Reproductive and sexual health

Ongoing assessment for toxicities/late effects

In patients with breast cancer ensure that follow-up care includes ongoing assessment and supportive care for possible long-term toxicities and late effects of adjuvant treatments (including secondary cancers, cardiovascular toxicity, lymphoedema, mental health (including distress, depression, anxiety, body image), sexual health, premature menopause, infertility, fatigue, weight gain, impaired cognitive function, musculoskeletal health, pain and neuropathy, and bone health).

Menopausal symptom management – Contraindications

Discuss the risks and benefits of therapies for managing menopausal symptoms (hot flushes, night sweats and vaginal dryness) associated with breast cancer treatments, noting that all forms of systemic menopausal hormonal therapy (MHT) including oestrogen-only, combined oestrogen and progestogen, tibolone, and compounded or bioidentical hormones are contraindicated in women with a personal history of breast cancer.

Sexual intimacy concerns

Ask patients about concerns with sexual intimacy, and refer for further therapy, if appropriate.

Vulvovaginal symptom treatments #1

In women with a history of breast cancer who have vaginal dryness, offer first-line treatment with non-alcohol based vaginal lubricants during sexual activity. Consider topical lidocaine treatments to the vulvovaginal area for women experiencing pain with sexual activity.

Menopausal symptom management – Non-endocrine systemic therapies

Consider second-line treatment with non-endocrine systemic therapies (venlafaxine, desvenlafaxine, paroxetine, escitalopram, clonidine, or gabapentin) at doses shown to be effective in the management of moderate to severe hot flushes or night sweats in women with a history of breast cancer. Women treated with any of these drugs should be monitored for the development of adverse effects which may include sexual dysfunction, gastrointestinal symptoms, anxiety, sleep disturbance, or in rare cases suicidal ideation. Be aware that paroxetine should be avoided in women treated with tamoxifen.

Vulvovaginal symptom treatments #2

In women with a personal history of breast cancer who have persistent vulvovaginal symptoms that are unresponsive to non-hormonal treatments, consider second-line treatment with vaginal oestrogens (low dose vaginal oestradiol, or vaginal oestriol).

Adjuvant chemotherapy – Combination with endocrine therapy

Chemotherapy can be given concurrently with the gonadotropin-releasing hormone (GnRH) agonist goserelin but not with tamoxifen.

Sexual function – Exogenous testosterone

Exogenous testosterone is not recommended as a treatment to improve sexual function in women with a personal history of breast cancer as the efficacy and long-term safety after breast cancer has not been established. 

Fertility considerations – Referral

Discuss fertility issues and the implications of premature menopause with all premenopausal women. Arrange early referral to a fertility specialist to maximise the opportunity for consideration of fertility preservation if appropriate and feasible.

Pregnancy considerations

Premenopausal women should be counselled regarding the risk of becoming pregnant while on chemotherapy, endocrine therapy, anti-HER2 therapy, or during radiation therapy, even in the presence of amenorrhoea.

Contraception considerations #1

Discuss and offer barrier contraceptive options (condoms or diaphragms, a copper intrauterine device, or surgical options) for premenopausal women with breast cancer, noting that systemic hormonal contraception is contraindicated irrespective of disease subtype.

Systemic therapy planning considerations – Premenopausal women

Offer temporary ovarian suppression with a gonadotrophin releasing hormone (GnRH) agonist such as goserelin during chemotherapy to all premenopausal breast cancer patients undergoing chemotherapy who are interested in preventing early menopause and/or preserving fertility. Commence goserelin at least one week prior to the commencement of chemotherapy.

Contraception considerations #2

Premenopausal women should be advised not to use a levonorgestrel-releasing intra-uterine device (LNG-IUD) and to use alternative non-hormonal contraception, as the safety of the LNG-IUD among women with breast cancer has not been determined.

Radiation therapy considerations – Pregnant women

In pregnant women with breast cancer with a high risk of recurrence, the multidisciplinary team should consider the risks and benefits of radiation therapy to the woman and the fetus, and these should be discussed with the woman.

Radiation therapy timing – Pregnant women

In pregnant women with breast cancer with a low to intermediate risk of recurrence, delay radiation therapy until after delivery of the baby. 

Infertility after treatment – Specialist referral

Patients of childbearing age who experience infertility after treatment for breast cancer should be referred to a specialist in reproductive endocrinology and infertility as soon as possible.