Breast cancer survivors constitute the largest group of cancer survivors in the United States. This is a reflection of advances in earlier detection techniques and improvements in in surgical and oncological management.(1)

Survivorship begins at the time a cancer is detected. It must address health care issues beyond diagnosis and treatment. The quality of life of survivors can be improved by guiding them to the care available, and acknowledging the late effects of treatment. It is estimated that at least 50% of cancer survivors will experience long term sexual dysfunction.(1)

The predictors of sexual morbidity include:

1)         Poor emotional well-being

2)         Presence or absence of vaginal dryness

3)         Quality of the relationship

4)         Partner sexual dysfunction

We must always be cognisant that the treatments offered can have the greatest influence on sexual consequences.


The younger the patient at the time of diagnosis, the greater the impact. This is due to the features of premature ovarian insufficiency. They have greater concerns about decreased physical activity, weight gain, hair loss and the decline in mental health. There are enormous body image problems. The loss of fertility can be  a significant concern for some individuals.

It is important to dissect the effect on the partner. Pre-diagnosis discord may get exaggerated. Exhaustion due to care giving and not seeing the person with cancer as a sexual partner may warrant counselling.


The greatest impact here is also from the symptoms of ovarian insufficiency. The cytotoxic effects of the alkylating chemotherapeutic agents are responsible for the ovarian failure. The latter is influenced by the duration and cumulative dose of therapy.

The symptoms include fatigue, nausea, weight fluctuations, alopecia, neuropathy and infertility


There can be varying effects, with once again the impact being greater in younger women. There is a lowered perceived sexual attractiveness.

Breasts are often viewed as a basic part of beauty and womenhood. The touching of breasts is a common part of foreplay; and surgery may interfere with pleasure from breast caressing.


There are acute skin changes. The skin can become swollen, red and tender. Nausea, vomiting and fatigue can ensue.


Aromatase inhibitors block the conversion of testosterone to estrogen. This leads to severe vulvo-vaginal atrophy. The data on tamoxifen is conflicting; and the side effects are greater with the aromatase inhibitors.

A quote from the European Sexual Society of Medicine syllabus  stated ”The most common culprit in causing sexual dysfunction may not be the loss of a breast, but the premature and severe menopausal impact of systemic therapy.”

The main concerns in sexual rehabilitation of cancer survivors is that sexuality is poorly addressed in a busy oncology setting. There is poor training of medical professionals, as dysfunctional sexuality is a rare topic in medical curricula. The cancer survivors may minimise sexual issues as they feel shame in desiring intimacy after a life threatening illness.

Sexual rehabilitation should focus on the attainment of a new norm. Elliot and Stevenson (4) stated that the important facets in sexual health rehabilitation in cancer patients include:

1)         Maximising the remaining physiologic capacities

2)         Adaptation to residual limitations by exposing the patient to specialised therapies

3)         Persistence of rehabilitation efforts in order to ensure a positive outlook for both patient and her partner

Co morbid illnesses often take a back seat in the presence of a diagnosis of cancer. In the rehabilitation process, this needs to be analysed in detail. Medications that are negatively affecting the sexual response need to be either changed, dose altered or discontinued after discussion with the relevant physician.

The  management programme obviously involves guidance to a proper nutrition programme, a healthy exercise regimen and minimal alcohol intake. Adressing time management and privacy concerns must be part of the counselling.

Specific sexual therapy involves assigning sexual tasks or homework which can involve erotic reading assignments, self stimulation exercises, relaxation techniques and use of sensate focus. The above aims to change the role of the partner from caregiver (acute phase of disease) to intimate companion (survivorship). We aim to move the partner from physical intimacy (enjoying each other’s company) to emotional intimacy (sharing  desires), then move up a gear to a sensual level where there is erotic content, and finally genital play and penetrative sex, if possible.

The education of a patient or couple may involve the following:

1)         Teaching of pelvic anatomy often with the use of hand held mirrors

2)         Discussion of the sexual response cycle

3)         Dispelling of sexual myths

4)         Improvement of self esteem

5)         Alternate forms of sexual positioning

6)         Information on other forms of sexual expression, eg. massaging and caressing

7)         Effective pain management, often with the aid of genito-pelvic therapists.

In caring for the terminally ill, the attending medical team must ensure privacy for the couple to maintain intimacy if so desired. Sexual connection may provide an opportunity for the cancer patient to say goodbye and also help in closure for the surviving partner.


Estrogens and androgens are essential sexual steroids for desire and arousal.

Prior to prescribing hormone therapy, the benefit risk profile has to be assessed and proper informed consent taken, especially if off label therapy is used. An individualised evidence based medicine approach is needed.

The first approach in the treatment of vasomotor symptoms in this select group of patients has to be behavioural and environmental modifications plus non-hormonal therapies. Limited knowledge on the aetiology and mechanisms of hot flushing represents a major obstacle for the development of new targeted, non hormonal treatments and no current alternatives are as effective as estrogen.

Clonidine, SSRI’s and gabapentin have also shown an improvement in flushing, whilst Vitamin E, evening primrose oil and acupuncture have been shown to be of no benefit. Black cohash or any compound with estrogenic properties should be used with extreme caution in women with a history of breast cancer.

Vaginal atrophy almost always occurs as a result of estrogen deficiency, and it is the one symptom of the menopause that gets worse with time. The symptoms of dryness, burning and pruritis leads to dyspareunia, which often has a negative impact on all domains of the sexual response cycle. About a third of breast cancer survivors have moderate to severe vaginal dryness.

Estrogen treatment is the most effective therapy for vaginal atrophy. There is limited systemic absorption. Symptom relief was noted as early as 2 weeks after initiation of therapy on a daily basis for 14 days and then twice a week. It is best to start treatment early before irrevocable changes have been estabilished. Symptoms will return on cessation of therapy.

Other therapies that are under investigation for the treatment of vaginal atrophy include intravaginal tamoxifen, intravaginal DHEA, ospemifene tablets (newer SERM ), and vaginal moisturiser. The latter must be differentiated from vaginal lubricants which provide comfort during sexual intercourse, and are used at the time of coitus, similar to condom use. Moisturisers work by hydrating the vaginal mucosa and have to be used consistently several times a week.


The aromatase enzyme system present in breast stromal tissue can convert androgens into estrogens. Therefore breast cancer concerns have always been part of the debate involving androgen therapy in women.

Presently there is no FDA approved androgen prescription product available for women. The use of male or bio-identical products is unregulated.

An on-going study in the United States of America using transdermal topical testosterone gel for HSDD (hypoactive sexual desire disorder) has not raised safety concerns.

In 29 patients who underwent female to male sex change, the histology of their mastectomy specimens showed no differences as far as histology and receptor status when compared to specimens from breast reduction surgery.

Shufel and Braunstein writing in Menopause International in 2008, stated that “epidemiological studies , controlled for endogenous estrogen levels, showed either a decreased or no increased risk of breast cancer with testosterone therapy.”

The future may see another drug which has already been launched in Europe. It is a tissue selective estrogen compound which combines a SERM ( selective estrogen receptor modulator) called bazedoxifene with conjugated equine estrogen. It has the potential to reduce vasomotor symptoms, improve vaginal health, decrease bone turnover while being neutral as far as the uterus and breast are concerned. Breast tenderness, vaginal bleeding and rates of endometrial hyperplasia are similar to placebo therapy.

The role of a multidisciplinary team in the management of a breast cancer survivor is unquestioned, but the patients requiring specialised help have to be recognised and directed appropriately. Hence, in sexual medicine the PLISSIT model is often employed.

Also, remember the 5As framework:

1)         Ask about sexual health

2)         Advise that help is available

3)         Assess the problem

4)         Assist by directing the patients to educational materials, web sites and refer to ancillary services.

5)         Arrange follow up so that patients realize that their issues are being taken seriously and the remaining challenges can be addressed.


I conclude with a quote by Sharon L Bober et al: “ for the majority of female cancer survivors, optimising sexual function can lessen emotional distress and improve psychosexual adjustment. Physical pleasure and emotional intimacy are life affirming experiences that can relieve stress and promote closeness and healing for both survivors and partners.”