Sexual Healthcare for Cancer Survivors

For many women with cancer, sexual health is a core component of recovery. Changes in desire, function and comfort — whether related to cancer treatment or otherwise — affect not only physical well-being, but also identity, relationships and overall quality of life.

In an editorial recently published in JCO Oncology Practice, Pelin Batur, MD, Staff in Cleveland Clinic's Department of Subspecialty Care for Women's Health, advocates for clinicians to help their patients by prioritizing the sexual-health treatments supported by strong data.

“When we consider sexual health in cancer survivors, the key is to focus on therapies that have demonstrated safety and efficacy,” says Dr. Batur. “There are many options available, but not all are supported by strong evidence. In some cases, such as hormone-based therapies for contraception and menopause symptoms, guidelines have changed over time. That can be confusing. So part of our role is helping patients navigate their options with clear, data-driven guidance.”

Key takeaways from Dr. Batur's article address therapies for hypoactive sexual desire disorder (HSDD), genitourinary symptoms of menopause (GSM), contraception, and the essential role providers play in educating patients about risks and benefits to support shared decision making.

Hypoactive sexual desire disorder

Psychopharmacologic medications may be an important healthcare component for patients with cancer, either to address HSDD itself or to manage mood disorders, which can contribute to sexual-health challenges.

In either case, it's important that providers avoid recommending medications with side effects that affect sexual function. And for the treatment of HSDD, the key is to know which drugs provide proven benefits.

Of note, Dr. Batur points out that bupropion typically is not an effective stand-alone treatment for HSDD; rather, it should be prescribed for mood disorders by itself or in combination with other drugs, such as select serotonin reuptake inhibitors, to mitigate their sexually suppressive side effects.

For treating HSDD, bremelanotide and flibanserin are both approved by the U.S. Food and Drug Administration (FDA). The anti-depressant desvenlafaxine s shown to be effective at addressing vasomotor symptoms, has a lower sexual dysfunction profile, and it doesn't interfere with tamoxifen metabolism, which makes it suitable for breast cancer survivors.

Treating genitourinary symptoms and dyspareunia

Within hormone-based options for treating genitourinary symptoms and dyspareunia, local, low-dose vaginal estrogen remains the gold standard. Although the FDA recently lifted a black box warning on vaginal estrogen, decades of confusing communication about risks of hormone therapy require clinicians to bring clarity to conversations, especially with cancer survivors.

Namely, Dr. Batur writes, " A systematic review and meta-analysis assessing the safety of vaginal estrogen used by breast cancer survivors reviewed evidence published up through September 2024. ... The findings showed that the use of local low-dose vaginal estrogen by breast cancer survivors was not associated with a higher risk of breast cancer recurrence or mortality."

Additionally, the non-estrogen therapy dehydroepiandrosterone (DHEA) also is shown to be safe and effective treatment for genitourinary symptoms and dyspareunia, but has not been studied head-to-head with vaginal estrogen.

In contrast, safety and efficacy of systemic hormone treatments in those with a history of hormone sensitive cancer needs further study. Formulations that can lead to supraphysiologic levels, such as hormone pellet therapy, is discouraged, Dr. Batur writes.

Contraception

Effective contraception is important for the health of patients with cancer, and too often patients with non-hormone-sensitive cancers have been restricted from using systemic hormones for contraception. Additionally, Dr. Batur writes, shared decision making should be used for patients with estrogen-sensitive cancers such as meningioma and cancers of the breast or uterus. Updated guidelines on the topic are available to help inform patient care decisions.

Laser therapies

Fractional CO2or erbium:YAG may hold promise in the treatment of GSM. Several studies have shown clinically meaningful symptom improvements. However, the evidence so far has been contradictory and limited in size and scope. Further studies are needed.

A balancing act in clinic

In the context of so many treatment options, clinicians should be aware that being overly restrictive with FDA-approved treatments carries a risk of driving patients to unregulated or even dangerous therapies. Transparent counseling that involves discussion of risks and benefits will empower patients with cancer as partners in their own sexual health.

“In a busy clinical setting, we have to make time for educating patients on treatments that are both evidence-based and that meet their needs,” says Dr. Batur. “That means focusing on interventions with a track record while being transparent about where the data are limited.”