Biological disruption of the sexual response, e.g., multiple sclerosis damaging pelvic autonomic nerves
Negative psychological consequences of the illness affecting sexual response, e.g., feeling sexually unattractive as a result of disfigurement from surgery, medication, stomas
Treatment of chronic illness, e.g., chemotherapy-inducing ovarian failure
Limited mobility, e.g., arthritis precluding intercourse, Parkinson’s disease precluding masturbation
Cardiac or respiratory compromise such that orgasm or movements of intercourse cause angina or intense dyspnea lowered sexual motivation. A recognized difficulty with recurrent herpes is viral shedding despite lack of skin lesions and uncertainty whether long-term antiviral therapy prevents shedding.
Lichen Sclerosis Tethering of the clitoral hood, which occurs with lichen sclerosis, may cause pain with clitoral stimulation. When this skin disorder involves the introitus, it may cause dyspareunia or prevent entry of penis, dildo, or fingers. Reduced sexual sensitivity of the involved vulvar skin is a common complaint. Topical corticosteroid administration is the primary treatment, although topical testosterone cream may be beneficial when loss of sexual sensitivity occurs.
Breast Cancer Sexual dysfunction following breast cancer treatment is likely to persist more than 1 year after diagnosis of breast cancer (63). Chemotherapy appears to be responsible for most of the resulting sexual difficulties, including loss of desire, subjective arousal, vaginal dryness, and dyspareunia (64). A small study of women with past breast cancer and complex endocrine status resulting from ongoing antiestrogen therapy found that, whereas relationship factors predicted desire, history of chemotherapy predicted disorders of arousal lubrication, orgasm, and dyspareunia but there was no connection between sexual function and androgen levels including androgen metabolites (65). A model for predicting sexual interest, function, and satisfaction after breast cancer has evolved from two large independent groups of breast cancer survivors (64). The most important predictors of sexual health were absence of vaginal dryness, presence of emotional well-being, positive body image, better quality of relationship, and lack of partner sexual problems. A temporary “medical menopause” from adjuvant GnRH agonist treatment is associated with reversible sexual dysfunction (66). Use of tamoxifen does not consistently alter sexual function, but use of aromatase inhibitors is often associated with severe dyspareunia from the profoundly estrogen-depleted state (67,68).
The optimal management of ongoing dyspareunia from the estrogen deficient state, especially when the woman is on aromatase inhibitors, is unclear. Zero systemic absorption of estrogen from vaginally administered preparations is the goal, and formulations are under investigation for efficacy at lower dosages than are currently available. Some oncologists will permit the use of local estrogen via a Silastic ring that does cause brief, but detectable (although not to premenopausal estrogen levels), systemic absorption. For most of the 3 months that the ring is in place systemic absorption is not detectable. Vaginal moisturizers can allow some benefit but do not restore the full elasticity.
Fertility preservation is considered along with the overall treatment plan for younger women, and a number of options are emerging. One is to delay treatment to undergo a cycle of hormone stimulation and oocyte retrieval, providing the growth of the tumor is not expected to be promoted by exogenous estrogen. Other techniques can avoid exposure to exogenous hormones by retrieving ovarian tissue and either aspirating the oocytes or reserving ovarian tissue strips and then using cryopreservation. An even newer technique called in follicle maturation involves obtaining immature follicles from the cryopreserved ovarian tissue, maturing them in vitro, to be followed by in vitro fertilization procedures (20).