This study assessed sexual function in postmenopausal women with breast cancer treated at a large, public university hospital in a developing country. FSFI scores were significantly reduced in women with breast cancer. In the immediate aftermath of diagnosis, patients already exhibited significant reductions in total score and across all FSFI domains as compared to controls. We can observe that merely receiving a diagnosis of breast malignancy is sufficient to produce a significant reduction on sexual function, even before patients have received any form of treatment. Survival-related concerns are highly influential at the pre-treatment stage and contribute to this decline in sexual functioning .
Administration of one cycle of primary anthracyclin-based chemotherapy was followed by another significant reduction in all domains of the FSFI score. The acute effects of chemotherapy—such as hair loss, weight gain, pallor, nausea, and vomiting—can make patients feel less attractive, and adverse effects such as vaginal dryness and itching contribute to reduced sexual function .
Patients over the age of 55 experienced more significant reductions in FSFI, as did women whose spouses or partners were older than 55. Maybe a greater distance from the borderline age of menopause can destabilize the couple’s sexual relationship, thus making it prone to the impact of cancer; however, further data are required to support this assertion. A diagnosis of cancer can also rekindle past conflicts between the couple, further contributing to a reduction in sexual function .
Although we found no significant association between reduction in FSFI scores and the prior diagnosis variable (treatment-naïve patients referred to our breast unit with clinical diagnosis of breast cancer), patients with advanced-stage disease experienced more significant losses in sexual function, particularly in the desire and arousal domains, which are more susceptible to the disturbances in self-image produced by locally advanced tumors.
Any discussion of female breast cancer must take into account not only the factors associated with cancer in general, but also the aspects related to the social function of the female body. In the field of symbolism, the breast plays fundamental roles in female identity, including sexuality and sensuality, as an object of pleasure and desire. A mutilated self-image disrupts the patient’s roles as spouse and mother and may give rise to feelings of helplessness, disgust and anguish [15–18].
Facing this crisis, which strikes at the physical, psychological, and social well-being of patients, requires adaptation to a new self-image. This, in turn, requires a supreme effort for which many women are unprepared. The challenges that arise upon diagnosis deeply unsettle the inner balance of patients and affect their relationships, making them more prone to conflicts at the personal and family level [16, 19–21].
Breast cancer can affect three domains of female sexuality: sexual identity, sexual function, and sexual relations .
Although sexuality is often associated with sexual intercourse alone, it is far more than that: it is the combined experience of all changes that take place and affect the manner in which one views oneself and one’s body. Regardless of age, sexual function is dependent on one’s physical identity and psychic wellbeing, as well as on habitual sexual activity [3, 20, 22].
A diagnosis of cancer is a profoundly stressful event for patients and their families; all must adapt to the shock and uncertainty such a diagnosis brings. Patients, partners, and other family members may be affected by clinical-level depression and varying levels of anxiety, fear and other stress reactions .
Anticipation of changes in body image may be brought about by common-knowledge perceptions of the disease, including the possibility of breast loss or mutilation, hair loss, pain, and changes in reproductive capacity, as well as changes in perception of one’s health status, with fear of death and disease recurrence—compounded by fears as to the integrity of the intimate relationship and the possibility of partner rejection. All of these factors can have a negative impact on the sexual functioning of patients; even in the general population, depression and anxiety are associated with increased female sexual dysfunction .
Psychosocial support and assessment of quality of life must be integrated into the treatment and follow-up of women who receive a diagnosis of breast cancer. Chemotherapy has already been included as a quality of life variable in several studies, with some authors concluding it has no long-term impact on quality of life and others believing it is an important determinant of lower quality of life in survivors [15, 17, 23, 24].
Time appears to be a determining factor of the influence of chemotherapy on quality of life after breast cancer treatment, its impact waning as years go by [1, 7, 12].
The adverse effects of breast cancer treatment, such as fatigue and nausea, must not be neglected. Patients who receive chemotherapy as part of their treatment regimens are apparently more likely to report severe, persistent fatigue than healthy women, affecting their sexual performance [22, 25, 26].