If changes in arousal are also associated with the endocrine changes of menopause, the option and evaluation of hormone replacement should be discussed. Some women may experience discomfort with penetration around the vaginal entrance and can learn to relax the pubococcygeus muscles with Kegel exercises.[38,49,50] Women who have lost vaginal depth or caliber as a result of pelvic surgery, radiation therapy, or graft-versus-host disease may also benefit from a program of inserting vaginal dilators of gradually increasing sizes, and at the same time, learning exercises to better relax the muscles surrounding the vaginal entrance.[38,51] Some women may also benefit, at least in the short term after cancer treatment, from lubricant or anesthetic gels to prevent pain in tender, dry vulvar areas.[Level of evidence: I] The FDA approved a nonpharmaceutical device to aid sexual arousal in women. The EROS clitoral therapy device (EROS-CTD) creates a gentle suction over the clitoris to increase blood flow and sensation. This device is only available by prescription and is clinically indicated for the treatment of female sexual dysfunction. It is expected to be particularly effective in postmenopausal women, women who have had hysterectomies, and those women who have surgically induced menopause. The efficacy of EROS therapy has been supported by several small pilot studies,[Level of evidence: III][55,56] one of which specifically examined its efficacy in alleviating the symptoms of sexual dysfunction among women with a history of irradiated cervical cancer.[Level of evidence: II] Three months posttherapy, this study found statistically significant improvements in all domains evaluated, which included increased sexual desire, arousal, lubrication, orgasm, sexual satisfaction, and reduced pain. Additionally, follow-up gynecological examinations revealed improved vaginal elasticity, mucosal color, and moisture and decreased bleeding and ulceration. Randomized controlled trials are warranted to fully assess the benefits of EROS therapy.
More specific information for the evaluation and treatment of female sexual dysfunction, including painful intercourse (i.e., dyspareunia), vaginismus, inhibited orgasm, and sexual arousal and desire disorders, is available in other resources.[39,49,57,58]
For both men and women, a persistent and complex sexual problem is loss of desire for sex after cancer treatment. In men who have not had prostate cancer and have clinically low levels of serum testosterone, replacement by injection or patch is often effective in restoring normal sexual function. Testosterone replacement tends to have little effect, however, if given to a man whose own hormone levels fall within the normal range. Safety, dosage, and delivery systems for androgen replacement in women need to be studied. Numerous studies have evaluated the use of transdermal testosterone in various populations.[59,60,61,62,63,64,65][Level of evidence: I] These populations include women who have hypoactive sexual desire disorder who have had oophorectomies, who are naturally postmenopausal, who are premenopausal, and who have a history of cancer. These studies used doses ranging from 150 μg to 10 mg daily. Most of the studies in women have used concomitant estradiol supplementation if estrogen levels fell outside the normal premenopausal range and found that testosterone supplementation significantly improved libido outcomes.