CLINICAL ACTIONS:

Previvor is a relatively recent term describing an individual who is at risk for cancer due to a genetic predisposition (e.g., women who are carriers for deleterious mutations in BRCA1 or BRCA2).  A previvor may opt to undergo risk-reducing bilateral salpingo-oophorectomy.  With the sudden drop in estrogen, women need to be informed of the potential impact on sexual function and a plan for dealing with Sexuality, Intimacy, and Menopausal Symptoms (SIMS) should be undertaken. Research indicates that one month following risk-reducing bilateral salpingo-oophorectomy, a majority of women will experience decreased sexual desire and activity due to symptoms associated with rapid estrogen depletion.

Consider the following treatment options

• Topical estrogen
  • First-line therapy for vaginal symptoms including dryness and ease of penetration
  • Available in cream, table or ring form
• Systemic hormone therapy
  • Studies have shown no increase in breast cancer risk in women who have had risk reducing salpingo-oopherectomy
  • Patients should receive counseling on systemic therapy with evidence review to enable shared decision making
  • Unopposed estrogen in a woman with a uterus is always contraindicated as it increases the risk for endometrial hyperplasia
• Testosterone
  • Shown to increase libido and improve sexual function and satisfaction
  • Not FDA approved in the US
• SSRIs and SNRIs
  • May be considered
  • Vasomotor symptoms may improve but can also result in further low libido
• Flibanserin
  • Daily dose of 100 mg at bedtime has been shown to provide up to 50% meaningful response
• Over the counter and herbal supplements that may be helpful include
  • Black cohosh for hot flashes, atrophy and anxiety and depression
  • Maca root or ashwagandha root for low libido
  • Vaginal moisturizers and lubricants
• Pelvic floor physical therapy
  • May be considered to help with vaginal pain
• Behavioral therapy, psychoeducation, and mindfulness training
  • May help with many changes in body image and feelings of well-being which may also impact on sexuality

SYNOPSIS:

Previvors should be fully informed regarding the potential effects of the surgery including hormonal changes.  Levels of androgens and estrogens decline and women may experience decrease in sexual desire, arousal and orgasm, vaginal atrophy, dyspareunia, and hot flashes as a result. Psychological and psychosocial effects may include reduced self-confidence, poor body image and feelings of guilt and anxiety. Unlike ovarian cancer survivors, many previvors will be younger, and risks surrounding early menopause is a concern.

KEY POINTS:

• While systemic hormonal replacement in cancer patients remains controversial, the abrupt loss of estrogen in premenopausal women has effects extending beyond cancer risk, including implications for bone and cardiovascular health
• There are a variety of treatment modalities available for these patient that can greatly improve their quality of life

Learn More – Primary Sources:

The management of Sexuality, Intimacy, and Menopause Symptoms (SIMS) after prophylactic bilateral salpingo-oophorectomy: how to maintain sexual health in “previvors”

Related ObG Topics:

Managing Sexual Concerns in Patients with Ovarian Cancer

North American Menopause Society: Hormone Therapy Statement

Treating Postmenopausal Vaginal Atrophy When Estrogen is Not an Option

Does Estrogen Therapy Have Cardiovascular Benefit in Early Postmenopause?

Prescribing Ospemifene for Postmenopausal Vaginal Atrophy