In patients with breast cancer, sexual dysfunction is a relatively frequent complaint both during and after treatment. Anxiety about the illness, concerns about disfigurement related to mastectomy, and loss of physiologic hormone support, in particular endogenous estrogen, as a result of chemotherapy can all contribute to a lack of interest in sexual activity.

Dyspareunia in patients with breast cancer may be due to loss of secretion from the secondary sexual glands, such as Bartholin’s glands, Skene’s glands, and the endocervical glands, or to spasm of the muscles around the vagina, particularly the levator ani muscle. Muscle spasms may result from painful coitus associated with vaginal dryness.  Sudden onset of dyspareunia indicates the possibility of a vulval or vaginal infection.

Another possible cause of dyspareunia in breast cancer patients is pre-existing psychosexual problems,  which may be aggravated by the cancer situation.  If sexual activity has been interrupted by extended or intensive treatment for breast cancer,  the patient and her partner may express concerns as to whether resuming coitus can be harmful.

In the Gynecologic Oncology Center, our main objective in the evaluation of breast cancer patients presenting with dyspareunia is to determine whether mechanical barriers or disease states exist that might interfere with sexual activity. These might include scarring or atrophy of the vaginal mucosa, acute infections, and other inflammatory conditions, such as endometriosis or chronic pelvic inflammatory disease.  Endometriosis is sometimes symptomatic even in the absence of normal ovarian function.

It is also important to determine whether dyspareunia may have preceded the diagnosis of breast cancer.

Patients who have obvious atrophy of the vulva and vagina need to be reassured and given guidance about using nonhormonal lubricants, which are available in the form of vaginal suppositories or gels with applicators.  These patients must be advised to use the lubricants on a regular basis, not just with sexual intercourse, as this routine should help to keep the vagina moisturized and pliable and decrease dyspareunia.

Many breast cancer patients have severe dyspareunia that is not relieved with nonhormonal lubricants. For such patients, another possible option is use of Estring, a slow-release estrogen vaginal ring that acts locally on the vaginal mucosa to decrease dyspareunia and has only a 7% systemic absorption rate. Patients must be counseled that no studies have been done to determine whether Estring increases the risk of breast cancer recurrence.

It is preferable to have the sex partner participate in discussions about dyspareunia and its treatment.  If the problem is not resolved by more straightforward measures, then referral to a sex therapist can be suggested.

Elizabeth R. Keeler, Pedro T. Ramirez, and Ralph S. Freedman
Committee on Gynecological Practice, the American College of Obstetricians and Gynecologists. Obstet Gynecol 2007

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