Addressing the Sexual Health Concerns of Women with Gynecologic Cancer: Guidance for Primary Care Physicians

There is limited data on the use of HRT in women with ovarian cancer but available studies do not show any difference in overall or disease-free survival between HRT groups and controls [27,30–32]. Many studies report a significant increase in quality of life with HRT. A 2013 retrospective chart review of 77 patients with epithelial ovarian cancer who received postoperative HRT showed no significant difference in progression-free survival [33].

The most controversy surrounds the use of HRT in patients with endometrial cancer [34]. The only major data available come from the Gynecologic Oncology Group’s truncated study, which was a large prospective randomized controlled trial. Over 1200 women treated for stage I and II endometrial cancer were enrolled between 1997 and 2003, and before the study was terminated these patients were followed for a median of 3 years following initiation of therapy. The recurrence rate of malignancy was low, 2.1, and an insignificant risk of recurrence of 1.27 was noted between with HRT and placebo groups (80% CI, 0.916-1.77) [35]. Women included in this study were between the ages of 26 and 91, and their indications for therapy included vasomotor symptoms, vaginal atrophy, as well as osteoporosis risk and cardiovascular disease risk. Gynecologist oncologists often use estrogen therapy to treat symptomatic women with early stage endometrial cancer given the very low risk of recurrence.

Tibolone is a synthetic steroid with activity on estrogen and progesterone receptors, and mainly acts as an agonist at estrogen receptors. It is prescribed outside the United States for osteoporosis and is being investigated as treatment for female sexual dysfunction. Efficacy on vasomotor symptoms has been positive thus far. One case-control study confirmed tibolone’s safety for endometrial cancer survivors, with no adverse effects on disease-free or overall survival [36]. One group recently examined tibolone in the setting of breast cancer patients in a prospective randomized controlled trial and reported an increased risk of breast cancer recurrences in women receiving tibolone for HT [37]. That study reported no increase in risk of gynecologic cancers and did report favorable outcomes for patients in terms of osteoporosis and vasomotor symptoms.

Topical Therapy

Women who are concerned about systemic HRT but who have been treated with radiation in addition to their surgery may be interested in topical estrogen therapy. These women may have vaginal stenosis and atrophic symptoms, and for them topical estrogen therapy can be helpful [38]. Many formulations of topical estrogen are available, including creams, tablets, and rings. Using vaginal estrogens and dilators can be useful to help with eventual resumption of sexual activity once healing has taken place and can help to avoid dyspareunia. Combination topical and systemic therapy can also be useful to relieve symptoms. Women concerned about absorption with topical therapy can be advised that while there is some absorption initially, absorption is reduced as atrophy is improved with treatment.

One recent study examined the use of alpha-tocopherol to reduce acute vaginal complications in women with endometrial and cervical cancer undergoing radiation treatment. The treatment group experienced reduced vaginal toxicity and pain, although vaginal secretion was not significantly different in the 2 groups studied [39]. No adverse effects were noted. This compound has not been studied further but may be beneficial in the future.