More Women Will Be Struggling with Sexual Side Effects of Aromatase Inhibitors

Between news from the Annual Meeting of the American Society of Clinical Oncology and recent published reports of clinical trials, more and more women with estrogen-positive breast cancer will be taking aromatase inhibitors. In postmenopausal women, aromatase inhibitors are more effective than tamoxifen at preventing second breast cancers or a return of the original cancer. Furthermore, evidence is growing that taking them for 10 years, rather than just 5 years, has added benefits. Premenopausal women with hormone-positive breast cancer have generally taken tamoxifen as hormone therapy, but now those at higher risk of a recurrence may be prescribed a combination of hormone shots to turn off their ovaries, along with daily aromatase inhibitor pills, for at least 5 years.

Oncologists typically think aromatase inhibitors have only minor side effects, but they do far more damage than tamoxifen to women's sex lives. Tamoxifen acts like a weak estrogen in the vagina, increasing vaginal fluids. Women who suddenly become menopausal after chemotherapy actually have fewer problems with vaginal dryness if they are taking tamoxifen. Aromatase inhibitors, in contrast, get rid of almost all estrogen in the bloodstream. Most women notice severe vaginal dryness, even if they feel sexually excited. Over time, the vagina actually shrinks and the lining gets thin and easily irritated. Not only does it hurt to try to have a finger, penis, or sex toy inside the vagina, but even pelvic exams can be extremely difficult. Oncologists have largely minimized these problems. When they give women questionnaires to measure the side effects of aromatase inhibitors, only a few items ask about sex. Journal articles say that extended treatment with aromatase inhibitors has only minor effects on "quality of life." Unfortunately, questionnaires on quality of life are very general, and tend to give a much rosier picture than questionnaires that ask detailed questions about pain during sex, loss of desire for sex, or troublesome muscle and joint pain.

Breast cancer survivors are willing to tolerate some nasty side effects in order to prevent having cancer again, but only about half manage to take the full 5 years of aromatase inhibitors, let alone staying on them for 10. If you are a woman who wants to have a sex life as well as staying alive, here are some ideas:

  • Even if you have not had pain or dryness during sex, start using a vaginal moisturizer at bed time, 3-7 times a week as soon as possible after starting on aromatase inhibitors. Studies suggest that an over-the-counter moisturizer containing a weak form of hyaluronic acid (HYALO GYN) is almost as helpful as using vaginal estrogen. Oncologists worry that even a low dose of vaginal estrogen could get enough into the bloodstream to reduce the benefits of an aromatase inhibitor.
  • When you have any kind of sexual caressing, add a water-based or silicone-based vaginal lubricant of your choice. Keep it handy so you can reapply it if it dries out during lovemaking. You and your partner can spread the lubricant around as part of sex play.
  • If you are not having sex that involves penetration at least twice a week, get a vaginal dilator (I personally think SoulSource dilators are excellent), slather it with lubricant, and use it a couple of times a week to stretch out your vagina.
  • Just getting sexually excited increases the flow of blood to the vaginal walls, clitoris and vulva. It is possible that regular sexual arousal can reduce the shrinkage and dryness somewhat. With all the cool vibrators available now, as well as lots of sexy stories and images, it cannot hurt to give your body some pleasure at least once a week. We need more research on whether sexual excitement reduces changes in the vagina and vulva after menopause.
  • If you try all of the above, but cannot have sex without pain, consider a low-dose vaginal estrogen. So far no research has actually shown that women who use it are more likely to get breast cancer again.
  • Women on aromatase inhibitors also report problems with loss of desire for sex and trouble getting excited. Often the pain is the root cause of these sexual problems.
  • If sexual pain (and joint and bone pain) are just unbearable, talk to your oncologist about risks and benefits of switching to tamoxifen. So far, women on aromatase inhibitors are less likely than women on tamoxifen to have another episode of breast cancer. However, the chance of dying in the next 10 years is basically equal on the two types of hormone therapy. It is far better for most women to take tamoxifen than to just stop any type of hormone therapy. Tamoxifen has its own risks, however, including cancer of the uterus or blood clots, so it is important to know your own risk profile.

This educational material is intended for informational purposes only and is not intended to replace, or substitute for, professional advice, counseling, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a condition. Never disregard professional advice or delay in seeking treatment because of something you have read in this educational material.

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