Female Sexuality in Premenopausal Patients with Breast Cancer on Endocrine Therapy

To the Editor: Breast cancer is the most frequent cancer in women and diagnosis in premenopausal women is made in 25% of cases (1). Its prognosis has improved and its management must therefore ensure psychological care with a particular focus on sexuality. Among treatments of breast cancer, endocrine therapy is known to have side effects which could alter the women’s sexuality, such as hot flashes, vaginal dryness, and dyspareunia. Sexuality among premenopausal women with breast cancer on endocrine therapy is therefore important to investigate in its different aspects, including interactions with clinical and therapeutic parameters on the one hand and with depression, anxiety, and marital harmony on the other hand. Patients were recruited from patients consulting in the department of medical oncology during the months of October and November 2015. Inclusion criteria were as follows: histologically proven breast carcinoma; no metastatic localization; ongoing adjuvant endocrine therapy; complete remission; married status; being not menopausal at time of diagnosis; consenting to participate in the study and being able to read and write in Arabic and French. We have not included patients having other organic comorbidities interfering with sexual activity or a mental disorder impeding the understanding of questionnaires. According to these criteria, thirty patients were recruited and all of them gave their informed written consent before participating in the study. All participants filled three auto-questionnaires: the Female Sexual Function Index (FSFI) (2) and the Hospital Anxiety and Depression Scale (HADS) (3) in their validated Arabic versions, in addition to the Locke and Wallace Marital Adjustment Test (MAT) in its French version (4). The FSFI maximum total score is 36 and a total score <26.55 has been proposed as a cut off value for the diagnosis of sexual dysfunction (5). The HADS consists of 14 items assessing anxiety symptoms (seven items, HADS-A) and depression symptoms (seven items, HADS-D). Total scores for HADS-A and HADS-D range between 0 and 21 and a pathological level is considered for a score above 11 (3). The MAT total scores range between 2 and 158 and marital agreement is considered to be high if the score is >99 (4). The mean age of patients was 41.33 1.16 years. All patients had surgery and 93% of them had adjuvant chemotherapy. Radiotherapy, which was used in 97% of cases, was well tolerated by 48.3% of patients. Two patients had targeted therapy with trastuzumab. Tamoxifen was used alone in 56.7% of cases and was associated with castration in 43.3% of cases. Most frequent side effects of endocrine therapy were hot flashes (93.3%), irritability (83.3%), and headache (83.3%). The mean FSFI score was 22.86 8.47 with 19 patients (63.3%) having a score indicating a sexual dysfunction. The anxiety and depression levels were pathological in 26.7% and 16.7% of cases, respectively. The mean subscores of the different aspects investigated by the FSFI and the mean scores of HADS-A and HADS-D are shown in Table 1. The mean MAT score was 100 6.72 with a score indicating high marital agreement in 60% of patients. An analytical study of sexual function based on all investigated parameters was performed (Table 2). There was no significant association with clinical data and most of therapeutic parameters. Sexual dysfunction was associated with irritability, headache, high levels of anxiety and depression and with a low marital harmony. Results of our study indicated that a sexual dysfunction was present in more than 60% of patients. Such an impairment has already been reported in patients with breast cancer in general (5) and was explained by fear of infertility and loss of perceived femininity (6). In accordance with other studies (7,8), endocrine therapy and most of its side effects (hot Address correspondence and reprint requests to: Daldoul Amira, Department of Medical Oncology, Farhat Hached University Hospital, Ibn El Jazzar Street, Sousse 4000, Tunisia, or e-mail: amira.krir@outlook.com