Sexual Health

CMECNE

Sexual Concerns of Previvors who Undergo Risk-Reducing Salpingo-Oophorectomy

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss ‘SIMS’ and the related symptoms this acronym describes
2. Counsel previvors as to their potential options in the treatment of SIMS

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from April 10 2018 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

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”

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