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As planned, this week's column is by Dr. Steven A. Roth of the Genesis Women's Center in Inverness. He will discuss female sexual dysfunction in the cancer patient from a gynecologist's standpoint.
It must be kept in mind that both research and information in this field are still evolving, which makes summary statements difficult. So the recommendations and conclusions made are based on the knowledge available today and is subject to change as more information becomes available.
Nonetheless, Dr. Roth's review is comprehensive and pertinent but laced with a healthy dose of skepticism for early inconclusive literature. The readers will find it both interesting and informative.
Dr. V. Upender Rao
Sex is a subject far too frequently ignored by doctors, so, first, let me thank Dr. Rao for this opportunity to discuss a very important topic. I hope that readers will find this article both informative and entertaining.
The scope of my practice with regard to discussions of female sexual dysfunction has changed dramatically during the past 15 years. I daresay that when I began my practice, it was rarely discussed during routine office visits. Now, a day doesn't go by that FSD is not brought up during my patient discussions.
I routinely ask my patients if there is anything that they would like to discuss regarding sex. The responses have ranged from "almost" embarrassing, and it takes a lot to embarrass me, to intentionally humorous.
I recall asking a patient in her early 80s if she were sexually active. She replied, "Well, not as much as I used to be, now only two or three times a week." Hallelujah.
Sexual health is important. Physical intimacy is part of the fabric that makes us human. Let's face it, I wouldn't have a job if it weren't for sex.
Cancer patients are a very special category with regard to FSD. There are a multitude of factors causing this. One major factor is altered body image. This is most obvious when we think about the mastectomy patient, but we must also consider patients with colostomies, prosthetic limbs and disfiguring facial surgeries.
Cancer patients also deal with depression, fatigue, physical limitations and chronic pain, all of which can deal a devastating blow to sexual intimacy.
As physicians, we must help these patients not only survive, but live. I recall years ago being called to the emergency room to see a young breast cancer patient who came in with vaginal bleeding.
She was visibly upset with tears streaming down her face. It seems that she had recently finished her last chemotherapy treatment and was having intercourse to celebrate. Unfortunately, she began having a fairly large amount of bleeding during coitus. My exam revealed a rather sizable tear in the vaginal tissue - not the result of a forceful or violent act, simply because the vaginal tissues were thin as a result of lack of estrogen.
She told me that she "would never have sex again." I reassured her that she had a treatable condition. Still, I remember thinking how sad it must be to feel that way.
It's hard to point to exactly what has caused this recent wave of discussions regarding sex. Certainly the introduction of excellent treatments for erectile dysfunction has helped fuel this. There is no doubt that in no small part this has led many women to ask, "What about us?"
Unfortunately, this also has led to many false beliefs about human sexual response, especially female sexual response. One of the most damaging is a belief that medications for erectile dysfunction are aphrodisiacs, which they are not.
As mentioned in Dr. Rao's previous article, decreased libido or decreased sexual desire is a major part of FSD.
Female sexual response is far more complicated than "Doc, my husband says my hormones are messed up." If that were always the case with decreased desire, then a little testosterone would almost always help.
To illustrate my point, I wonder how many of my female readers would say that they are more interested in sex when they are stressed. I will venture to say that it would be close to zero. Contrast this with male readers, most of whom would say that, when stressed, a night of sexual intimacy might help them relax. Bizarre, isn't it?
There is no doubt that in some women there is a role for androgens (i.e., testosterone) to enhance female sexual response. This is especially true for the woman who notices a dramatic "change" in her libido following the surgical removal of her ovaries.
The addition of methyl-testosterone to estrogen has been shown to help in two ways.
First, it is possible to take less estrogen and still control vasomotor symptoms, such as hot flashes and night sweats. Second, it might help restore a feeling of well-being that would include sexual well-being. Most people don't realize it, but estrogen and testosterone are found in both men and women. Certainly the effects and amounts of these hormones are very different in men and women, but nonetheless, we all had both at some point in our lives.
In women, the overwhelming majority of estrogen is secreted by the external surface (cortex) of the ovary while the internal portion (stroma) produces testosterone. Estrogen levels remain fairly constant throughout a woman's life until menopause. It is at this time that ovulation begins to stop, leading to decreased estrogen levels and, eventually, menopause.
Testosterone levels, on the other hand, fall much more slowly. This is the reason that the addition of testosterone to estrogen replacement seems to be more effective in the patient who has had her ovaries removed.
There are several problems with the recent discussions regarding androgen supplementation and FSD. The first has to do with the difficulty in obtaining accurate and meaningful testosterone levels in the blood. Laboratories are not standardized when it comes to this test, and therefore it puts the physician at a great disadvantage when it comes to interpreting these values.
Secondly, there are few, if any, well-controlled studies to support the use of androgens for FSD. This has to do with the subjectivity of what we are trying to measure. In other words, sexual satisfaction is different to different people. Some would say that having sex once a year is plenty, while another might say that once a day is not enough.
We all know people who seem to be happy, no matter what their current situation might be, and others who are never happy. It's the whole glass half empty or half full mentality.
The most common use for testosterone is in male androgen insufficiency, so there are a lot of studies to document the benefits of testosterone in men. Women, unfortunately, are not so lucky. At the present time there are lots of studies attempting to determine the effectiveness of various testosterone preparations to treat FSD. These preparations are administered as a pill, a patch, an injection, a vaginal gel or even under the tongue.
Only time will tell if these preparations are effective. At the present time there are only two commercially available formulations of an estrogen-testosterone combination indicated for women with androgen insufficiency: Estratest and Estratest HS.
The HS in the latter merely stands for "half strength." I have had fairly good success in using these products to treat decreased libido, especially in the patient who has had her ovaries removed.
Much has recently been made of the various testosterone-containing libido creams. I am not aware of a single medical study that corroborates the incredible libido enhancing claims by various magazines and talk shows. I have never had a pharmaceutical representative come to my office with any of these products, and I must believe that if they were effective, then the doors of my office would have been broken down by now.
These creams and gels can be compounded at many of our local pharmacies, and I do prescribe them from time to time, but only after a thorough discussion with my patient. They are generally applied daily to the clitoris or inner thigh, but, let's face it, I'm not sure that rubbing anything to that area on a daily basis wouldn't result in an increased sexual response.
My advice: Use the money that you would spend on these products and have a romantic evening with your husband. I believe that there is a far greater chance that a candle-lit dinner or romantic movie will put you in the mood.
Steven A. Roth M.D., FACOG, practices at the Genesis Women's Center in Inverness. He can be reached at Genesis@atlantic.net