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Sexual dysfunction in female cancer survivors: Addressing the problems and the remedies

  • Taryn Smith
    Correspondence
    Corresponding author at: Section of Women's Health, Division of General Internal Medicine, Mayo Clinic, 4500 San Pablo Rd S/ Davis 8, Jacksonville, FL 32224, United States of America.
    Affiliations
    Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, United States of America

    Mayo Clinic Women's Health, Rochester, MN, United States of America
    Search for articles by this author
  • Sheryl A. Kingsberg
    Affiliations
    Department of OBGYN, University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America
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  • Stephanie Faubion
    Affiliations
    Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, United States of America

    Mayo Clinic Women's Health, Rochester, MN, United States of America
    Search for articles by this author

      Highlights

      • Sexual dysfunction in female cancer survivors is prevalent yet underdiagnosed and undertreated.
      • Multiple direct and indirect factors can contribute to sexual dysfunction in female cancer survivors.
      • Clinicians should, at a minimum, be aware of the various potential treatment modalities, taking into account contributing physical, psychological and interpersonal factors.
      • Management of sexual health concerns should be individualized based on influencing factors.

      Abstract

      This narrative review examines current evidence regarding sexual function in female cancer survivors, focusing on the impact of cancer treatments as well as the evaluation and management of sexual concerns in this population. Sexual dysfunction in female cancer survivors is prevalent, yet underdiagnosed and undertreated. Many healthcare professionals feel ill-equipped to address the sexual health needs of female cancer survivors. Multiple direct and indirect factors can contribute to sexual dysfunction in female cancer survivors, including effects on the hormonal milieu and physical and sexual well-being. Factors influencing sexual function after cancer may be multifaceted, warranting a multidisciplinary approach to care. Validating and normalizing sexual health concerns and providing education and appropriate therapies, as well as timely referral to appropriate sexual health experts, are key to optimizing cancer survivorship care in women. Clinicians should, at a minimum, be aware of the various potential treatment modalities, taking into account contributing physical, psychological and interpersonal factors. Management of sexual health concerns should be individualized based on contributing factors.

      Keywords

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      References

        • Siegel R.L.
        • Miller K.D.
        • Fuchs H.E.
        • Jemal A.
        Cancer statistics, 2022.
        CA. Cancer J. Clin. 2022; 72: 7-33https://doi.org/10.3322/caac.21708
        • Dizon D.S.
        • Suzin D.
        • McIlvenna S.
        Sexual health as a survivorship issue for female cancer survivors.
        Oncologist. 2014; https://doi.org/10.1634/theoncologist.2013-0302
        • Melisko M.E.
        • Narus J.B.
        Sexual function in cancer survivors: updates to the NCCN guidelines for survivorship.
        JNCCN J. Natl. Compr. Cancer Netw. 2016; https://doi.org/10.6004/jnccn.2016.0193
        • Stabile C.
        • Goldfarb S.
        • Baser R.E.
        • Goldfrank D.J.
        • Abu-Rustum N.R.
        • Barakat R.R.
        • Dickler M.N.
        • Carter J.
        Sexual health needs and educational intervention preferences for women with cancer.
        Breast Cancer Res. Treat. 2017; https://doi.org/10.1007/s10549-017-4305-6
        • Krychman M.L.
        • Pereira L.
        • Carter J.
        • Amsterdam A.
        Sexual oncology: sexual health issues in women with cancer.
        Oncology. 2007; https://doi.org/10.1159/000100521
        • Basson R.
        Sexual function of women with chronic illness and cancer.
        Womens Health. 2010; https://doi.org/10.2217/whe.10.23
        • Park E.R.
        • Bober S.L.
        • Campbell E.G.
        • Recklitis C.J.
        • Kutner J.S.
        • Diller L.
        General internist communication about sexual function with cancer survivors.
        J. Gen. Intern. Med. 2009; https://doi.org/10.1007/s11606-009-1026-5
        • Krychman M.
        • Millheiser L.S.
        Sexual health issues in women with cancer.
        J. Sex. Med. 2013; https://doi.org/10.1111/jsm.12034
        • Ohsumi S.
        • Shimozuma K.
        • Kuroi K.
        • Ono M.
        • Imai H.
        Quality of life of breast cancer patients and types of surgery for breast cancer–current status and unresolved issues.
        Breast Cancer. 2007; https://doi.org/10.2325/jbcs.14.66
        • Janz N.K.
        • Mujahid M.
        • Lantz P.M.
        • Fagerlin A.
        • Salem B.
        • Morrow M.
        • Deapen D.
        • Katz S.J.
        Population-based study of the relationship of treatment and sociodemographics on quality of life for early stage breast cancer.
        Qual. Life Res. 2005; https://doi.org/10.1007/s11136-005-0288-6
        • Ganz P.A.
        • Anne Schag C.C.
        • Lee J.J.
        • Polinsky M.L.
        • Tan S.-J.
        Breast conservation versus mastectomy. Is there a difference in psychological adjustment or quality of life in the year after surgery?.
        Cancer. 1992; https://doi.org/10.1002/1097-0142(19920401)69:7<1729::AID-CNCR2820690714>3.0.CO;2-D
        • Onujiogu N.
        • Johnson T.
        • Seo S.
        • Mijal K.
        • Rash J.
        • Seaborne L.
        • Rose S.
        • Kushner D.M.
        Survivors of endometrial cancer: who is at risk for sexual dysfunction?.
        Gynecol. Oncol. 2011; https://doi.org/10.1016/j.ygyno.2011.07.035
        • Jensen P.T.
        • Groenvold M.
        • Klee M.C.
        • Thranov I.
        • Petersen M.A.
        • Machin D.
        Early-stage cervical carcinoma, radical hysterectomy, and sexual function: a longitudinal study.
        Cancer. 2004; https://doi.org/10.1002/cncr.11877
        • Maas C.P.
        • Ter Kuile M.M.
        • Laan E.
        • Tuijnman C.C.
        • Weijenborg P.T.M.
        • Trimbos J.B.
        • Kenter G.G.
        Objective assessment of sexual arousal in women with a history of hysterectomy.
        BJOG Int. J. Obstet. Gynaecol. 2004; https://doi.org/10.1111/j.1471-0528.2004.00104.x
        • Song T.
        • Choi C.H.
        • Lee Y.Y.
        • Kim T.J.
        • Lee J.W.
        • Kim B.G.
        • Bae D.S.
        Sexual function after surgery for early-stage cervical cancer: is there a difference in it according to the extent of surgical radicality?.
        J. Sex. Med. 2012; https://doi.org/10.1111/j.1743-6109.2012.02723.x
        • Modh R.A.
        • Mulhall J.P.
        • Gilbert S.M.
        Sexual dysfunction after cystectomy and urinary diversion.
        Nat. Rev. Urol. 2014; https://doi.org/10.1038/nrurol.2014.151
        • Krouse R.
        • Grant M.
        • Ferrell B.
        • Dean G.
        • Nelson R.
        • Chu D.
        Quality of life outcomes in 599 cancer and non-cancer patients with colostomies.
        J. Surg. Res. 2007; https://doi.org/10.1016/j.jss.2006.04.033
        • El-Bahnasawy M.S.
        • Osman Y.
        • El-Hefnawy A.
        • Hafez A.
        • Abdel-Latif M.
        • Mosbah A.
        • Ali-Eldin B.
        • Shaaban A.A.
        Radical cystectomy and urinary diversion in women: impact on sexual function.
        Scand. J. Urol. Nephrol. 2011; https://doi.org/10.3109/00365599.2011.585621
        • Baumgart J.
        • Nilsson K.
        • Evers A.S.
        • Kallak T.K.
        • Poromaa I.S.
        Sexual dysfunction in women on adjuvant endocrine therapy after breast cancer.
        Menopause. 2013; https://doi.org/10.1097/gme.0b013e31826560da
        • Crean-Tate K.K.
        • Faubion S.S.
        • Pederson H.J.
        • Vencill J.A.
        • Batur P.
        Management of genitourinary syndrome of menopause in female cancer patients: a focus on vaginal hormonal therapy.
        Am. J. Obstet. Gynecol. 2020; https://doi.org/10.1016/j.ajog.2019.08.043
        • Broeckel J.A.
        • Thors C.L.
        • Jacobsen P.B.
        • Small M.
        • Cox C.E.
        Sexual functioning in long-term breast cancer survivors treated with adjuvant chemotherapy.
        Breast Cancer Res. Treat. 2002; https://doi.org/10.1023/A:1019953027596
        • Damast S.
        • Jeffery D.D.
        • Son C.H.
        • Hasan Y.
        • Carter J.
        • Lindau S.T.
        • Jhingran A.
        Literature review of vaginal stenosis and dilator use in radiation oncology.
        Pract. Radiat. Oncol. 2019; https://doi.org/10.1016/j.prro.2019.07.001
        • Morris L.
        • Do V.
        • Chard J.
        • Brand A.H.
        Radiation-induced vaginal stenosis: current perspectives.
        Int. J. Women's Health. 2017; https://doi.org/10.2147/IJWH.S106796
        • Mirabeau-Beale K.
        • Hong T.S.
        • Niemierko A.
        • Ancukiewicz M.
        • Blaszkowsky L.S.
        • Crowley E.M.
        • Cusack J.C.
        • Drapek L.C.
        • Kovalchuk N.
        • Markowski M.
        • Napolitano B.
        • Nyamwanda J.
        • Ryan D.P.
        • Wolfgang J.
        • Kachnic L.A.
        • Wo J.Y.
        Clinical and treatment factors associated with vaginal stenosis after definitive chemoradiation for anal canal cancer.
        Pract. Radiat. Oncol. 2015; https://doi.org/10.1016/j.prro.2014.09.003
        • Kirchheiner K.
        • Nout R.A.
        • Lindegaard J.C.
        • Haie-Meder C.
        • Mahantshetty U.
        • Segedin B.
        • Jürgenliemk-Schulz I.M.
        • Hoskin P.J.
        • Rai B.
        • Dörr W.
        • Kirisits C.
        • Bentzen S.M.
        • Pötter R.
        • Tanderup K.
        Dose-effect relationship and risk factors for vaginal stenosis after definitive radio(chemo)therapy with image-guided brachytherapy for locally advanced cervical cancer in the EMBRACE study.
        Radiother. Oncol. 2016; https://doi.org/10.1016/j.radonc.2015.12.025
        • Yi J.C.
        • Syrjala K.L.
        Anxiety and depression in cancer survivors.
        Med. Clin. N. Am. 2017; https://doi.org/10.1016/j.mcna.2017.06.005
        • Howard-Anderson J.
        • Ganz P.A.
        • Bower J.E.
        • Stanton A.L.
        Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review.
        J. Natl. Cancer Inst. 2012; https://doi.org/10.1093/jnci/djr541
        • Hungr C.
        • Bober S.
        Sexual health and body image after breast cancer.
        Breast Cancer Young Women. 2020; https://doi.org/10.1007/978-3-030-24762-1_14
        • Goerling U.
        • Bergelt C.
        • Müller V.
        • Mehnert-Theuerkauf A.
        Psychosocial distress in women with breast cancer and their partners and its impact on supportive care needs in partners.
        Front. Psychol. 2020; https://doi.org/10.3389/fpsyg.2020.564079
        • Hawkins Y.
        • Ussher J.
        • Gilbert E.
        • Perz J.
        • Sandoval M.
        • Sundquist K.
        Changes in sexuality and intimacy after the diagnosis and treatment of cancer.
        Cancer Nurs. 2009; https://doi.org/10.1097/ncc.0b013e31819b5a93
        • Reese J.B.
        • Porter L.S.
        • Regan K.R.
        • Keefe F.J.
        • Azad N.S.
        • Diaz L.A.
        • Herman J.M.
        • Haythornthwaite J.A.
        A randomized pilot trial of a telephone-based couples intervention for physical intimacy and sexual concerns in colorectal cancer.
        Psychooncology. 2014; https://doi.org/10.1002/pon.3508
        • Lemieux J.
        • Maunsell E.
        • Provencher L.
        Chemotherapy-induced alopecia and effects on quality of life among women with breast cancer: a literature review.
        Psychooncology. 2008; https://doi.org/10.1002/pon.1245
        • Park E.R.
        • Norris R.L.
        • Bober S.L.
        Sexual health communication during cancer care. Barriers and recommendations.
        Cancer J. 2009; https://doi.org/10.1097/PPO.0b013e31819587dc
        • Wazqar D.Y.
        Sexual health care in cancer patients: a survey of healthcare providers’ knowledge, attitudes and barriers.
        J. Clin. Nurs. 2020; https://doi.org/10.1111/jocn.15459
        • Clayton A.H.
        • Goldstein I.
        • Kim N.N.
        • Althof S.E.
        • Faubion S.S.
        • Faught B.M.
        • Parish S.J.
        • Simon J.A.
        • Vignozzi L.
        • Christiansen K.
        • Davis S.R.
        • Freedman M.A.
        • Kingsberg S.A.
        • Kirana P.S.
        • Larkin L.
        • McCabe M.
        • Sadovsky R.
        The International Society for the Study of Women’s sexual health process of Care for Management of hypoactive sexual desire disorder in women.
        Mayo Clin. Proc. 2018; https://doi.org/10.1016/j.mayocp.2017.11.002
        • Rosen R.
        • Brown C.
        • Heiman J.
        • Leiblum S.
        • Meston C.
        • Shabsigh R.
        • Ferguson D.
        • D’Agostino R.
        The female sexual function index (Fsfi): a multidimensional self-report instrument for the assessment of female sexual function.
        J. Sex Marital Ther. 2000; https://doi.org/10.1080/009262300278597
        • Isidori A.M.
        • Pozza C.
        • Esposito K.
        • Giugliano D.
        • Morano S.
        • Vignozzi L.
        • Corona G.
        • Lenzi A.
        • Jannini E.A.
        Development and validation of a 6-item version of the female sexual function index (FSFI) as a diagnostic tool for female sexual dysfunction.
        J. Sex. Med. 2010; https://doi.org/10.1111/j.1743-6109.2009.01635.x
        • Bartula I.
        • Sherman K.A.
        Development and validation of the female sexual function index adaptation for breast cancer patients (FSFI-BC).
        Breast Cancer Res. Treat. 2015; https://doi.org/10.1007/s10549-015-3499-8
        • Derogatis L.R.
        • Revicki D.A.
        • Rosen R.C.
        • Jordan R.
        • Lucas J.
        • Spana C.
        Psychometric validation of the female sexual distress scale-desire/arousal/orgasm.
        J. Patient-Reported Outcomes. 2021; https://doi.org/10.1186/s41687-021-00359-1
        • Derogatis L.
        • Clayton A.
        • Lewis-D’agostino D.
        • Wunderlich G.
        • Fu Y.
        Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder.
        J. Sex. Med. 2008; https://doi.org/10.1111/j.1743-6109.2007.00672.x
        • Hopwood P.
        • Fletcher I.
        • Lee A.
        • Al Ghazal S.
        A body image scale for use with cancer patients.
        Eur. J. Cancer. 2001; 37: 189-197https://doi.org/10.1016/S0959-8049(00)00353-1
        • Walker L.M.
        • Hampton A.
        • Robinson J.W.
        Assessment of relational intimacy: factor analysis of the personal assessment of intimacy in relationships questionnaire.
        Psychooncology. 2014; 23: 346-349https://doi.org/10.1002/pon.3416
        • Anderson S.R.
        • Tambling R.B.
        • Huff S.C.
        • Heafner J.
        • Johnson L.N.
        • Ketring S.A.
        The development of a reliable change index and cutoff for the revised dyadic adjustment scale.
        J. Marital. Fam. Ther. 2014; 40: 525-534https://doi.org/10.1111/jmft.12095
        • Perz J.
        • Ussher J.M.
        • Gilbert E.
        Constructions of sex and intimacy after cancer: Q methodology study of people with cancer, their partners, and health professionals.
        BMC Cancer. 2013; https://doi.org/10.1186/1471-2407-13-270
        • Bygdeman M.
        • Swahn M.L.
        Replens versus dienoestrol cream in the symptomatic treatment of vaginal atrophy in postmenopausal women.
        Maturitas. 1996; https://doi.org/10.1016/0378-5122(95)00955-8
        • Mitchell C.M.
        • Reed S.D.
        • Diem S.
        • Larson J.C.
        • Newton K.M.
        • Ensrud K.E.
        • LaCroix A.Z.
        • Caan B.
        • Guthrie K.A.
        Efficacy of vaginal estradiol or vaginal moisturizer vs placebo for treating postmenopausal vulvovaginal symptoms a randomized clinical trial.
        JAMA Intern. Med. 2018; https://doi.org/10.1001/jamainternmed.2018.0116
        • Goetsch M.F.
        • Lim J.Y.
        • Caughey A.B.
        A practical solution for dyspareunia in breast cancer survivors: a randomized controlled trial.
        J. Clin. Oncol. 2015; https://doi.org/10.1200/JCO.2014.60.7366
        • Sokol E.R.
        • Karram M.M.
        Use of a novel fractional CO2 laser for the treatment of genitourinary syndrome of menopause: 1-year outcomes.
        Menopause. 2017; https://doi.org/10.1097/GME.0000000000000839
        • Quick A.M.
        • Hundley A.
        • Evans C.
        • Stephens J.A.
        • Ramaswamy B.
        • Reinbolt R.E.
        • Noonan A.M.
        • Van Deusen J.B.
        • Wesolowski R.
        • Stover D.G.
        • Williams N.O.
        • Sardesai S.D.
        • Faubion S.S.
        • Loprinzi C.L.
        • Lustberg M.B.
        Long-term follow-up of fractional CO2 laser therapy for genitourinary syndrome of menopause in breast cancer survivors.
        J. Clin. Med. 2022; https://doi.org/10.3390/jcm11030774
        • Gordon C.
        • Gonzales S.
        • Krychman M.L.
        Rethinking the techno vagina: a case series of patient complications following vaginal laser treatment for atrophy.
        Menopause. 2019; https://doi.org/10.1097/GME.0000000000001293
        • Faubion S.S.
        • Shuster L.T.
        • Bharucha A.E.
        Recognition and management of nonrelaxing pelvic floor dysfunction.
        Mayo Clin. Proc. 2012; https://doi.org/10.1016/j.mayocp.2011.09.004
        • Smith T.
        • Sahni S.
        • Thacker H.L.
        Postmenopausal hormone therapy—local and systemic: a pharmacologic perspective.
        J. Clin. Pharmacol. 2020; https://doi.org/10.1002/jcph.1740
        • Crandall C.J.
        • Hovey K.M.
        • Andrews C.A.
        • Chlebowski R.T.
        • Stefanick M.L.
        • Lane D.S.
        • Shifren J.
        • Chen C.
        • Kaunitz A.M.
        • Cauley J.A.
        • Manson J.E.
        Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the women’s health initiative observational study.
        Menopause. 2018; https://doi.org/10.1097/GME.0000000000000956
        • Bhupathiraju S.N.
        • Grodstein F.
        • Stampfer M.J.
        • Willett W.C.
        • Crandall C.J.
        • Shifren J.L.
        • Manson J.A.E.
        Vaginal estrogen use and chronic disease risk in the nurses’ health study.
        Menopause. 2019; 26: 603-610https://doi.org/10.1097/GME.0000000000001284
        • Ponzone R.
        • Biglia N.
        • Jacomuzzi M.E.
        • Maggiorotto F.
        • Mariani L.
        • Sismondi P.
        Vaginal oestrogen therapy after breast cancer: is it safe?.
        Eur. J. Cancer. 2005; https://doi.org/10.1016/j.ejca.2005.07.015
        • Faubion S.S.
        • Larkin L.C.
        • Stuenkel C.A.
        • Bachmann G.A.
        • Chism L.A.
        • Kagan R.
        • Kaunitz A.M.
        • Krychman M.L.
        • Parish S.J.
        • Partridge A.H.
        • Pinkerton J.V.
        • Rowen T.S.
        • Shapiro M.
        • Simon J.A.
        • Goldfarb S.B.
        • Kingsberg S.A.
        Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer.
        Menopause. 2018; 25: 596-608
        • de Villiers T.J.
        • Altomare C.
        • Particco M.
        • Gambacciani M.
        Effects of ospemifene on bone in postmenopausal women.
        Climacteric. 2019; : 1-6https://doi.org/10.1080/13697137.2019.1631789
        • Wurz G.T.
        • Read K.C.
        • Marchisano-Karpman C.
        • Gregg J.P.
        • Beckett L.A.
        • Yu Q.
        • DeGregorio M.W.
        Ospemifene inhibits the growth of dimethylbenzanthracene-induced mammary tumors in sencar mice.
        J. Steroid Biochem. Mol. Biol. 2005; https://doi.org/10.1016/j.jsbmb.2005.06.027
        • Archer D.F.
        • Goldstein S.R.
        • Simon J.A.
        • Waldbaum A.S.
        • Sussman S.A.
        • Altomare C.
        • Zhu J.
        • Yoshida Y.
        • Schaffer S.
        • Soulban G.
        Efficacy and safety of ospemifene in postmenopausal women with moderate-to-severe vaginal dryness.
        Menopause. 2019; https://doi.org/10.1097/gme.0000000000001292
        • Goldstein S.R.
        • Bachmann G.A.
        • Koninckx P.R.
        • Lin V.H.
        • Portman D.J.
        • Ylikorkala O.
        Ospemifene 12-month safety and efficacy in postmenopausal women with vulvar and vaginal atrophy.
        Climacteric. 2014; https://doi.org/10.3109/13697137.2013.834493
        • Labrie F.
        • Archer D.F.
        • Koltun W.
        • Vachon A.
        • Young D.
        • Frenette L.
        • Portman D.
        • Montesino M.
        • Côté I.
        • Parent J.
        • Lavoie L.
        • Beauregard A.
        • Martel C.
        • Vaillancourt M.
        • Balser J.
        • Moyneur É.
        Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause.
        Menopause. 2018; https://doi.org/10.1097/GME.0000000000001238
        • Bouchard C.
        • Labrie F.
        • DeRogatis L.
        • Girard G.
        • Ayotte N.
        • Gallagher J.
        • Cusan L.
        • Archer D.F.
        • Portman D.
        • Lavoie L.
        • Beauregard A.
        • Côte I.
        • Martel C.
        • Vaillancourt M.
        • Balser J.
        • Moyneur E.
        Effect of intravaginal dehydroepiandrosterone (DHEA) on the female sexual function in postmenopausal women: ERC-230 open-label study.
        Horm. Mol. Biol. Clin. Investig. 2016; https://doi.org/10.1515/hmbci-2015-0044
        • Labrie F.
        • Martel C.
        • Bérubé R.
        • Côté I.
        • Labrie C.
        • Cusan L.
        • Gomez J.L.
        Intravaginal prasterone (DHEA) provides local action without clinically significant changes in serum concentrations of estrogens or androgens.
        J. Steroid Biochem. Mol. Biol. 2013; https://doi.org/10.1016/j.jsbmb.2013.08.002
        • Barton D.L.
        • Sloan J.A.
        • Shuster L.T.
        • Gill P.
        • Griffin P.
        • Flynn K.
        • Terstriep S.A.
        • Rana F.N.
        • Dockter T.
        • Atherton P.J.
        • Tsai M.
        • Sturtz K.
        • Lafky J.M.
        • Riepl M.
        • Thielen J.
        • Loprinzi C.L.
        Evaluating the efficacy of vaginal dehydroepiandosterone for vaginal symptoms in postmenopausal cancer survivors: NCCTG N10C1 (Alliance).
        Support Care Cancer. 2018; https://doi.org/10.1007/s00520-017-3878-2
        • Barton D.L.
        • Shuster L.T.
        • Dockter T.
        • Atherton P.J.
        • Thielen J.
        • Birrell S.N.
        • Sood R.
        • Griffin P.
        • Terstriep S.A.
        • Mattar B.
        • Lafky J.M.
        • Loprinzi C.L.
        Systemic and local effects of vaginal dehydroepiandrosterone (DHEA): NCCTG N10C1 (Alliance).
        Support Care Cancer. 2018; https://doi.org/10.1007/s00520-017-3960-9
        • Simon J.A.
        • Kingsberg S.A.
        • Shumel B.
        • Hanes V.
        • Garcia M.
        • Sand M.
        Efficacy and safety of flibanserin in postmenopausal women with hypoactive sexual desire disorder: results of the SNOWDROP trial.
        Menopause. 2014; https://doi.org/10.1097/GME.0000000000000134
        • Kingsberg S.A.
        • Clayton A.H.
        • Portman D.
        • Williams L.A.
        • Krop J.
        • Jordan R.
        • Lucas J.
        • Simon J.A.
        Bremelanotide for the treatment of hypoactive sexual desire disorder.
        Obstet. Gynecol. 2019; https://doi.org/10.1097/aog.0000000000003500
        • Titchener J.L.
        Human sexual inadequacy.
        in: Masters W.H. Johnson V.E. Little, Brown, Boston. Teratology. 487. 1971: 1970https://doi.org/10.1002/tera.1420040411