Mary Panjari

Sexual Function after Breast Cancer

INTRODUCTION Breast cancer (BC) remains the most common non-skin cancer in women and an increasing number are living as BC survivors. AIM The aim of this article is to evaluate the impact of the first diagnosis of invasive BC and its treatment, menopausal symptoms, and body image on sexual function. METHODS The BUPA Foundation Health and Wellbeing after Breast Cancer Study is a prospective cohort study of 1,684 women recruited within 12 months of their first diagnosis with invasive BC. Each participant completed an enrollment questionnaire (EQ) and first follow-up questionnaire (FQ1) 12 months post-EQ. MAIN OUTCOME MEASURE Sexual function was evaluated by the Menopause-Specific Quality of Life Questionnaire embedded within the FQ1. RESULTS Of the 1,011 women in the analyses, 70% experienced sexual function problems and 77% reported vasomotor symptoms. Women experiencing sexual function problems were postmenopausal (P = 0.02), experienced vasomotor symptoms (P < 0.01), and used aromatase inhibitors (P = 0.03). Women with vasomotor symptoms were twice as likely to experience sexual function problems (odds ratio [OR] 1.93, 95% confidence interval [CI] 141, 2.63; P < 0.001). This association was more extreme for women on aromatase inhibitors (OR 3.49, 95% CI 1.72, 7.09; P = 0.001) but did not persist in women not using endocrine therapies (OR 1.41, 95% CI 0.84, 2.36; P = 0.19). Women on aromatase inhibitors were more likely to report sexual function problems (OR 1.50, 95% CI 1.0, 2.2, P = 0.04) and women with body image issues were 2.5 times more likely to report sexual function problems (OR 2.5 95% CI 1.6, 3.7, P < 0.001). Women using tamoxifen were not more likely to experience sexual function problems (OR 1.1, 95% CI 0.8, 1.5, P = 0.6); however, women with body image issues were twice as likely to experience sexual function problems (OR 2.1, 95% CI 1.5, 3.0, P < 0.001). CONCLUSION Seventy percent of partnered BC survivors less than 70 experienced sexual function problems. Sexual problems are related to the use of aromatase inhibitors which can exacerbate menopausal symptoms.

DHEA Replacement for Postmenopausal Women

CONTEXT It has been proposed that because dehydroepiandrosterone (DHEA) and its sulfate, DHEAS, are important precursors for estrogen and androgen production, treatment with DHEA is a physiologically based strategy for the alleviation of hormone deficiency symptoms in postmenopausal women. We have summarized the physiology of DHEA in women and reviewed the findings from randomized controlled trials (RCT) of the effects of DHEA therapy in postmenopausal women with normal adrenal function. EVIDENCE ACQUISITION We reviewed the medical literature for key papers investigating DHEA physiology and RCT of the use of DHEA in postmenopausal women through November 2010. The focus was on sexual function, well-being, metabolic parameters, and cognition as study endpoints. EVIDENCE SYNTHESIS Although cross-sectional studies have indicated a link between low DHEA levels and impaired sexual function, well-being, and cognitive performance in postmenopausal women, placebo-controlled RCT do not show benefits of oral DHEA for any of these outcomes or favorable effects on lipids and carbohydrate metabolism. CONCLUSIONS Taken together, findings from this review of the published literature of studies do not support the use of DHEA in postmenopausal women at this time.

DHEA for postmenopausal women: A review of the evidence

BACKGROUND Dehydroepiandrosterone (DHEA) and its sulphate DHEAS are the most abundant sex steroids in women and provide a large reservoir of precursors for the intracellular production of androgens and estrogens in non-reproductive tissues. Levels of DHEA and DHEAS decline with age. It has been proposed that restoring the circulating levels of these steroids to those found in young women may have anti-aging effects and improve sexual function and wellbeing in postmenopausal women. AIM To review the published literature for the efficacy of DHEA therapy data regarding safety. METHODS A systematic literature search of MEDLINE (Ovid) and Pub-Med (1966 to November 2009) for original studies that included any of the terms dehydroepiandrosterone, DHEA or DHEAS, sexual function, wellbeing, women and metabolic parameters of interest. RESULTS Overall the interpretation of the data was limited by inadequate sample size and short treatment duration of available studies with inconsistent results. The more recent randomized controlled trials however do not support a benefit of oral DHEA therapy for women. A possible benefit that emerged is that vaginally administered DHEA may improve vaginal atrophy with concomitant improvements in sexual function in women who are estrogen deficient due to menopause. The potential value of oral DHEA therapy for postmenopausal women is called into question.

Vaginal DHEA to treat menopause related atrophy: A review of the evidence

Vaginal atrophy is a common symptom of postmenopausal estrogen deficiency and can present as dryness, irritation, infection and dyspareunia and can affect sexual function and quality of life. Currently vaginal atrophy is treated with the intravaginal application of preparations containing estradiol or estriol, which are both effective and safe. It has been proposed that intravaginally administered dehydroepiandrosterone (DHEA) can be used to treat vaginal atrophy. DHEA and its sulphate DHEAS are the most abundant circulating sex steroid hormones in women, and provide a large precursor reservoir for the intracellular production of androgens and estrogens in non-reproductive tissues. Levels of DHEA and DHEAS decline with age. Although there is some evidence to support the use of intravaginal DHEA for postmenopausal women with symptoms of vaginal atrophy, independent studies are required to confirm this. In addition studies regarding the effects of vaginal DHEA on sexual function in women without vaginal atrophy are needed. Given that the efficacy and long term safety of low dose vaginal estradiol and estriol therapy is well established and that vaginal estrogen requires application of 2-3 times a week, rather than daily dosing; the benefit of daily vaginal DHEA over estrogen also needs to be considered as women may find it unpalatable to adhere to daily dosing with a cream preparation.

A Randomized Trial of Oral DHEA Treatment for Sexual Function, Well-Being, and Menopausal Symptoms in Postmenopausal Women with Low Libido

INTRODUCTION Dehydroepiandrosterone (DHEA) and its sulfate DHEAS, which are the most abundant steroids in women, decline with age. We have shown association between low sexual function and low circulating DHEAS levels in women. AIM The aim of this study was to evaluate whether restoration of circulating DHEA levels in postmenopausal women to the levels seen in young individuals improves sexual function. METHODS Ninety-three postmenopausal women not using concurrent estrogen therapy were enrolled in a 52-week randomized, double-blind, placebo controlled trial and received either DHEA 50 mg or placebo (PL) daily. MAIN OUTCOME MEASURES Efficacy was assessed through 26 weeks. The main outcome measures were the change in total satisfying sexual events (SSE) and the change in the Sabbatsberg Sexual Self-Rating Scale (SSS) total score. Secondary measures were the Psychological General Well-Being Questionnaire (PGWB), and the Menopause-Specific Quality of Life Questionnaire (MENQOL). Hormonal levels, adverse events (AEs), serious adverse events (SAEs) and clinical labs were evaluated over 52 weeks. RESULTS Eighty-five participants (91%) were included in the 26-week efficacy analysis. There were no significant differences between the DHEA and PL groups in the change in total SSE per month or the SSS, PGWB, and MENQOL change scores. Overall AE reports and number of withdrawals as a result of AEs were similar in both groups; however more women in the DHEA group experienced androgenic effects of acne and increased hair growth. CONCLUSIONS In this study treatment of postmenopausal women with low sexual desire with 50 mg/day DHEA resulted in no significant improvements in sexual function over PL therapy over 26 weeks.

The safety of 52 weeks of oral DHEA therapy for postmenopausal women

OBJECTIVE The aim of this study was to evaluate the safety of 52 weeks of DHEA 50mg daily oral dose given to postmenopausal women with low libido to improve sexual function. METHOD 93 postmenopausal women were enrolled in a 52-week randomised, double-blind, placebo-controlled trial and received either DHEA 50mg or placebo (PL) daily. The effects of DHEA versus placebo on lipid profile, insulin-glucose homeostasis and the endomentrium were assessed over 52 weeks. RESULTS Oral DHEA, 50mg/day, was not associated with any effects on blood lipids or insulin resistance. The pattern of breakthrough bleeding did not substantially differ between the DHEA and PL groups and no significant adverse endometrial effects were apparent. CONCLUSIONS The use of 50mg oral DHEA did not significantly alter lipid profile, insulin sensitivity or adversely affect the endometrium in postmenopausal women.

Menopausal symptoms in breast cancer survivors nearly 6 years after diagnosis.

ObjectiveWe investigated the prevalence and severity of menopausal symptoms, nearly 6 years from diagnosis, in women who had not experienced recurrent breast cancer or a new primary breast cancer (active disease) and were no longer taking oral adjuvant endocrine therapy (OAET). MethodsA total of 1,683 women recruited within 12 months of diagnosis with invasive breast cancer completed an enrollment questionnaire and five annual follow-up questionnaires. Only women who had never reported active disease and were not taking OAET at their fifth follow-up were included in the analysis. Women previously recruited to a study of sex steroid levels provided community control data. Menopausal symptoms were assessed with the Menopause-Specific Quality of Life Questionnaire (MenQOL). ResultsEight hundred forty-three women without active disease and not taking OAET completed the fifth follow-up questionnaire, on average, 5.8 years after diagnosis. Most had stage I (59.5%) and hormone receptor–positive disease (77.9%) at diagnosis and were postmenopausal (92.8%). Those aged 50 to 59 years were more likely to report any symptoms (P = 0.01) and more severe symptoms (P < 0.001) than older and younger women. There was no independent impact of chemotherapy on MenQOL vasomotor and sexual domain scores. Women with breast cancer had significantly higher vasomotor domain (P ⩽ 0.002) and sexual domain (P ⩽ 0.004) scores than community controls. ConclusionsVasomotor and sexual symptoms are highly prevalent in breast cancer survivors and are not simply a function of OAET or chemotherapy. Given the adverse impact of these symptoms, effective interventions are needed to alleviate them in women who have completed their breast cancer treatment.

Breast cancer survivors' beliefs about the causes of breast cancer.

Objective: To explore the beliefs held by breast cancer (BC) survivors about the factors that contribute to the development of their BC.

Methodology and challenges to recruitment to a randomized, double blind, placebo controlled trial of oral DHEA in postmenopausal women

OBJECTIVE To report on the issues encountered in the recruitment of healthy naturally menopausal women in the community to a randomized placebo-controlled trial of dehydroepiandrosterone (DHEA) therapy for treatment of loss of sexual desire. METHODS Recruitment of women was achieved by advertising and media publicity. We have reported on the method by which women initially contacted us and the reasons for nonparticipation. RESULTS Nine hundred and eighteen women contacted us about participating in the study; 706 of these were telephoned screened, and 93 of these (10%) women were randomized to therapy. The main determinants for nonparticipation included ineligibility on phone screening (58%), withdrawal of interest either before or after screening (55%), and preexisting pathology after attending for screening (8%). CONCLUSIONS Despite ongoing interest by women to participate in research for therapies to treat low libido, concerns about the use of any hormonal treatment and the time poverty experienced by many women at midlife present new barriers to recruitment and need to be considered in assessing the feasibility of studies in this field.

A comparison of the characteristics, treatment and outcome after 5 years, of Australian women aged 70+ with those aged <70 years at the time of diagnosis of breast cancer

BACKGROUND Management of older women with breast cancer (BC) is challenging, as age-related comorbidities may limit treatment. We present 5-year follow-up data from women aged 70 years or older (70+), at the time of diagnosis of their BC, compared with younger women (<70 years). METHODS Data is from an Australian cohort study of women with their first episode of invasive BC (Bupa study). Participants completed an enrollment questionnaire (EQ) within 12 months of diagnosis and annual follow-up questionnaires (FQ) for 5 years (FQ1-5). Data collected included details of the BC and its treatment. Psychological wellbeing was measured by the Psychological General Wellbeing Index (PGWB). RESULTS At diagnosis, 274 (16%) women were aged 70+ and of them, 90% were aged 70-79 years. Compared with women aged <70 years, the women aged 70+ were less likely to have positive nodes, they were less likely to receive radiotherapy and chemotherapy and were more likely to have pre-existing cardiovascular morbidities. By FQ5 women aged 70+ were less likely to be taking oral adjuvant endocrine therapy (OAET) and were more likely to have died from causes other than BC. At FQ5, women 70+ reported less anxiety and better self-control. CONCLUSIONS Women aged 70+, compared to <70 years, had less advanced disease, received radiation and chemotherapy less often, were more likely to have cardiovascular disease at the time of diagnosis, were less likely to be taking OAET at the 5-year assessment, and were more likely to die of causes other than breast cancer.