Why It Matters

Sexual dysfunction is one of the most common and under-addressed long-term effects of cancer treatment in women.

 

Key Statistics 

78.2% of breast cancer survivors reported at least one sexual concern following diagnosis.

• Sexual dysfunction affects 30–80% of female cancer survivors across studies.

• Women with breast cancer have a 3.5-fold higher risk of sexual dysfunction compared with women without cancer.

• Gynecologic cancer survivors experience significantly higher rates of:

  • Vaginal dryness

  • Dyspareunia

  • Overall sexual dysfunction

• Only 5.4% of patients reported that healthcare providers discussed sexual side effects before treatment.

• Only 33.6% said sexual health was addressed at any point during cancer care.

• Male survivors are more likely to be asked about sexual health than female survivors (53% vs 22%).

Despite its prevalence, sexual dysfunction remains underdiagnosed and undertreated, contributing to poorer quality of life.

 

 

Common Sexual Health Concerns

Cancer treatments (surgery, chemotherapy, radiation, endocrine therapy) can contribute to:

• Vaginal dryness

• Dynerpareunia (pain with intercourse)

• Vaginal atrophy

• Low libido

• Decreased arousal

• Orgasmic dysfunction

• Pelvic pain

• Vaginal stenosis

• Urinary symptoms

• Negative body image

• Anxiety and psychological distress

• Relationship difficulties

 

Practical Clinical Approach: Starting the Conversation

Sexual health should be discussed routinely throughout the cancer continuum, including at diagnosis, during treatment, and during survivorship. Many patients will not raise concerns unless invited.

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Normalize the discussion

Brief Sexual Health Screening Questions

(Adapted from the Brief Sexual Symptom Checklist for Women and survivorship recommendations.)

1. Are you currently sexually active?

   • If no: Are there any sexual concerns you would still like to discuss?

2. Are you satisfied with your current sexual function?

3. Have you noticed any changes since your cancer diagnosis or treatment?

4. Are you experiencing any of the following?

   • Vaginal dryness

   • Pain during sexual activity

   • Reduced sexual desire

   • Difficulty becoming aroused

   • Difficulty reaching orgasm

   • Vaginal tightening or discomfort

   • Bleeding after intercourse

5. Have these changes affected your quality of life or your relationship?

6. Would you like help or more information about these concerns?

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Screening Recommendations

Routine assessment should become part of survivorship care.

 

Recommended validated tools include:

• Female Sexual Function Index (FSFI)

• PROMIS Sexual Function and Satisfaction Measure (PROMIS SexFS)

• Brief Sexual Symptom Checklist (BSSC)

• Arizona Sexual Experience Scale (ASEX)

• Sexual Symptom Checklist for Female Patients After Cancer (SOGC)

 

SOGC additionally recommends:

• Detailed medical history

• Sexual history

• Pelvic examination

• Vulvar assessment

• STI assessment when appropriate

• Imaging or diagnostic testing when clinically indicated

 

 

Guideline Consensus (ASCO, NCCN, SOGC, ESO-ESMO)

 

First-line Management

All major guidelines recommend non-hormonal therapies first, including:

• Personal lubricants

• Vaginal moisturizers

• Vaginal gels

• Hyaluronic acid products

• Natural oils

Recommended use:

• Moisturizers 3–5 times/week

• Lubricants during sexual activity

 

Hormonal Therapy

If symptoms persist despite non-hormonal treatment:

Consider low-dose vaginal estrogen:

• Creams

• Tablets

• Capsules

• Rings

Additional options:

• Vaginal DHEA (prasterone)

• Testosterone (specialist supervision)

Recent evidence suggests:

• No increased breast cancer recurrence with vaginal estrogen

• No increase in mortality

• Rare adverse events among gynecologic cancer survivors

These findings provide reassurance regarding topical estrogen when clinically appropriate.

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Management of Pain and Dyspareunia

Recommended interventions include:

• Vaginal dilators

• Pelvic floor physiotherapy

• Lubricants

• Moisturizers

• Low-dose estrogen

• Hyaluronic acid

• Vitamin E suppositories

• Topical lidocaine

• Ospemifene

• DHEA

 

Vaginal Dilators

Recommended by ASCO, NCCN and SOGC.

SOGC suggests beginning:

• 2–4 weeks after pelvic radiation

ASCO recommends offering dilators early to women at risk of vaginal stenosis, regardless of sexual activity.

 

 

Pelvic Floor Physiotherapy

Recommended for:

• Pelvic pain

• Dyspareunia

• Vaginal stenosis

• Urinary incontinence

• Orgasmic dysfunction

Pelvic floor exercises (Kegels) may reduce discomfort and improve function.

 

 

Sexual Aids

Recommended options include:

• Vibrators

• Clitoral stimulation devices

• Masturbation/regular stimulation

These may improve:

• Sexual response

• Arousal

• Orgasm

 

 

Pharmacologic Options for Low Sexual Desire

Potential treatments include:

• Testosterone

• Flibanserin

• Bremelanotide

• Bupropion

• Buspirone

Current evidence remains limited.

 

Flibanserin

FDA-approved for premenopausal hypoactive sexual desire disorder.

Evidence in cancer survivors:

• Increased satisfying sexual events from 0 to 2.2 per month in a pilot study.

• Larger randomized trials are still needed.

 

 

Psychological Care

All guidelines emphasize multidisciplinary management.

Recommended interventions include:

• Psychosexual counselling

• Cognitive behavioural therapy (CBT)

• Mental health referral

• Couple-based counselling

• Sex therapy

• Body image support

• Social support

Assessment should include:

• Anxiety

• Depression

• Relationship concerns

• Trauma

• Cultural considerations

• Sexual orientation

• Health literacy

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Emerging Therapies

Vaginal Laser Therapy

Fractional CO₂ and Er:YAG lasers have shown improvements in:

• Vaginal health

• Vaginal atrophy

• Dryness

• Dyspareunia

• Sexual function

Typical treatment:

• Three laser sessions

• 30–40 days apart

However:

• Long-term safety remains uncertain.

• FDA issued a warning regarding insufficient evidence.

• More research is required before routine use.

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Limitations in Current Guidelines

Current gaps include:

• Limited evidence for pharmacologic therapies.

• Lack of large cancer-specific randomized trials.

• Limited guidance for transgender and non-binary survivors.

• Insufficient inclusion of sexual minority populations.

• Existing screening tools often:

  • assume heterosexual relationships,

  • assume current sexual activity,

  • inadequately assess distress,

  • lack cancer-specific questions.

 

Practical Recommendations for HCPs

Healthcare professionals should:

• Initiate conversations about sexual health early and routinely.

• Normalize discussions throughout survivorship.

• Use validated screening tools.

• Offer first-line non-hormonal therapies before escalating treatment.

• Consider topical vaginal estrogen when appropriate based on current evidence.

• Refer to:

  • Pelvic floor physiotherapy

  • Sexual medicine

  • Gynecology

  • Mental health

  • Sex therapy

• Include partners in counselling when appropriate.

• Improve clinician education and confidence in discussing sexual health.

• Incorporate sexual health into survivorship care plans.