Okay, so I'm talking about a topic that I asked that they, that Linda Van Lee asked me would I give this talk because I was talking to her. My wife is an oncology social worker and she asked me to put this talk together for their society. I am not an expert on this. I just did the, the, the, the, the literature searches and, and, and I've dealt with my patients over the years and actually I've used my wife a lot in the, in, in the management of, of, of my patients, a couple of disclaimers. Number one, this is a really hard talk to give in 10 minutes because there's just, it's so I'm compressing a lot. Number two, most of the data here is from North America and some Europe. Number three, to my radiation oncology colleagues, most of the data here really encompasses old timey radiation. It certainly doesn't encompass IMRT, which is what we're used to now. So forgive me if I don't have any information with that. So the question is, is there a problem with sexual dysfunction after cancer? And it really depends on who you ask, right? If you ask the patients, absolutely there's a problem. If you ask the providers, you know, most of them are going to say not really. And it's sort of that don't ask, don't tell mentality because most of us are just uncomfortable with the topic and don't bring it up unless the patient brings it up. Next slide. So some data on this. What's the prevalence of sexual dysfunction in the United States? Just baseline prevalence. This has nothing to do with cancer, 40% in women, 31% in men. It approaches 90% in the GYN oncology patient population. And so it's no surprise that 75% of women with cancer report problems with sex or sexuality. Cancer survivors had 14 times more dyspareunia than non-cancer population. And it even affects relationships. You can see that many of them end up within a year of the completion of treatment. And the bottom line is it's common. We need to do a better job of addressing it. And timing is everything. Next slide. So why does it occur? Well, I think it's obvious. Our cancer treatment directly affects certain organs. Abrupt treatment-related menopause. That's brutal. I mean, that's really hard. They can't sleep. They're hot flashes. They have vaginal dryness. As time goes on, the lubrication is lost. And if you offer treatment to the pelvis, certainly in the older days, we're much better with IMRT. The radiation effects to the vagina just make it less pliable. And not to mention the effect that fatigue has on sexual function. In the midst of treatment, who wants to talk about that? They're worried about, am I going to live? And how do I feel tomorrow? Next slide. So a little bit about female sexual response. I was going to take this out, but I thought it was important to segue into what I'm going to talk about. It's way more complex than males. Much bigger psychological component. It needs a longer warmup, what we call foreplay. And it's very, very susceptible to menopause at many, many different levels. So not only does menopause affect your libido, but when you have all those symptoms like not sleeping and hot flashes, it makes you irritable. Then the vagina becomes dry and less pliable. And on top of all that, if that's not enough, then it's very difficult to achieve a climax or more difficult. So no surprise that the female sexual response really takes a hit during treatment. Next slide. Particularly in GYN cancers, about almost 90% of patients with endometrial cancer report some sort of sexual dysfunction, if you ask. There really wasn't any difference between whether they had pelvic RT and vaginal brachy. I thought that was interesting because I was brought up with the notion that if you did vaginal brachy, that sexual function would be more affected than if you just gave them pelvic RT. In the cervical cancer world, surgery has its effect as well. Radhis patients have lower quality of life. They have lower libidos. They have orgasmic problems, vaginal shortening. They have issues with dyspareunia. Some of this you'll pick up with some of the chemo radiation in this population as well. Ovarian cancer patients, you know, it's interesting, their biggest concern is pain with intercourse and body image. But most of their issues are caught up with their overall prognosis. Vulvar cancer is also very unique in that it's the most disfiguring of all the cancers that we treat. It really causes a lot of issues with body image, pain, depression, lymphedema. So clearly GYN cancers are affected with sexual dysfunction. So the key is you got to make a diagnosis. And honestly, the best way to do it is use a validated tool. They come in different complexities. You can do a structured interview with a detailed history, but most of us don't have the time in our practice to do that unless you devote that visit to that. A checklist is helpful. Many practices, certainly in the OBGYN world, have checklists. But let me go to the next slide. And here's an example of a very simple four-question checklist. Are you satisfied with sexual function? If the answer is yes, the rest doesn't really matter. If the answer is no, you get just some ideas, and at least it's something to, it's a springboard to begin the discussion and to address it. Next slide. There are other tools, the Brief Index of Sexual Functioning Tools, 22 items. It's a self-reported measure of overall sexual function, and it assesses the major dimensions as some of the others do. There's a decreased sexual desire screening, which is an instrument that was recently found to have a pretty high sensitivity to diagnose sexual dysfunction, both in North America and in Europe. And then there's the 19-question Female Sexual Function Index, which also addresses all the various domains. I think these are, for people that are going to take this to the next level, these are tools that you can use to diagnose it. Next slide. Exam is very important because you've got to look. If there's atrophy, you've got to figure out what's causing the dysfunction. Is it a lubrication problem? Is it a pliability issue? Is it a length problem? And if they struggle with the exam, that's telling in and of itself. So exam is also very important. Next slide. So what to do? I'm going quickly here. I can't stress the importance of patience, that it's going to take them a while to improve because it took them a while to get there. And there's a lot of different options in the world of lubrication, dilators. There's some role for limited hormone therapy, depending on the type of cancer. There are now topical creams that increase the circulation of blood flow to this area that it's very important to what I would call set realistic goals and keep assessing them. Are you improving? Are you satisfied with what we're doing? Do we need to change our goals? I left the reference down there, particularly in G1 oncology to address some of these things. I thought that would be helpful. Next slide. So looking at dyspareunia, painful sex, it's probably the most common complaint in our cancer survivors. It comes from either atrophy, which leads to the inflammatory response of an atrophic vagina with loss of lubrication, perhaps some narrowing and shortening after surgery, or maybe even radiation. And what happens when it's not pliable, it's tighter, it's smaller, they have these tears. Imagine a tear in the skin there, how sensitive and how painful that is. It's very, very tender. And these tend to also occur particularly in the foreshadow, which is the area that's most affected. Next slide. So the treatments for dyspareunia are going to fall into two basic from a medication point of view. There's the non-hormonal vaginal moisturizers and lubricants. Moisturizers really are meant to be used every day. Those with people who have symptoms just daily, where a lubricant is more used obviously during sexual activity. They come in over-the-counter water or silicone-based products are the preferred ones for lubrication because they're just easier. Some folks have mixed reviews on topical lidocaine. I think that probably works better on the mucosal surface of the vestibule rather than on the squamous with keratinized outside skin. Hormonal therapy, that's honestly the best treatment if you can get it, if you can use it. It's really the preferred. It helps the majority of women, whether you give it vaginally or orally, there's systemic absorption. And there's a whole bunch of different ways you can give estrogen. A tablet in the vagina, a low-dose ring, and estrogen cream. Next slide. Libido. That's another form of sexual dysfunction. Once you make the diagnosis, if that's the case, think of hormones first, low-dose estrogen, obviously would be the preferred therapy. This is very, very complicated in a breast cancer population where the medical oncologist is sending her to me because they have low libido. Why me? Because I'm a cancer doctor that takes care of women. So they make that connection. It's not because I have any expertise in this. And then we get into the discussion about quality of life. And sometimes a little bit of estrogen, especially vaginally, to improve some of the dryness for a short period of time is not going to overall affect her cancer prognosis, but it might really improve her quality of life. Topical testosterone for libido. I have not had any really good success with this. Certainly the medications in the United States that include testosterone and estrogen, EstroTest I think, or half-strength or full-strength, that's just not enough testosterone to do anything. And so you have to order it separately. And I've just not had much success, even though in the literature, some people have reported some success. There are three drugs I want to point out here. I don't know whether they're available overseas or not. Ospemiphene. This is the only FDA approved drug for the treatment of dyspareunia due to atrophy. It's not for the treatment of libido. I put it in here because it was a recently approved drug. It's in the CIRM family, right? Like tamoxifen and raloxifen and things like that. And it works because it has some estrogenic properties. And this you can use really on any age group. In the premenopausal patient, there are a couple of other drugs that are available. Again, I'm not an expert. I found this out when I was putting the talk together. The first one, vibanacerin, is a pill that you take pretty much every day. And it functions by adjusting dopamine and norepinephrine levels to a more positive position. And the other drug, the bramlanotidide, is a shot that you're supposed to inject in the abdominal wall like you give Lominox 45 minutes before you're planning sexual activity. That's what's available for libido. Next slide, please. For narrowing, you know, dilators work. Everybody looks at me with these big eyes like, how could you do this? Just start slow. If you're patient and you go slow, it really does work. A little estrogen really, really, really helps a lot. And if you're patient with it and you go slow, it'll help with relaxation. There's pelvic floor physical therapy that really helps. If you give me the next slide, this is an area of expertise within the world of physical therapy. And this is not just any PT. They have to be particularly good at pelvic floor PT, where they know how to give biofeedback and they can actually pinpoint with little electrodes they put in the vagina, it doesn't hurt, and they can tell you which muscles to relax. If you look at what the Canadians did with this, with aggressive pelvic floor physical therapy, after 12 weeks of treatment, they had a sustained response at one year. And that's the data I could find. Next slide. I want to leave you with this as my last slide. The American Cancer Society has 10 suggestions to help sexual desire after cancer. Exercise and nutrition, I don't think anybody can argue with that. If you're depressed, notice that they focused on trying short-term counseling rather than going to the SSRI families, because those have loss of libido as a side effect. Number three, watch medication side effects, because certainly a lot of the medications that we use will provide side effects. If you're feeling unattractive, work on the look good and feel good notion of getting makeup and a wig that makes you look attractive, those kinds of things that make you feel good. Try and work on controlling distracting thoughts. I always think that's like telling a depressed person, don't be depressed, but that's number five in the recommendation. Practice to feel sexual pleasure, whether that's with self-touch or some sort of masturbation. In the males, get help. Women for dyspareunia, get help. If there's an attraction issue, a loss of attraction, get couples therapy. And honestly, if all else fails, the good old fashioned in the United States, Dr. Ruth Westheimer was famous sexual therapist. When I give this longer talk, I have a picture of her, but consider seeing them. You have to find them. They are around in your communities, at least in the US they are, but just not as popular as Dr. Ruth. Thank you for your time. I hope I didn't offend anybody. If anybody has questions, I'm willing to answer them.

sexual dysfunction

cancer treatment

healthcare providers

prevalence

gynecologic oncology