In a Livestrong Foundation survey, male and female cancer survivors reported that sexual concerns were their third-most prevalent physical complaint. Fewer than 50 percent said they received medical attention for those problems. In another study, half of all breast cancer survivors said they had sexual health difficulties — some of them experiencing issues years after treatment. It’s a topic that providers don’t discuss enough with patients, say physicians at Baptist Health Miami Cancer Institute who are working to raise awareness and offer help.

“We know that impaired sexual function leads to a lower quality of life, so if there are things we can do to intervene, we will improve our patients’ lives,” said Naomi Dempsey, M.D., a breast medical oncologist with Baptist Health Miami Cancer Institute. Dr. Dempsey provided an update on sexual health in breast cancer at the Institute’s Women’s Cancer Symposium, a day-long educational program featuring multidisciplinary strategies for managing complex challenges in women’s cancer care.

The reasons for sexual health problems among breast cancer patients and survivors are varied, Dr. Dempsey said. They range from low libido and a lack of positive body image to physical issues that can make intercourse painful, such as vaginal dryness. Additionally, partners may feel the patient is fragile and may worry about harming them during sexual activity. Then add in another factor such as menopause — as a result of cancer treatment or naturally occurring — and there are more concerns.

Depending on the cause(s) of sexual dysfunction, Dr. Dempsey recommends:

• Eliminating vaginal irritants.
• Applying vaginal moisturizers and lubricants.
• Using topical lidocaine for pain.
• Practicing pelvic floor relaxation techniques.
• Using vaginal dilators to stretch the vagina.
• Considering hormone therapy for some patients who do not respond to other treatments.
• Seeing a sex therapist.

Genitourinary syndrome of menopause can cause vaginal dryness, urinary urgency and frequency, unusual spotting or discharge, urinary burning and pain with sex. “The first step is to eliminate any irritants,” Dr. Dempsey said. This includes stopping the use of douches, harsh soaps or any sort of fragrance.

Next, use a vaginal moisturizer. “It should be used five times a week and re-applied one hour before planned sexual activity. It’s like regularly applying lotion on your skin, but for the vagina,” she said. There are several brands available without prescription. Over-the-counter lubricants during sex should also be used, particularly silicone-based lubricants.

For women with estrogen deficiency who experience painful penetration, a study showed that topical lidocaine decreased pain significantly in all participants. And nearly all of the patients who were abstaining from sex because of pain at the start of the study, returned to intimacy with the use of lidocaine.

Relaxation of the pelvic floor is another technique that many women find helpful. “We often hear about Kegel exercises to strengthen the pelvic floor, but in this case, it is relaxation we are aiming for,” Dr. Dempsey said. Exercises to relax the pelvic floor include diaphragmatic breathing and yoga poses such as child’s pose, the happy baby, yogi squat and sphinx pose. A physical therapist can help with proper technique.

Some women experience vaginal stenosis, particularly if scar tissue has formed as a result of surgery or radiation therapy. It makes the vagina narrower and shorter, and can cause sex, or even inserting a tampon, to be painful. Using vaginal dilators and a lubricant can help stretch the walls of the vagina. As the patient becomes comfortable with a small dilator, she can move to a larger size.

While many women ask about C02 lasers, two randomized trials have shown that they do not improve symptoms compared to sham control, and there are concerns that they may be dangerous because the lasers are meant for other parts of the body, not the very sensitive tissue of the vagina.

Vaginal estrogen therapy is an option offered to some women. “Our general approach is to start with all of the other treatments first. If none of those things are helpful, then we can talk about vaginal hormones,” Dr. Dempsey said.

A Danish study showed that systemic or vaginal hormone therapy after early breast cancer can be safe and did not result in a higher risk of recurrence, yet doctors still caution against estrogen therapy for specific cancer patients. Most oncologists feel comfortable with vaginal estrogen for breast cancer patients with genitourinary syndrome of menopause. Further discussion about risks and benefits of systemic hormone therapy should also be conducted on an individual basis for patients with breast cancer.

During and after treatment for breast cancer, some patients report their interest in sex has waned. Sexual arousal disorder can occur due to body changes such as the loss of a breast or change of the shape of a breast, scars, lymphedema, pain or numbness in the chest or arm, weight changes, infertility, early menopause, pain, fatigue and reduced stamina.

There have been some small studies that have looked at medications to improve sexual arousal, and flibanserin is an option. For men with breast cancer, however, medications such as sildenafil may help with sexual arousal disorder.

Finally, Dr. Dempsey encourages patients and their partners to consider seeing a sex therapist with expertise in addressing the emotional challenges and impact of cancer on sexuality. She also suggests online resources that include support groups, pelvic floor therapy exercises, podcasts and educational Instagram sites.