Efficacy of interventions to manage sexual dysfunction in women with cancer: a systematic review

Abstract

Importance: Cancer and its treatment negatively affect female sexual health and function. The prevalence of female sexual dysfunction after cancer is between 33% and 43%. Numerous studies have addressed treatment options for sexual dysfunction in women with cancer, but it still remains a challenge to select the most efficacious option for patients.Objective: To compile and appraise recent evidence of any interventions for managing sexual dysfunction in female cancer survivors.Evidence Review: A literature search of the electronic databases MEDLINE, EMBASE, PsycINFO, and Cochrane Central Register of Controlled Trials (January 2011 to February 2021) was conducted using general search terms of ''women'', ''cancer'', ''intervention'', ''sexual dysfunction''. We included randomized controlled trials (RCTs) and uncontrolled before-after studies that evaluated the efficacy of intervention for female sexual dysfunction in women with history of cancer. Methodological quality of studies was assessed using Risk of Bias (RoB) 2.0 for RCTs and National Institutes of Health (NIH) assessment tools for uncontrolled before-after studies.Findings: Thirty-six studies were included for qualitative synthesis (14 RCTs (n ¼ 1284), 17 uncontrolled trials (n ¼ 589), and 5 cohort studies (n ¼ 497). Only four studies were at low risk of bias. Topical interventions (vaginal gels or creams) were able to alleviate vaginal dryness and dyspareunia, with intravaginal dehydroepiandrosterone (DHEA) (6.5 mg) gel showing evidence of improved sexual function. Evidence for estriol-lactobacilli vaginal tablets was unreliable due to a small-scale study. Psychoeducational therapy (internet-based cognitive behavioral therapy [CBT]) studies typically were at high risk of bias, but all displayed significant improvements of sexual function. Both laser therapy (fractional CO 2 and erbium) and multimodal approach studies were at concerning risk of bias, although suggesting beneficial effects on sexual function.Conclusions and Relevance: The most reliable evidence for improvement was from a study of DHEA vaginal gel, but in general, gels or creams were useful in reducing dyspareunia. Pharmacological, psychoeducational, laser therapy, and multimodal approaches demonstrated potential in managing cancer-related sexual issues, but most were small in size (10-70 participants), with moderate to high risk of bias. Therefore, large-scale, double-blind, RCTs with long-period follow-up, and at low risk of bias are needed to show efficacy for these interventions.

Priorities for alleviating menopausal symptoms after cancer

“…32 For those patients for whom estrogen is contraindicated, effective treatment options for sexual dysfunction include cognitive behavioral therapy and dehydroepiandrosterone gel. 33 Although joint pain is a common adverse effect of aromatase inhibitors and reduces adherence, 13,34,35 we found that breast cancer patients were no more likely to prioritize joint pain than patients with other cancers. This could reflect the nature of treatment priority-even if joint pain is more common among breast cancer patients than patients with other cancers, breast cancer patients might prioritize their joint pain below other symptoms.…”

“…Vaginal estrogen is effective in treating vaginal dryness and is not contraindicated after cancer apart from requiring an individualized approach in breast cancer 32 . For those patients for whom estrogen is contraindicated, effective treatment options for sexual dysfunction include cognitive behavioral therapy and dehydroepiandrosterone gel 33 …”

“…This corresponds to moderate severity. 27 In patients who prioritized fatigue, the median Fatigue Scale score was 28 (IQR, [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36], more severe than the general population median of 47 and the median of 42 among nonanemic cancer patients. 28 Among patients who prioritized sleep disturbances, a few met the criteria for severe clinical insomnia (11.4%, n = 10), and most had moderately severe clinical insomnia (36.4%, n = 32) or subthreshold insomnia (36.4%, n = 32).…”

“…In patients who prioritized vasomotor symptoms, medians on the "problem," "distress," and "interference" dimensions of the Hot Flash Related Daily Interference Scale were, respectively, 6.0 (interquartile range [IQR], 5.0-8.0), 5.5 (IQR, 3.0-8.0), and 5.0 (IQR, 3.-7.0), indicating moderate severity. In patients who prioritized fatigue, the median Fatigue Scale score was 28 (IQR,(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36), 37% worse than general population.Conclusions: Vasomotor symptoms, fatigue, sexual problems, and vaginal dryness/soreness were the leading priorities for treatment. Understanding symptom severity and patient priorities will inform better care for this growing population.…”

“…In patients who prioritized vasomotor symptoms, medians on the "problem," "distress," and "interference" dimensions of the Hot Flash Related Daily Interference Scale were, respectively, 6.0 (interquartile range [IQR], 5.0-8.0), 5.5 (IQR, 3.0-8.0), and 5.0 (IQR, 3.-7.0), indicating moderate severity. In patients who prioritized fatigue, the median Fatigue Scale score was 28 (IQR,(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36), 37% worse than general population.…”