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    Sexuality and Reproductive Issues (PDQ®): Supportive care - Health Professional Information [NCI] - Treatment of Sexual Problems in People With Cancer

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    When women experience changes in arousal, most notably vaginal dryness and irritation, vaginal moisturizers (e.g., Replens) and water-based lubricants (e.g., Astroglide and K-Y Liquid) may be suggested, especially in women who cannot use estrogen replacement. The approval of the estradiol-releasing vaginal ring (Estring), containing a slow-release preparation, 2 mg of micronized 17-beta-estradiol, may also provide a less risky alternative to systemic estrogen replacement for women with postmenopausal vaginal atrophy.[45][Level of evidence: I][46] Estring has demonstrated a decreased recurrence of urinary tract infections in postmenopausal women and a significant maturing effect on vaginal and urethral mucosal cells, decreasing the urogenital symptoms of postmenopausal women.[47][Level of evidence: I]

    Another alternative to local estrogen replacement is the first-available 25-μg 17-beta-estradiol vaginal tablet (Vagifem). A study comparing Vagifem tablets with 1.25-mg conjugated equine estrogen vaginal cream (Premarin) found both to be equivalent in relieving symptoms of atrophic vaginitis, with patients who received Vagifem experiencing less endometrial proliferation or hyperplasia. This study also found that women rated vaginal tablets more favorably than vaginal cream.[48][Level of evidence: I] The long-term safety of the use of vaginal estrogens by women who should avoid estrogens has not been determined.

    If changes in arousal are also associated with the endocrine changes of menopause, the option and evaluation of hormone replacement may 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.[52][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.[53] The efficacy of EROS therapy has been supported by several small pilot studies,[54][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.[55][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.

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