HJBR Jul/Aug 2022

HEALTHCARE JOURNAL OF BATON ROUGE I  JUL / AUG 2022 53 Lauren A. Zatarain, MD Hematologist Oncologist Our Lady of the Lake Cancer Center patient’s healthcare team should initiate the discussion on sexual health. In a survey, 41% of breast cancer patients wanted medical care, yet only 7% asked for advice from their physician. Continued assessments of sexual health should be made periodically through treatment and surveillance. There are many barriers to conversations on sexual health, including patient embarrassment, physi- cian discomfort, lack of time in clinic, and limited awareness of treatment options. The guidelines recommend starting the conver- sation when the patient is alone and later engaging their partner in the conversation if the patient desires to. A useful model for assessing sexual functioning is the PLISSIT model — Permission, Limited Information, Specific Suggestions, and Intensive Thera- py. An example would be to ask permission: “Sexual concerns are common among breast cancer patients. Are you having any con- cerns?”Provide limited information such as, “Aromatase inhibitors can frequently cause vaginal dryness.” Then provide a specific suggestion such as, “Using vaginal moistur- izers regularly and lubricants during inter- course can help.” If needed, offer intensive therapy, “If that doesn’t help, we can try a prescribed medication today.” There are many forms of sexual health dysfunction, including, but not limited to: sexual response difficulties (decreased de- sire/libido, arousal disorders, anorgasmia), body image concerns, intimacy and rela- tionship problems, overall sexual function and satisfaction, and vasomotor symptoms and genital symptoms (vulvovaginal atro- phy and dyspareunia). Hypoactive sexual desire disorder incidence is very common, and more than 80% of patients with breast cancer never feel sexual desire at some point in their diagnosis and survivorship. There are several nonpharmacologic interventions to improve low libido, including scheduling sex, utilization of phone apps such as Rosy to educate women through online videos, and manual stimulation. Several pharmaco- logic options exist to improve libido, includ- ing flibanserin (Addyi) and bremelanotide (Vyleesi). Arousal disorders affect 40% of breast cancer patients, and depressive symptoms are highest in this group. Medi- cations often prescribed to patients with cancer — including antidepressants, hor- mone-blocking agents, histamine receptor blockers, anti-epileptics, and opioid agonists — can have negative effects on sexual func- tion. Multiple serotonergic antidepressants lead to anorgasmia, andWellbutrin should be considered as an alternative. L-arginine creams such asArginMax for women, Stron- vivo, Scream Cream and Zestra Rush topi- cals should be avoided as there are estro- genic effects, and studies have shown no improvement in sexual function in breast cancer patients. Body image disorders af- fect 30% of female cancer survivors and are more common in younger breast can- cer patients. Preexisting depression or body image issues prior to cancer diagnosis also increase the risk. Psychosocial counseling should be offered. Sensate focus therapy is a tool that can improve relationship and intimacy con- cerns in cancer patients and their partners. An individual focuses on their own sensa- tion rather than on what the partner is feel- ing during the exercise session. Couples do not talk during the exercise, but discussion afterward is strongly encouraged. Each ses- sion should be 20 to 60 minutes long and practiced about two to three times weekly. Phase 1 includes non-genital/breast touch. Phase 2 includes genital/breast touch. Phase 3 includes penetrative sensate focus. Cou- ples should remain in each phase at least one week prior to advancing to the next phase. Sensate focus therapy takes the pres- sure off penetrative intercourse as the end goal, and it should be recognized that not “Sexual health is an important component of quality of life, irrespective of age, sexual orientation, or stage of disease. … Sexual dysfunction can lead to nonadherence or discontinuation of cancer therapy.”