Australian doctors Belinda Yeo and Virginia Baird gave a very enlightening and frank presentation on sexual health at Breast Cancer Trials’ recent conference in Hobart, with some excellent advice not only for women experiencing breast cancer but also their doctors.
Sexual health has a much broader definition than most of us might think. WHO defines it 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. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possiblity of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.”
Low sexual desire, orgasmic disorder, body image concerns, relationship concerns, dyspareunia (pain during intercourse), loss of nipple/breast sensation and genitourinary syndrome of menopause are some of the concerns that 75 to 90% of breast cancer patients report.
Many factors can affect sexual health after breast cancer:
- Treatment - surgery, radiotherapy and chemotherapy
- Age at diagnosis - proximity to menopause, energy levels, diabetes, obesity (75% of breast cancer patients are obese or overweight at the time of diagnosis)
- Mental health – mood, fear of recurrence, anxiety, depression, body image
- Relationship changes – socio economic stress, caregivers
- Sexual life – baseline sexual functioning, contraception, value placed on sexual health.
Treatments for hormone receptor positive (HR+) breast cancer (i.e. over 70% of all cases), which are designed to decrease oestrogen levels, are particularly problematic for sexual health. Oestrogen performs many functions in the body and disrupting it can lead to rapid noticeable changes. Aromatase inhibitors (letrozole, anastrozole and exemestane) all suppress oestrogen synthesis to nearly undetectable levels in a few days. Tissues in the vagina, vulva, urethra and bladder all contain oestrogen receptors and thus undergo atrophy with aromatase inhibitor treatment. This results in decreased vaginal tissue elasticity and decreased vaginal fluid secretion, leading to pain during sex (as reported by 45% of patients).
Sadly, doctors are not good at ameliorating side effects of these treatments, such as hot flushes, low mood, weight gain, arthralgias (joint pain), low or no libido, dry vagina, pain with intercourse, fatigue and fractures.
Furthermore, these concerns can persist for years after diagnosis. A 2021 survey found high levels of menopausal symptoms in women six years after their diagnosis: 90% had hot flushes and sleep disturbance, 75% had vaginal dryness, 62% had mood swings and 59% had sexual difficulties. Less than a third were offered treatment and less than half of those found this to be effective.
Patients are often advised to ‘talk to your doctor’, but Dr Yeo admitted many cancer doctors don’t really know what to say on this topic.
Fortunately, Dr Baird who specialises in sexual health, menopause and breast cancer, had some useful advice on how doctors can respond and how they should be proactive in bringing up the subject.
She recommended screening for sexual dysfunction at all stages of the breast cancer journey, looking for untreated symptoms at diagnosis, during all treatments and beyond the end of active treatment (especially after long-term endocrine therapy). She noted that women tend not to initiate conversations about genito-urinary syndrome of menopause (conditions of the vagina, vulva, pelvic floor issues, urinary tract, sexual function and loss of libido) and that vaginal atrophy is progressive – if not treated, it will get worse.
She suggested that doctors ‘normalise’ the subject by using phrases like “It’s normal to notice…”; she warned against making assumptions about who and what they are doing, and recommended using a screening tool (questionnaire) for symptoms like that issued for doctors by the Australasian Menopause Society.
In practical terms, Dr Baird suggested giving women advice on standard vulval care (only wash with water, pat dry, don’t rub or scratch, don’t wear synthetic pads for too long, wash after wearing synthetic gym clothes or underwear); have regular sexual activity if possible (it increases blood flow – use it or lose it); use vaginal moisturisers such as Replens or YesVM; use lubricants (water-based, silicone-based or oil-based such as almond, olive or coconut oil) during sex; for pain during intercourse try prescribing lignocaine cream or amitriptyline. Cognitive Behavioural Therapy, pelvic floor physio, and counselling for couples or with a specialist sex therapist could also be beneficial.
On the topic of using oestradiol vaginal creams after breast cancer, both Dr Yeo and Dr Baird noted that newer preparations deliver lower doses than old ones and suggested that they could be used safely by some. (Unfortunately, the patient leaflet in one preparation says ‘do not use if you have had breast cancer’.) Audience members suggested that if an oncologist prescribes oestradiol cream, they should let the woman’s GP know so that they can continue to receive a supply of this medicine. A review of the scientific evidence (Kastora et al. 2025) has concluded that use during treatment with tamoxifen did not increase recurrence or mortality risk, but it could be associated with an increased risk of recurrence in those taking aromatase inhibitors. However, mortality risk in those taking aromatase inhibitors was not affected.
Drs Yeo and Baird concluded their talk with the advice: “Doctors have to ask!”
You can read more about sex and relationships after breast cancer here.
You can read more about hormone (endocrine) therapy for breast cancer and managing side effects here.
9 August 2025
