Holistic treatment isn’t just about utilizing alternative medicine and techniques, I feel it is more about comprehensively assessing and creating a complete plan of care that addresses all the client’s concerns and functional limitations.
Breast cancer doesn’t just affect the breasts, but the entire person including pelvic health.
Over 3 million women have a history of breast cancer which is the 2nd most common cancer in women (behind skin cancer). Based on the Female Sexual Function Index (FSFI), more than 77% of survivors qualify as having sexual dysfunction. Sexual function and satisfaction were ranked the 3rd most frequently reported concern amongst breast cancer survivors, but less than 50% receive proper medical care.
Furthermore, women with breast cancer may experience pelvic floor dysfunction including urinary incontinence, fecal incontinence, and sexual dysfunction after receiving breast cancer treatment.
What is sexual dysfunction?
The Diagnostic and Statistical Manual (DSM-V) defines sexual health as having three entities:
(The DSM also states that to classify as a sexual health disorder, their presence must be more than a “nuisance”, last at least 6 months, be self-reported, and provide clinically significant distress. Their presence may not be explained by non-sexual conditions, be secondary to substance or medication use, or severe relationship distress.)
As a pelvic floor physical therapist, I will it is my professional obligation and responsibility to adequately educate and sympathize with my breast cancer clients that these are true symptoms and common side effects of medical intervention that can be treated within the scope of my physical therapy practice act and that we are advocates for pelvic health.
Who is at risk for sexual dysfunction due to breast cancer?
The common adjuvant treatment options for those that have breast cancer are radiation therapy, chemotherapy, and endocrine therapy, however, they all have their side effects on sexual and pelvic health. Pelvic floor symptoms appear to be more severe in women with breast cancer than postmenopausal women without breast cancer due to prolonged and higher degrees of hypoestrogenism.
Radiation therapy can result in regional issues, including persistent breast pain, arm, and shoulder discomfort, loss of flexibility, and possible lymphedema development; all of which are associated with sexual function, well-being, and breast satisfaction.
Chemotherapy in those not yet menopausal can induce ovarian failure and early menopausal onset. Lower estrogen levels can:
These symptoms can persist for at least 1 year after completion of chemotherapy. Furthermore, at least 25% of women experience new or worsened UI within 3 months of receiving neoadjuvant chemotherapy.
Endocrine therapy lowers estrogen levels and is given to people whose breast cancer proliferates in response to estrogen. Aromatase inhibitors (AI) are often prescribed to post-menopausal women. Approximately 50% of people taking AIs report sexual complaints (reduced interest/desire, insufficient lubrication, and dyspareunia). Tamoxifen is prescribed to pre-menopausal women whose cancer responds to estrogen, and approximately 30-40% report sexual dysfunction. Up to 93% of women met the criteria for sexual dysfunction per the FSFI who adhered to taking this life-saving medication for the first 2 years of treatment.
How can we improve sexual dysfunction in breast cancer survivors?
The medical community can do a much better job in education, communication, and advocacy within a holistic and comprehensive approach for pelvic health/sexual issues. Discussions of sexual health necessitate a trusting doctor-patient relationship relying on open communication.
Research recommends multimodal treatment with pelvic floor muscle assessment by skilled rehab providers, as well as the use of vaginal moisturizers and lubricants as needed during sexual activity. Cognitive behavioral therapy (CBT) can help to address body image, sexuality, and mood; all of which are important factors of sexual health.
Sexual health for breast cancer survivors starts with healthcare professionals providing an environment for their patients filled with open and non-judgmental communication, and a holistic approach to truly provide client-centered care that works to optimize health and quality of life.
Boswell, EN and Dizon, D. “Breast cancer and sexual function.” Transl Androl Urol 2015;4(2):160-168.
Colombage, UN, et al. “Experiences of pelvic floor dysfunction and treatment in women with breast cancer: a qualitative study.” Supportive Care in Cancer 2022;30:8139-8149.
ABOUT THE AUTHOR
Shirlea North PT, DPT, GCS, CLT
Shirlea is a Kickpink Practitioner, a physical therapist, and owner of NorthStar Physical Therapy, LLC in Northern VA. She has a variety of specialties within niches like Parkinson's, MS, lymphedema and lipedema, and pelvic floor dysfunctions.