15.5 Reproductive & Sexual Health

Why Reproductive and Sexual Health Are Tested

Breast cancer treatment can end fertility, trigger abrupt menopause, and cause sexual dysfunction that persists for years. These topics are often left out of clinic visits unless nurses raise them. The CBCN exam expects you to initiate conversations, know the options, and time referrals correctly.

Treatment Effects on Fertility

• Chemotherapy: alkylating agents such as cyclophosphamide cause the greatest ovarian damage. Risk of permanent amenorrhea rises with age (especially after 35 to 40), cumulative dose, and lower baseline ovarian reserve (for example, low anti-Müllerian hormone).
• Endocrine therapy: does not itself destroy eggs, but 5 to 10 years of therapy delays childbearing while ovarian reserve declines with age.
• HER2-directed and other therapies: require pregnancy avoidance during treatment and for a period afterward.
• Chemotherapy-induced amenorrhea is not reliable contraception: ovulation can resume.

Fertility Preservation Options

Young women with early-stage breast cancer face significant gonadotoxic risks from alkylating chemotherapy, leading to permanent amenorrhea and premature ovarian insufficiency:

• Immediate Pre-Treatment Referral: Every reproductive-age woman diagnosed with breast cancer must be offered an immediate referral to a reproductive endocrinology and infertility (REI) specialist prior to initiating systemic chemotherapy.
• Cryopreservation: Oocyte and embryo cryopreservation represent the gold-standard fertility preservation methods. Controlled ovarian hyperstimulation protocols incorporate concurrent aromatase inhibitors (e.g., letrozole) to keep serum estradiol levels within safe physiological ranges throughout follicular stimulation.
• Ovarian Function Suppression during Chemotherapy: The POEMS trial (in hormone receptor-negative disease) and the PROMISE-GIM6 trial (which enrolled mostly hormone receptor-positive patients) demonstrated that administering a gonadotropin-releasing hormone (GnRH) agonist (such as goserelin 3.6 mg subcutaneous injection) at least 1 to 2 weeks prior to chemotherapy initiation and continued monthly throughout chemotherapy significantly reduces the risk of premature ovarian insufficiency and increases subsequent pregnancy rates.

Additional Fertility Preservation Points

• Refer early, ideally at diagnosis, before surgery if chemotherapy is likely.
• Random-start stimulation can begin at any point in the menstrual cycle and usually takes about 2 weeks, so it rarely delays treatment meaningfully.
• Ovarian tissue cryopreservation is an established option (no longer considered experimental) when there is no time for stimulation.
• GnRH agonist ovarian protection during chemotherapy is an adjunct and does not replace cryopreservation for patients who want future pregnancy.
• Cost and insurance coverage are major barriers; some states mandate coverage for fertility preservation when treatment may cause infertility.

Contraception After Breast Cancer

Teach contraception needs clearly: tamoxifen and trastuzumab are harmful in pregnancy, and trastuzumab labeling advises contraception for 7 months after the last dose.

Pregnancy After Breast Cancer

Pregnancy after treatment does not appear to worsen breast cancer outcomes. Many clinicians advise waiting about 2 years after diagnosis, when recurrence risk is highest, but timing is individualized.

The POSITIVE trial enrolled women with early HR-positive breast cancer who paused endocrine therapy after 18 to 30 months to attempt pregnancy. The 3-year rate of breast cancer events (8.9%) was similar to an external control group (9.2%), and about three quarters became pregnant. Participants then resumed endocrine therapy to complete the planned course. Breastfeeding from the untreated breast is often possible, and some women can lactate from a breast treated with lumpectomy and radiation, although milk supply is usually reduced.

Sexual Health

Up to about 70% of survivors report sexual problems, often long-lasting. Causes include:

• Physical: vaginal dryness and atrophy (worst with aromatase inhibitors and ovarian suppression), dyspareunia, reduced libido, fatigue, pain, loss of breast and nipple sensation, and lymphedema.
• Psychological: body image distress, depression, anxiety, and fear of recurrence.
• Relational: partner fears, role changes, and communication problems.
• Medications: antidepressants and opioids can reduce desire and orgasm.

Assessment Models

• PLISSIT: give Permission to discuss sexual concerns; provide Limited Information (for example, that dryness is common on aromatase inhibitors); offer Specific Suggestions (moisturizers, lubricants, positions); refer for Intensive Therapy (sex therapy, pelvic floor therapy) when needed.
• BETTER: Bring up the topic, Explain concern for quality of life, Tell the patient about resources, Timing (it can be revisited any time), Educate about side effects, Record the assessment.

Use inclusive language that does not assume a partner's gender or type of sexual activity.

Interventions

1. Vaginal moisturizers used regularly (typically 2 to 5 times weekly) and lubricants (water- or silicone-based) during sexual activity.
2. Topical 4% aqueous lidocaine applied to the vulvar vestibule for about 3 minutes before penetration reduced pain in a randomized trial in breast cancer survivors with dyspareunia.
3. Vaginal dilators and pelvic floor physical therapy for pain and muscle tension.
4. Low-dose vaginal estrogen or vaginal DHEA (prasterone) may be considered for severe symptoms after discussion with oncology, with extra caution for patients on aromatase inhibitors. Ospemifene is not recommended for people with a history of breast cancer.
5. Counseling and sex therapy for desire, arousal, and relationship concerns; addressing depression and adjusting medications that impair sexual function.
6. Partner involvement and communication skills.