4.1. Surgical Treatment Alteration of breast anatomy by lumpectomy or mastectomy may negatively influence sexual self-image, self-esteem, and confidence, affecting sexual intimacy and overall sexual well-being [ 32 , 33 , 34 ]. Many surgery-related changes can be long-term and disfiguring, such as loss of breast volume, asymmetry, fat necrosis, and occasionally seromas, which can develop after lumpectomy. Removal of the breasts and nipples can not only be disfiguring but can also diminish breast-related sensation and arousal. Occasionally, nerve injury can cause hyperesthesia or dysesthesia of the chest wall, further disrupting potentially pleasurable sexual sensations [ 35 ]. The type of surgical modality seems to influence sexual health. Women who had breast lumpectomy reported significantly greater satisfaction with breast appearance and more pleasurable breast caress than women who had a mastectomy with reconstruction ( p = 0.002 and p = 0.01, respectively) [ 36 ]. Aerts et al. [ 37 ] reviewed the type of breast surgery and its impact on sexual function and found that women who underwent breast-conserving surgery had better sexual adjustment and reported less impairment of sexual desire, arousal, and orgasm than women who underwent mastectomy. Nipple-sparing mastectomy has been associated with better psychosocial and sexual well-being than skin-sparing mastectomy followed by nipple reconstruction [ 38 , 39 , 40 ]. Breast reconstruction with nipple-areolar reconstruction is associated with improved results on the BREAST-Q psychosocial and sexual well-being scales ( p < 0.002 and p < 0.001, respectively), and this improvement did not change over time [ 41 ]. Other surgical aspects in node-positive breast cancer, such as axillary lymph node removal, can lead to lymphedema of the chest wall, axilla, and arm [ 42 ] and can affect sexuality. In a small study by Mulkoglu et al. [ 43 ] comparing women who underwent mastectomy and who had similar emotional scores with and without lymphedema after breast cancer treatment, women with lymphedema had poorer sexual function and quality of life. Some premenopausal patients with hormone receptor-positive breast cancer may require a prophylactic bilateral salpingo-oophorectomy and possibly long-term endocrine therapy to improve treatment outcomes. This treatment can lead to premature surgical menopause, which is a major risk factor for sexual difficulties [ 44 ].

Radiation therapy for breast cancer can reduce locoregional and metastatic disease and can improve the survival rate, but it has associated acute and chronic toxicities. Acute toxic effects may include fatigue, esophagitis, breast edema, induration, dermatitis, and subsequent hyperpigmentation of the skin over the breast. Chronic toxic effects may include radiation pneumonitis, lymphedema, hypothyroidism, and cardiac toxicity [ 50 ]. In addition, radiation therapy can affect the aesthetic outcomes of reconstructive surgery [ 51 ]. All these toxic effects can negatively influence sexual function.

Immune checkpoint blockade has been found to help patients with triple-negative breast cancer, resulting in longer event-free survival compared with chemotherapy alone [ 59 ]. This treatment modality is still in the early stages of development. Currently, the longer-term influence of immune therapy on breast cancer survivors and its influence on sexual health is not known and needs additional research. Immunotherapy has been used to treat other cancers and is known to cause substantial toxicities. Common adverse effects are colitis, pneumonitis, hepatitis, and nephritis. Immunotherapy can also lead to endocrinopathies such as diabetes mellitus, hypoparathyroidism, hypothyroidism, and even adrenal insufficiency. Practitioners who provide care to breast cancer survivors need to be able to recognize these adverse effects. In addition, these effects can influence sexual health due to the presence of fatigue, poor quality of life, and various endocrinopathies. This area needs further research.

Female sexual health is complex, and managing sexual difficulties in women needs a multidisciplinary team approach. Because sexual problems in breast cancer survivors are multifactorial, the initial step is to promptly identify the contributing factors for sexual problems. Then, the treatment approach includes the management of vaginal dryness and sexual pain with vaginal lubricants, massagers, moisturizers, local hormone therapy when not contraindicated, and referral to a pelvic floor physical therapist. Management of mood disorders, sexual self-image concerns, and relationship issues may need a referral to a sex therapist. Many patients will see substantial improvement with these measures, but patients who need additional intervention can be considered for medication management. Medications should be individualized based on the patient’s clinical presentation. For example, patients with depression can be treated with bupropion, which has minimal sexual adverse effects. 6.1. Impact of Lifestyle on Sexual Function Poor physical health is a major risk factor for female sexual dysfunction. Conditions such as metabolic syndrome [ 69 ], diabetes [ 70 ], hypertension [ 71 ], dyslipidemia, and obesity [ 72 ] predict female sexual difficulties [ 73 , 74 , 75 ]. Adhering to the healthy lifestyle recommendations set forth by the American Cancer Society and the American Institute for Cancer Research (AICR) was associated with reduced disease-specific and overall mortality and improved health-related quality of life (HRQoL) among breast cancer survivors [ 76 , 77 ]. These recommendations included managing one’s weight; following a whole food, plant-predominant dietary pattern; regularly exercising; and avoiding alcohol and tobacco use. These same lifestyle elements are linked to improved sexual function. A tailored health education program centered on the AICR recommendations was part of a 12-week healthy living program that also provided clinical consultations; 55 breast cancer survivors aged 45 to 60 years were randomly assigned to either the intervention group or a control group [ 78 ]. At 12 weeks, women in the intervention group reported clinically significant reductions in sexual dysfunction, vasomotor symptoms, somatic symptoms, and overall menopausal symptoms compared with the control group. The direct impact of nutrition on sexual function among women is not yet fully elucidated; however, nutritional improvements in body weight, cardiometabolic health, vascular endothelial function, blood glucose regulation, and mood may have a role in improving sexual function [ 79 ]. Investigators of multiple randomized controlled trials and cross-sectional studies have examined the effect of the Mediterranean diet on reported sexual function and found that adherence to this eating plan resulted in better sexual function in a dose-dependent manner [ 80 ]. More than half of all women who undergo adjuvant chemotherapy for early-stage breast cancer have substantial gains in fat mass and reduction in lean mass [ 81 ]. Only 10% of women with breast cancer-related weight gain return to their pretreatment weight [ 82 ]. Weight gain after breast cancer treatment is associated with poorer breast cancer-related morbidity and mortality, and body image changes are related to high psychological distress. The AICR Continuous Update Project reported strong evidence linking the Mediterranean dietary pattern to a decreased risk of being obese or overweight and to reduced weight gain. Weight management efforts are known to improve breast cancer outcomes [ 83 ]. Achieving ideal body weight is known to restore physical health, which could improve sexual function. Additionally, a randomized study of 38 postmenopausal women found that a low-fat, vegan diet supplemented with 86 g (0.5 c) of whole soybeans daily improved quality of life in vasomotor, sexuality, physical, and psychological domains [ 84 ]. Regular exercise has been shown in some studies to prevent the development of sexual dysfunction in middle-aged women and to maintain breast cancer survivors’ sexual activity. In a prospective study, 537 breast cancer survivors aged 35 to 68 years were randomly assigned to a 12-month exercise trial and followed up for 5 years; their HRQoL was compared with that of the age-matched, female general population. The mean HRQoL was statistically and clinically impaired for breast cancer survivors vs. the general population, although the overall mean HRQoL of breast cancer survivors did not improve significantly over 5 years; however, the domains of sexual activity, usual activities, depression, and distress did improve from baseline [ 85 , 86 ]. Researchers have reported the effects of tobacco and alcohol use on sexual function in the general population. Tobacco use has been linked to a 30% reduction in genital arousal, delayed orgasm, and reduced vaginal lubrication, and those with alcohol dependence had sexual problems and reduced vaginal lubrication

To date, two medications are approved by the US Food and Drug Administration (FDA) for the treatment of HSDD in premenopausal women: flibanserin and bremelanotide. These medications do not have a hormonal mechanism for improving sexual function, but they have not been well studied in breast cancer survivors, and additional research is needed in this population. The antidepressant bupropion, which is not FDA approved for HSDD treatment, is an option for breast cancer survivors with depression and associated sexual concerns. 6.3.1. Flibanserin Flibanserin works as a 5-HT 1A receptor agonist and a 5-HT 2A receptor antagonist; it is FDA-approved as a daily oral therapy for the indication of acquired, generalized HSDD in premenopausal women in the US [ 99 ]. In Canada, flibanserin also is approved for postmenopausal women aged 60 years or younger [ 100 ]. The drug’s exact mechanism of action is unknown. Results of several studies showed that flibanserin has a positive influence in both premenopausal and postmenopausal women on sexual desire, number of satisfying sexual events, and decreased sexual distress with clinically meaningful benefits [ 99 , 100 , 101 , 102 , 103 , 104 ]. Flibanserin, at a dosage of 100 mg daily, is generally well tolerated, except for central nervous system and gastrointestinal adverse effects [ 105 ]. Strong caution with alcohol intake is advised, as is attention to drug interactions [ 105 ]. In a small study of women with breast cancer receiving tamoxifen therapy, flibanserin over 24 weeks improved overall sexual function in most women [ 106 ]. A larger randomized placebo-controlled study is still needed.

Bupropion is a selective norepinephrine receptor inhibitor and is an antidepressant with a dual effect on norepinephrine and dopamine neurotransmitter systems with no known serotonergic activity [ 113 ]. Studies have noted that bupropion has the advantage among antidepressant medications of having less effect on sexual function and may even enhance sexual function for certain persons. Bupropion can be used as a first-line treatment option for breast cancer survivors with depression and associated sexual concerns.

Substantial research documents a negative association between the impact of breast cancer treatment on body image and, in turn, sexual health for cisgender women [ 120 , 126 , 127 , 128 ]. In qualitative studies, such women have described their physical appearance after breast cancer treatment as “bizarre,” “weird,” or “does not look right” [ 129 ]. Body image concerns in breast cancer survivorship generally relate to two issues: (1) chest size and shape and (2) posttreatment scarring due to surgery or port placement for chemotherapy. Survivors also report body image and sexual health-related concerns around hair loss and weight gain [ 30 , 53 , 129 ]. Patients who had more than 20% of their breast tissue removed were reported to be at increased risk for dissatisfaction with postoperative scarring [ 130 ]. Because of their breast cancer surgical scars, cisgender women have reported discomfort being seen naked and often avoid nudity or even certain types of clothing to manage the concern [ 127 ]. Body image and sexual concerns related to cancer survivorship are common across all ethnic groups; however, important cultural differences exist. Results of a qualitative study of breast cancer survivors showed that African American, Asian American, and Latina women were more likely to receive mastectomies, and African Americans were less likely to receive adjuvant therapies [ 131 ]. African American patients with early-stage breast cancer reported a higher burden of symptoms than White patients. Future studies focusing on the impact of treatment-based outcomes among diverse racial/ethnic groups would help define the differences and diminish the disparities [ 29 , 132 ]. Altered body image can impact sexual function, and it requires a multimodal approach to improve sexual function [ 133 ]. A text-based online group therapy intervention involving 60 breast or gynecologic cancer survivors showed a significant reduction in distress about body image. Psychosexual dysfunction and quality of life improved but not significantly [ 134 ]. Sexual dysfunction can be especially difficult among young breast cancer survivors requiring long-term ovarian suppression. Results of a small study of young breast cancer survivors showed significant improvements in sexual function with a psychosexual group intervention that included health rehabilitation, body awareness exercises, and mindfulness-based cognitive therapy [ 53 ]. Breast cancer survivors can have sexual health difficulties because of changes to their breast anatomy and physiologic function. They can also have psychological and relational challenges compounded by their lack of communication about the effect of cancer treatments on sexual health [ 60 , 135 ]. Providing sexual health counseling to patients and their partners is critical, which ideally should begin before any treatment interventions and continue until their symptoms resolve [ 11 , 135 , 136 , 137 ]. The American Cancer Society/American Society of Clinical Oncology [ 65 ] and the National Comprehensive Cancer Network [ 66 ] recommend that HCPs promptly refer affected patients for multidisciplinary sexual health treatment. Referrals may be appropriate for any of the following: individual psychotherapy, couples counseling, gynecologic care, urologic care, physical therapy of the pelvic floor, and sexual health specialty care [ 65 , 66 ]. Access to such services, however, may be limited or unavailable in certain geographic areas.

Because sexual dysfunction in this patient population results from a combination of factors, a multimodal and individualized approach is required for pelvic physical therapy. Pelvic health physical therapists acknowledge that sexual dysfunction is a complex and global issue involving more than vulvar and vaginal tissues. The therapist carefully assesses all possible contributors to the patient’s sexual pain and dysfunction from the beginning of treatment to support realistic and positive treatment expectations [ 141 ]. Pelvic health physical therapists are trained to be sensitive to both physical and psychosocial aspects of patients’ sexual function and to talk with patients about topics such as body image, quality of intimate relationships, and their thoughts and beliefs about their condition or conditions. It is important to address both the physical and psychosexual mechanisms of dyspareunia through a multimodal treatment approach [ 142 ]. Concerns beyond the therapist’s scope of practice should prompt a referral to other practitioners. A multimodal 12-week physical therapy intervention for women with dyspareunia after gynecologic cancer treatment showed significant improvement in sexual distress, pain-related anxiety and catastrophizing, pain-related self-efficacy, depressive symptoms, and body image concerns. The PHPT intervention comprised education, PFM exercises with biofeedback, manual therapy, and home exercises [ 143 ]. Typically, PHPT combines weekly in-clinic sessions with a home program between sessions.

PFM training refers to exercises taught by HCPs, such as pelvic floor physical therapists, to improve the relaxation, coordination, strength, and endurance of the PFMs. These exercises were shown to have a positive effect on stress urinary incontinence and the symptoms of GSM, including vaginal dryness and dyspareunia. A study of postmenopausal women with GSM and urinary incontinence participating in a 12-week PFM therapy program found improved blood flow in vulvovaginal tissues, ability to relax the PFMs, and elasticity of vulvovaginal tissues [ 147 ]. Women experiencing dyspareunia after breast cancer treatment typically have myofascial pelvic pain and weakness, increased tone, and reduced length of the PFMs. Contributing factors include a hypoestrogenic state; tissue changes related to a hiatus in vaginal penetration and sexual intimacy for the duration of the cancer treatments; anxiety, depression, or both; changes in body image; pain; fatigue; and gastrointestinal distress. The goals of PFM therapy are improving the circulation, relaxation, and lengthening of the tissues around the vagina and improving the awareness and coordination of the PFMs. Often, PFM therapy is enhanced by digital feedback (patient or therapist), visual feedback (use of a mirror), real-time ultrasonography, or the use of pressure or surface electromyography-type equipment.

Vaginal insertion by a finger or dilator often is incorporated into the treatment of women who have pain with penetration. These exercises are meant to stretch the vaginal tissues and release tension in them by gradually increasing the size of the dilator inserted [ 149 ]. Because the aim of insertion practice is to desensitize the tissues, it serves as a graded exposure strategy. Through the regular practice of mindfully inserting the dilator while practicing relaxation techniques—both general and specific for the PFM—patients can gradually reduce their fear of painful penetration and improve their confidence about resuming sexual activity with penetration. Generally, clinicians recommend that patients use the dilator without their partner, so they are in full control of the exercise, before attempting partnered penetration. Many clinicians recommend the use of insertion techniques three times weekly, but optimal parameters for dilator use have not been established for preserving or improving vaginal size, either during cancer treatment or after menopause. Meditating, playing relaxing music, and using the dilator for more than 3 months are factors that may result in better outcomes [ 150 ]. Limited adherence to dilator use has been observed in multiple studies [ 151 ]. The pelvic health physical therapist can provide accountability and help support patient treatment adherence during follow-up sessions by using motivational interviewing and other coaching techniques [ 152 ].

Breast cancer survivors should be considered at high risk for sexual difficulties because preexisting health conditions may worsen, and new sexual health problems often develop. All breast cancer treatment modalities can lead to sexual health problems through various mechanisms. Patients should be queried early and frequently by their health care team regarding their sexual health. Sexual health is complex, and sexual problems are multifactorial and should be addressed thoroughly with survivors. Multiple treatment options exist for sexual problems, and these options should be discussed with the patient. A multidisciplinary approach usually gives the best results in the treatment of breast cancer patients with sexual dysfunction.