Anaheim, CA—The primary reason that nurses cite for not approaching the topic of sexual health with their patients is lack of knowledge. At the Oncology Nursing Society (ONS) 44th Annual Congress, Lisa Chism, DNP, APRN, NCMP, FAANP, Clinical Director, Women’s Wellness Clinic, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, set out to change that by arming oncology nurses with enough knowledge to broach the subject confidently with their female patients.
According to Dr Chism, the topic of sexual health is undoubtedly within the nurse’s realm of expertise. The World Health Organization defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.”1 The definition also refers to respecting, protecting, and fulfilling the rights of all persons.
“Isn’t that something we talk about in nursing?” asked Dr Chism. “So, how do we fix the problem? We get comfortable. We increase the knowledge base, and we get more comfortable with sexuality ourselves, so that we can talk to our patients.”
Broaching the Topic of Sex
Therapies used to treat cancer can alter a woman’s sexual health in many ways. Most alterations to female sexual health occur because of therapies that cause temporary or permanent menopause, resulting in vaginal issues such as dyspareunia (pain with intercourse), dryness, and decreased desire.
Many patients do not mention these concerns to their oncologists because they do not want to appear ungrateful that their lives were saved. To assess sexual health in patients, Dr Chism recommends starting with specific questions, such as “Are you having any sexual health concerns?” “Are you having any difficulty with arousal?” “Are you able to achieve orgasm?” She also recommends using the PLISSIT model:
- P: Asking Permission.
“May I ask you about your pain with penetration/intercourse?” Or, give the patient permission to talk about it herself, with a statement such as, “Many women experience pain with penetration because of hormonal changes after menopause. Are you experiencing pain with penetration?”
- LI: Limited Information.
“How long has this been going on? How often does this happen?”
- SS: Specific Suggestions.
“Have you tried any vaginal moisturizers or lubricants?”
- IT: Intensive Treatment referral.
“Would you feel comfortable talking with someone about this?”
During further assessment, nurses should strive to normalize the problem for their patients. Dr Chism noted that the Rosemary Basson’s Female Sexual Response Model resonates with the majority of her patients. The model focuses on the idea that for women, arousal often precedes desire.
She encourages them to rethink sexual activity and consider replacing spontaneity with anticipation. “Sometimes you have to get ready for sex, and that’s ok,” Dr Chism said. “Maybe that means first finding out if you are able to become aroused. If arousal is a problem, if orgasm is a problem, then desire is going to be a problem.”
She also advocates the use of sensate focus techniques, which encourage individuals to concentrate on intimacy, rather than sex, performance, and orgasm.
Treatments to Improve Sexual Function
Hyposexual desire disorder (HSDD) is characterized by a persistent lack of desire over a persistent period of time, along with marked distress. Distress—experienced by either the patient or her partner—is the key here, Dr Chism noted. HSDD may not be amenable to cognitive behavioral therapies and, in these cases, medication may be necessary.
Flibanserin (Addyi) is the first US Food and Drug Administration (FDA)-approved medication for HSDD, and has been shown to increase desire, improve the number of satisfying sexual events, and markedly reduce distress associated with low desire in both pre- and postmenopausal women. Testosterone, which has demonstrated a similar effect in female populations, is not FDA approved for the treatment of HSDD in women, but is widely used off-label.
Dr Chism noted that she is very excited about a new drug on the horizon called bremelanotide (Vyleesi). In clinical trials, this on-demand subcutaneous injection has shown to significantly improve sexual function when taken 45 minutes before a planned sexual event. The most frequently observed side effect with bremelanotide is nausea, which is easily treated with ondansetron.
“What’s interesting is this is going to be an as-needed drug,” Dr Chism explained. “And I believe there’s a market for both. There’s a market for women who want that everyday sense of well-being and improved sense of desire on a regular basis. And then there’s the women who want it for date night, a weekend away, or a Tuesday…whatever.”
“When I talk to my patients about an injection that’s coming, believe me, they don’t turn their nose up at it,” Dr Chism added.
Treating Vaginal Atrophy in Postmenopausal Women
Vaginal atrophy is now part of a larger classification called genitourinary syndrome of menopause, which encompasses any vaginal tissue changes, pH abnormalities, and urinary symptoms, such as leakage or frequent urinary tract infections.
Before medically treating postmenopausal women who have symptoms of vaginal atrophy, healthcare providers should conduct a vaginal inspection exam to rule out any other pathology.
“Make sure women understand why this is happening,” Dr Chism stressed. “They know they’re going to get hot flashes and night sweats because of menopause, but they don’t realize that their vagina changes because of the lower levels of estrogen.”
Lubricants and moisturizers are suggested as first-line treatment. For the most part, these do not cure vaginal atrophy but do provide symptomatic relief. Vaginal moisturizers, such as Replens or Luvena, can restore natural vaginal pH; increase moisture and elasticity; and reduce pain, itching, and irritation.
However, moisturizers containing hyaluronic acid (eg, Revaree and Hyalo Gyn) have been found to normalize vaginal pH; reduce itching, dryness, dyspareunia; and improve symptoms of vaginal atrophy in some studies.
As far as lubricants are concerned, there are many, but Dr Chism only recommends those that are silicone-based. These are longer lasting, safe with all condoms and nonsilicone products, odorless, tasteless, and safe for sensitive skin.
“But women don’t realize there’s a difference between vaginal moisturizers and lubricants,” Dr Chism noted. Moisturizers should be used as maintenance every 2 to 3 days, whether or not the patient is having sex. Lubricants should be used at the time of intercourse, even if the patient is already using moisturizers.
Regarding medications, vaginal estrogen is indicated for vaginal atrophy in many forms (eg, cream, tablet, ovule), but daily use of ospemifene (Osphena) may also improve symptoms. Pelvic floor rehabilitation can also help to release tight muscles, thereby helping with pain on vaginal entry.
However, vaginal dehydroepiandrosterone is Dr Chism’s choice for the medical treatment of vaginal atrophy and pain with penetration. Off-label, it has also been shown to increase arousal, possibly caused by increasing nerve sensitivity or nerve fiber growth.
Vaginal fractionated carbon dioxide laser therapy is also gaining traction as a treatment, but it is not FDA approved for the treatment of vaginal atrophy, so patients must pay out of pocket. In addition, it requires continuous treatments, or “tune-ups,” she said.
If a patient has not had penetrative intercourse for several years, she should be counseled regarding vaginal dilators at her initial visit. She should start with the smallest size, eventually working her way up, and use in combination with a vaginal moisturizer and lubricant.
“This stretches the vagina, but it also helps with anticipatory fear when they’re afraid of penetration,” she noted. “If they know they can tolerate the largest dilator, then they know they’re going to be okay with intercourse.”
Dr Chism says she also talks to patients about self-stimulation, noting that it often helps to frame it as a medical intervention. A study of irradiated cervical cancer patients revealed that a clitoral pump used 4 times a week for 3 months significantly improved sexual desire, arousal, lubrication, orgasm, sexual satisfaction, and pain. “So, I tell women: science shows that masturbation helps,” she said.
Dr Chism emphasized the importance of shared decision-making when discussing potential treatments with patients. Nurses should ask the patient what sounds best to her, and discuss the adverse events associated with each treatment.
“It’s all about that risk-benefit discussion,” she said. “And that does require time.”
- World Health Organization. Defining sexual health: report of a technical consultation on sexual health. January 28-31, 2002. www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf. Accessed July 1, 2019.