Sexual health after a breast cancer diagnosis

Transcript

Kristin Rojas, MD, FACS, FACOG (00:00:10):

So I am originally a gynecologist, and then I crossed over into the breast surgical oncology world. And when I was a fellow, which is the very, very last year of your training, in New York, I would follow my boss around and patients … I don’t know if patients had looked me up and saw that I was a former gynecologist or because we were women and my boss was a man, but I always ended up staying behind and chatting with patients. And they’d be like, “OK, but this pill is actually doing this. What do I do about this?” And so I’d say, “Let’s chat.”

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Then I realized that we should probably have a home for these symptoms — its own clinic, its own space — because the treatment of issues with sexual health during and after cancer treatment is your cancer treatment. That is a core component. For a long time it’s been a really taboo topic, but menopause is having a moment. So finally we’re allowed to say it out loud.

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I’m so thrilled to be here. Thank you to Living Beyond Breast Cancer for having me and for giving some time to this discussion.

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You might hear me say some brand names and talk about different devices, but I don’t have any financial disclosures. I’m going to hit all the major topics today. We’re going to talk about menopause symptoms, hot flashes, vaginal dryness, painful sex. I’m going to go there with vaginal hormones. I’m going to tell you exactly what you need to know. We’ll talk a little bit about systemic hormones, which is where your whole body gets them. The safety of all of these things with different treatments. We’re also going to talk about devices and new things out there. And then also a shout out to the partners and caregivers. Please don’t leave. I promise not to make you too uncomfortable. And thank you for being here.

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I’m also going to talk about desire, which is a really tough topic historically, but we actually have a lot of new treatments out there and so I’m going to talk about those things.

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When I started this program, it was originally called MUSIC. I was in Brooklyn, New York, at a very conservative hospital, and I was like, OK, we can’t call it the sex clinic because not everyone’s going to want to come. But what’s so wrong with MUSIC? No one hates music. And so it was called Menopause Urogenital Sexual Health and Intimacy Clinic. And now that I’m in Houston, it’s called OASIS, Oncomenopause and Intimacy Specialist. But since most of our patients actually present with vaginal dryness, a bunch of people have been like, “It’s a little on the nose, the OASIS part.” But now that we’re very busy, I like to say that I’m drowning in the OASIS, but actually I’m really happy to have this part of my practice.

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What we’ve done, both online and in person, is we’ve tried to get a sense of what are the biggest problems that our patients are facing. It’s not just vaginal dryness and painful sex. It’s problems with orgasm that we never talked about before. It’s low desire. It’s body image. And 1 in 4 women or patients that we examine in the program, because I tell patients it’s like a super subspecialized GYN visit. Most patients have vaginal dryness and painful sex, so we usually end up doing an exam, a pelvic exam. And what we found is that patients who are on a lot of these medications for a long period of time who haven’t been treated actually have narrowing and shortening of the vagina. So telling someone, “Oh, here’s a lubricant.” And I’ve heard patients tell me they’ve been told if you don’t use it, you’ll lose it. Things like that. That’s just not going to cut it. And so we’ve actually seen what’s going on with our patients on treatment, especially now that we have new therapies like immunotherapies. Of course, no one has studied what they’re doing to the vagina.

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I’m also going to say vagina a lot today.

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So now we’re going to start talking about them. For those of you with estrogen receptor-positive breast cancer, you all know about estrogen-blocking medications. They decrease the risk of recurrence in patients with early-stage disease. And for patients with stage IV disease, they keep the disease stable. However, whether patients are able to continue taking these medications because of these side effects is a big deal. We know that patients don’t always tell us if they’re not taking these medications because, I don’t know, they don’t want to hurt our feelings. But I want to encourage you all to really speak up because there are things that we can do about this and there are also other medications to try. You heard my colleague, Dr. Teplinsky talking about oral SERDs today. It’s very exciting. Some of these drugs have better side effect profiles. But if we don’t talk about it, our doctors aren’t going to know what to do, and the pharmaceutical industry isn’t going to respond with medications with a better side effect profile.

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But this is not just for patients with ER-positive breast cancer. Patients with estrogen receptor-negative breast cancer that’s not responsive to hormones also have these issues. These issues can show up after chemotherapy. They can show up after radiation. Some of the issues with desire could be not only biological with the drop in hormone but also all of the trauma and all of the stress going on with us poking you with a million needles and bringing you to the OR and then giving you chemotherapy.

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So first let’s start with menopause symptoms and hot flashes. Chemotherapy, ovarian suppression shots, which are the medications that hide your ovaries away from whatever treatment we’re giving you. And then some patients even have their ovaries removed. We have the medications that block hormones. And even patients who are on systemic HRT and then are diagnosed and have to stop abruptly can experience these symptoms and they’re not gradual as the usual menopause transition is. They can sometimes be very abrupt. So this results in hot flashes, joint pains, mood changes, and vaginal dryness and painful sex. It can happen at any age, often more suddenly from these treatments as well.

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There are options that are not pharmacological. Most of us have heard these: dress in layers, keep the bedroom cool. There’s actually special sheets for people with night sweats, special mattresses. There’s a lot to do here. We know that exercise can help. My patients tell me if they exercise in the morning and sweat it out, they’re less likely to have hot flashes during the day.

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You want to know what your triggers are, whether it’s spicy food, chocolate, red wine, everyone’s different. And we know that cognitive behavioral therapy and acupuncture have solid evidence. They’re probably not going to take the hot flashes completely away, but they will make them less noticeable.

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You do want to save your money though, and that’s soy supplements and evening primrose oil, ginseng, and other menopause supplements. Remember how I said menopause is having a moment? Every supplement, just like pink washing, there’s menopause washing. Every supplement or non-FDA approved therapy that’s being marketed to menopausal patients doesn’t necessarily mean that it’s effective. And these things have really little data for these types of symptoms.

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So what can you take that are nonhormonal medications? You can take a very low dose of an antidepressant. Venlafaxine is probably the one with the best evidence, the most effective. A lot of my patients shy away from this. They’re like, “Oh no, I don’t want to take an antidepressant.” I’m like, this does not have to be forever. You may need a little extra brain chemical support during this time while we’re doing all these things to you. It also functions specifically in your brain’s thermometer, kind of turns the volume down on the hot flashes, can help with sleep, it can help with anxiety, but it’s usually a really, really low dose. And if it doesn’t work, we’ll stop it and we’ll try something else.

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Oxybutynin is actually a bladder medication that was FDA approved a long time ago, so it’s actually very available, but they did a randomized controlled trial and showed that it actually significantly decreases the frequency and severity of hot flashes. And we use this a lot in our OASIS program. It’s very effective because a lot of my patients present with urinary urgency, or overactive bladder as we call it. So this medication can actually treat both.

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Gabapentin is an older drug, but I’d caution with sedation. Some people can get very, very sleepy. Gabapentin’s most effective at higher doses. It can also treat neuropathy, but just make sure you’re getting on and off gabapentin under the advisement of your doctor because usually we like to slowly titrate you up and not give you a big dose because you’ll be very sleepy.

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So what about hormone pills or patches? After breast cancer, systemic hormones, meaning a patch you put on your body, a pill you take by mouth, doesn’t matter if your tumor or cancer was estrogen receptor positive or negative, for right now, our overwhelming guidelines, according to ASCO, even with the black box being removed from a lot of these products, is that they should not be the first-line treatment for our patients with breast cancer. However, we need to start with nonhormonal options, and I think that over the next couple years this is going to change because we know not all hormone treatments are the same and there are some that can actually decrease activity in the breast and we might be able to use them in patients as HRT.

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We do need to start with nonhormonal options first, but I do have a couple of patients who they finished their primary treatment because that’s the most important thing is that you get the treatment that we know is going to decrease your risk of recurrence or treat your breast cancer. And they might be several years out, still younger than the natural age of menopause, and they want to know: Why can’t I take these hormones? So it’s a very complicated discussion.

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If you’ve talked to your doctor and they wrote you off, you can also speak to a Menopause Society-certified practitioner, which you can find on the Menopause Society. So build your little multidisciplinary team to kind of come up with, OK, this isn’t working, what’s the next step?

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But it’s important to know for daughters, sisters, friends, overwhelmingly the systemic menopausal hormone therapy, what we used to call HRT, is safe. Barring any other absolute contraindications, patients around the age of natural menopause or who have gone through menopause within 10 years, FDA-approved therapies. We typically think of these as safe, even if you have a family history of breast cancer or have had a benign breast biopsy before.

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Moving on to dryness and painful sex. So low estrogen or estrogen-blocking medications can cause not just dryness, but also change in the architecture of the vagina. So the vagina, which is the internal part and the vulva externally, so they can become less stretchy, which results in painful sex. Sometimes patients report they feel this feeling of paper cuts or knives and that’s from the lack of stretchiness. And the vagina was made to be stretchy, that’s how babies are born. And so you lose some of that when the estrogen goes low because those tissues are really sensitive to those drops in estrogen.

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All the things that go along with this, dryness, painful sex, recurrent bladder infections are called genitourinary syndrome of menopause or GSM. We don’t say vaginal atrophy anymore, thank the Lord. But now we call it GSM, which I’m not sure is better. Sorry.

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Important to know: It’s treatable. We developed four easy steps to addressing dryness and painful sex. Number 1, skipping irritants. Who’s heard of the gut microbiome? My nutrition colleague was talking about it earlier. Great. Your vagina also has one, and I’ll tell you a little bit about it. But there are some things that we do that can actually wreck the vaginal microbiome, and that causes burning and stinging. So that combined with the estrogen-blocking medications can start this cycle of burning and stinging that’s hard to treat, but we can fix it.

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The second step is moisturize. So just like you have your skin-care regimen before you go to bed at night, your under-eye cream, think about it the same way. So you’re going to plan to moisturize the vulva, the vagina in some way, and I’ll tell you how, at least three times a week. And that’s on days you don’t plan sexual activity.

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Lubricants are for anything going in the vagina, no matter what that is, whether it’s a device or during sexual activity. And we’re not going to forget about the pelvic floor, which I’ll tell you more about.

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So steps 1 and 2. The first thing we usually do in our program is talk about everything that’s touching those delicate tissues. What about artificial fragrances and the detergent you wash your underwear? Is your toilet paper really fragrant? Is there formaldehyde in your toilet paper? Are you sitting in a bathtub full of bath bombs with glitter? All these things with artificial fragrance can affect the vaginal microbiome. Just because it says it’s gentle or safe for babies does not mean that it’s OK for that area, especially if you’re on estrogen-lowering medications.

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I tell patients the hair-bearing area, you wash like the rest of your body, but the area without hair, we typically don’t use these products with artificial fragrances. And if you go in the supermarket, there’s an entire aisle dedicated to this. So a lot of times we end up undoing a lot of those practices, kind of reset, and bring the good bacteria back to the vaginal microbiome because the microbiome is a balance of good and bad bacteria.

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Number 2 is moisturize. So we like to start with a hyaluronic acid suppository. There are some brand name ones out there that are quite pricey. There’s also some versions on Amazon with the same ingredients. So all you have to do is look up hyaluronic acid suppository. And so we use those three times a week, and we like to improve the tissue quality of that area before we think about the next step.

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If you experience burning and stinging, we love to start with single-ingredient organic coconut oil, same stuff you get at Trader Joe’s, solid at room temperature. You just want to make sure it’s the only ingredient. This functions to protect the vulva and the vagina, so burning and stinging, it protects it from acidic urine, from whatever products you might be exposed to, helps kind of calm down the tissue so that we can start our vaginal moisturization regimen.

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But there’s a lot of endocrine disruptors in feminine hygiene products. So that supermarket aisle that I told you about, a lot of the ingredients in these products are actually illegal in Europe, but we don’t have the same kinds of regulatory standards here. They’ve been tied to things like cervical cancer, ovarian cancer. These “washes,” “feminine washes,” as we call them now, should not be placed in the vagina. They contain chemicals called phthalates, and phthalates are shown to be excreted in your urine when you urinate. They’re floating around your body affecting the rest of your body. And we know that certain patients have higher levels of phthalates in their urine and they’re set up for worse outcomes.

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Vaginal hormones, it should not be a hard no, but a conversation. So I’m going to give you the tools to bring to your oncologist if you think that this is the right next step for you.

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Remember, vaginal hormones is different from systemic hormones. So systemic hormones, we get in a pill or a patch, your whole body sees them. Vaginal hormones function locally. We give small doses right there to the tissues of the vulva and the vagina, and we do certain things in the OASIS program to limit the amount of hormone that gets absorbed into your bloodstream.

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They come in a couple different formats. It’s a cream, an ultralow dose tablet, or a ring. We have really, really low doses that are very different from the studies that we did in the past that show that the estrogen levels in a person’s blood went up when they use these products. So much, much lower doses.

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So we have low dose vaginal estrogen, which comes in a couple different formats, but we also have vaginal DHEA. Who’s heard of DHEA? OK. It’s like a cousin of testosterone. In the vagina, it’s a tablet. It actually functions like estrogen. It works locally. It diffuses from cell to cell and then it’s deactivated before it’s released into the bloodstream. And we actually have a study for patients on aromatase inhibitors, that’s patients on letrozole, anastrozole, or exemestane who used vaginal DHEA, which is FDA approved for painful sex. They did not have absorption of estrogen into their bloodstream. So for patients on tamoxifen, we say tamoxifen functions like a shield, blocking your breast from any estrogen floating around your body. So patients on tamoxifen, it should never — I don’t want to say never because I don’t want to contradict anyone’s doctor. It’s almost never a hard no for vaginal hormones because it doesn’t even matter if any is absorbed in your body. We give tamoxifen to patients whose ovaries are still working. They have very high levels of estrogen floating around and tamoxifen is still effective.

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Aromatase inhibitors rely on the level of estrogen being very, very low. So that’s when oncologists might get a little more sensitive about the idea of absorption of estrogen into the blood. But we have this study showing that vaginal DHEA works well for those patients.

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In order to limit absorption, what we do first is we treat with the nonhormonal moisturizer, the coconut oil, hyaluronic acid. We do that for a few weeks. We’re improving the tissues in the vagina and the vulva. We’re keeping them from being so thin, and then we add a vaginal hormone. And we might add it once a week and then increase to twice a week. And we think that that really limits the risk of estrogen getting into your bloodstream.

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So it’s all done very thoughtfully, low dose, and we start with nonhormonal options because usually when used consistently, patients do get better.

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What does the evidence say about vaginal hormones? There’s no reliable evidence that vaginal estrogen increases the risk of recurrence. There is a very controversial study that came out in 2022 that actually overall showed that it doesn’t increase the risk of recurrence, but then the researchers went back and looked at just the patients on aromatase inhibitors and they said, “We think we see an increased risk in recurrence in these patients.” But hopefully some of you know, especially from some of the other great talks today, that there’s good science and then there’s not so great science. So the cohort of patients studied in this study were from a very long time ago, predating before we used Herceptin. Most of the patients in that study weren’t taking endocrine therapy. And so it really doesn’t mirror how we treat our patients today and what their risk of recurrence is. Most experts agree that that data does not apply.

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We also have a more recent study showing that breast cancer-specific mortality is lower in patients who get vaginal estrogen. Why might that happen? Well, if we actually treat patients’ sexual side effects, they’re probably going to take the medications that decrease the risk of recurrence. ACOG supports this, the Menopause Society, the American Society of Clinical Oncology. And we start with our nonhormonal moisturizer, we improve the tissues, and then we slowly add once a week vaginal hormone and then twice a week. If you read the old labels on some of these vaginal estrogen products, it’ll tell you every night for 2 weeks and then twice a week. We don’t do that. That’s how you see the bumps in the estrogen. If you’re giving it to someone every night, we know the levels of estrogen and your blood are going to go up. So we do once a week, increase it to twice a week. Think of it as an on-ramp.

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However, not all these products are the same. Bioidentical is a marketing term. The FDA made estradiol is also bioidentical. We just don’t call it that. However, compounded therapies, so medications that are creams, someone does your blood levels, which by the way, most of the time we don’t need to be doing estrogen or testosterone blood levels because they vary significantly throughout the day. So any menopause expert, we typically don’t even need to measure those levels. But if you’ve got someone measuring those levels and they create a special recipe for you and you take it to the compounding pharmacy, we actually don’t know that that concoction has what you think it has in it. And they’ve actually done studies where they send those to the lab and they look and it doesn’t have what you think it has in it and it doesn’t have it in the amount that you think it has.

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So we really like to stick, especially for our patients with a history of cancer with FDA-approved therapies because we know the dose, we know how it’s going to react in your body, and we know what the levels are going to be.

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They’ve even done studies looking at this, specifically pelleted hormone therapies and the levels of estrogen or testosterone go really, really high in these patients, and it’s very unreliable. You can get irreversible side effects and we have no idea what that does from a cancer perspective.

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So that is my soapbox. I only have like four more soapboxes for this talk, so stay. All right.

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Next, step 3. Remember, number 1 is eliminate irritants. Two is moisturize. Three is lubricate. Anything that’s going to go in the vagina, you want to be very slippery. So these products have different qualities than our moisturizers. They’re going to be very slippery because less friction equals less pain. We like to start with a silicone-based lubricant. All my patients are like, “Oh, I can’t use silicone based.” Who started this rumor about silicone-based lubricants? They actually oftentimes have vitamin E, and there’s some really good brands that don’t have parabens or preservatives. They last longer, and for patients with vaginal dryness, they’re usually better because water-based lubricants can make vaginal dryness worse. However, one caveat, if you’re using a silicone device, you do want to use a water-based lubricant because silicone devices and silicone lubricants don’t go together usually.

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Some patients use oil-based lubricants as well, like coconut oil. There’s even a study using olive oil for the Italians in the room. However, important to know that if you’re using latex condoms, oils will degrade latex, so if you’re depending on condoms for STD or pregnancy protection.

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You want to make sure you’re reading the labels. Why? Because we are skipping irritants. So you want to avoid glycerin, parabens, preservatives. Anything that’s warming or scented or has a taste, not for you.

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Step 4, address the pelvic floor. So who’s heard of the pelvic floor? OK, fabulous. Not everyone. So I have some key audience here. The pelvic floor is like a basket of muscles at the bottom of your pelvis. It’s interwoven muscles. And when you have painful sex, when you think about sex in the future, those muscles are going to spasm without you even thinking about it. When those muscles are tight and you try to have sex again, it’s going to create more pain. OK?

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So who’s heard of Kegels? OK, guess what? I’m a doctor and you probably shouldn’t be doing Kegels. This is the patriarchy. So most people actually need to relax the pelvic floor and not tighten the pelvic floor. “How do you relax the pelvic floor?” you say. Well, I have a trick. Other than pelvic floor physical therapists and dilators. So first of all, if you do a lot of Pilates, my patients that do a lot of Pilates, very, very contracted pelvic floors. A lot of core strength, but oftentimes we need to get them to relax the pelvic floor. The more you can relax the pelvic floor, which you can do in different ways, which I’ll elaborate on, the less painful sex will be. So if you take your fingers, we’re going to do a demonstration, and this is totally PG, I promise. So take your fingers and point to your hip bone and then point to your knee and you’re going to take your fingers and put them halfway in between. Right here. So if you can put your fingers there and your inner thigh muscle is relaxed, if you focus on relaxing that muscle, your pelvis is relaxed. You’re welcome.

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I’m just kidding. There’s other things too.

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So no Kegels for you. The only people that should be Kegeling are people that leak urine with coughing and sneezing. And for those people, we say Kegel before you cough and you sneeze. I’m serious. That’s really serious.

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All right. So vaginal dilators. These look scary, but they’re not, I promise. So you can get these medical devices online or from your pelvic physical therapist, and they start small and you work your way up. They do two things. Number 1, they gently stretch the tissues for patients who’ve had vaginal dryness for a long time where the vagina might be a little bit more narrow, but they also help retrain your brain if sex has been stressing you out. These dilators are really helpful if you haven’t had sexual activity in a while because you put the lubricant on, quiet time, listen to a meditation podcast, you place the dilator, and you do that exercise where you think about relaxing your inner thigh muscles and relax your muscles around the dilator.

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This is really important. It’s a great exercise to try before sexual activity.

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If you’re not sexually active, I highly recommend using a dilator on your own time when it’s not game time before getting back in the swing of things.

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All right. Next is where it gets spicy. So you guys have waited all day for this. These are medical devices. We call them vibratory arousal aids, according to the American College of OB-GYNs. Vibratory devices increase blood flow. They increase natural lubrication. They relax the pelvic floor muscles. They can be used internally or externally. This is 2026. There’s all kinds of devices out there, and I’m going to show you. Two is dilators like we just discussed, but there’s also something called collision dyspareunia aids. And this is essentially bumpers that go around the penis and limit the depth of penetration — the penis or anything going in the vagina. And that’s why this company called Ohnut, I’ll show you, which you can see in the bottom right there.

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So if you’re someone who’s had a hysterectomy or you feel like you have pain with deeper penetration during sexual activity, the Ohnut is a great tool because you can stack these rings and it limits the depth of penetration.

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Also, pillows and wedges. There’s really all kinds of things out there, especially if you’re having hip pain, back pain, history of lymphedema. If you need to change positions, these can be really helpful.

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There’s all kinds of devices out there. There’s devices that are body adaptive, and these are for a medical reason. So how do you bring these things up? Sex isn’t just about penetration. Intimacy isn’t just about that either. You want to talk about these things outside of the bedroom if you’re going to talk about it with your partner. These are great for solo play, but you can also incorporate them into sexual activity.

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I like to tell patients to have these conversations outside the bedroom, when it’s not game time. You want to keep the conversation simple. If you’re someone, and you’ve just started dating someone and you’re having a history of painful sex or another thing we call vestibulodynia, keep it fact based. See how they respond. If they don’t respond in a way that makes sense to you, maybe they’re not worth your time.

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And you want to frame this as an opportunity for sexual creativity. These are tools, not replacements, and no one needs to be threatened by them. We have some devices that can actually bend different shapes, some devices with handles if you have wrist arthritis. You have external devices that are just vibrating externally to increase that blood flow and it’s good for nerve regrowth. And then you have suction devices, the Ohnut. And then if you go to the Ohnut website, they also have a device for external stimulation called the Kiwi. So there’s all kinds of things out there. You just want to make sure you choose a product that has high-quality silicone or nonporous silicone, and then check the device website for what kind of lubricant you should use with it.

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Let’s do an example. A 55-year-old patient had a lumpectomy, radiation. She started on her aromatase inhibitor and I, the busy breast surgeon, am just getting up to leave the room and she’s like, “Oh wait, I have one thing to tell you. Actually, sex hurts. It’s hurt for a year. It feels like knives and paper cuts.” And I’m like, “Oh, OK. Let’s talk about these different things.“ And it turns out she’s been given a prescription for vaginal estrogen, but she’s afraid to use it. So I sent her to the OASIS program for our team. We went through our plan. Number 1, eliminate irritants. Two, moisturize. We started with a nonhormonal moisturizer. And then because she’s on an aromatase inhibitor, we started vaginal DHEA once a week and then twice a week, which is FDA approved for painful sex, silicone lubricant for sexual activity, and now she’s doing better.

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How do you start this conversation with your team? Is my cancer sensitive to estrogen? Most of you probably already know the answer to that question. How important is this medication? There are some studies showing that maybe you don’t need to be on the medication as long or some patients may not need estrogen blocker medication. Circle back with your oncologist because this evidence updates every 6 months to a year. Make sure that this is still the right treatment if you’re on a multiyear treatment. Is there something else available that has a better side effect profile for me? We have options.

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Say you’ve tried your nonhormonal moisturizers and then ask your team, “What’s next for me?” And if they don’t have the answer to you that day, but if 10 patients ask that question, they’re going to go and figure out what are the next steps for these patients. Where’s the program that I can send patients to that have oncology-minded sexual health after cancer treatment? Then you can ask about the different hormone options that we talked about, and you want to make sure you’re following up with your oncologist in a few months. Hold them accountable. “Yes, I will try this medication because I trust you, but I will be back in 3 months to talk about the side effect profile.”

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Most patients don’t have a lot of side effects. Everyone’s different. Some patients have a lot, some patients have none. Most people fall somewhere in the middle. And we have different options.

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Bring your partner or your caregiver, write your questions down and then ask for a pelvic health PT referral or a sexual health program that’s oncology minded in your area.

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Desire. When I started this work, I thought this was the hardest part of my job. Even harder than breast cancer surgery, believe it or not, because desire is so complicated. It’s not It’s just the drops in hormones, it’s pain, fatigue, it’s all the medications that we’re giving you. All the medications we give you to treat side effects that are then zapping your desire, like antidepressants. It’s everything else that’s going on in your life. It’s your relationship, communication issues, stress.

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But what can we do? Well, first we need to treat the pain because if you’re having painful sex, you’re not going to have spontaneous desire because that’s your body protecting you. So it’s not going to show up spontaneously. You want to review your medication list. Many antidepressants are real libido zappers. There’s an antidepressant, an SSRI, where literally one of the side effects after you go through 100 side effects is anorgasmia. No one talks about this, but there are certain SSRIs that make it completely impossible to have an orgasm. Yes, and no one tells you that when they prescribe it. So talk to your prescribers if you think that one of them might be affecting your desire.

(00:31:01):

Sleep hygiene. Who’s heard this term? I think probably someone mentioned it today as well. So if you’re exhausted, you’re not going to have spontaneous desire. But also what’s happening when you get into bed at night? The bed is for sex and sleeping. That means if your kids are sleeping with you every night, probably desire’s not going to be spontaneous. If you’re watching true crime documentaries from bed every night, also probably not going to put you in the mood. So really think about what’s my routine getting ready for bed, and limiting my blue screen exposure. That’s your cell phone.

(00:31:34):

In my house, and by my house, I mean me and my dog, we turn the lights down at 7 p.m. We get ready for our nighttime routine. I stay off Instagram. I don’t watch TV from the bed. These are all really important for high-quality sleep. Even if you can get yourself asleep, if you’ve been zapping your brain with blue screen right until you fall asleep, you may wake up more and not have more restful sleep. If you don’t have good sleep hygiene, very unlikely you’re going to have spontaneous desire.

(00:32:02):

Next is “five-play.” So we’ve all heard of foreplay, and I took this term from Dr. Partridge who did a lot of work on whether patients can have pregnancy after breast cancer. Dr. Partridge in Boston. Where we used to say foreplay, now think of it as five-play. So however long your preparatory time was, double it.

(00:32:24):

They’ve done studies on this. During arousal for women, they did some MRIs. It’s a long process. The vagina gets longer. The uterus gets out of the way. Your pelvic organs literally reorganize themselves. When we’re suppressing your estrogen, that’s going to take longer to do. So give yourself plenty of time.

(00:32:44):

I tell patients schedule date night, and they’re like, “Oh, that’s so lame. I don’t want to schedule the date night.” But if you say, OK, Sunday morning is game time, then you have 3 days to prepare for it. And what can you do during those 3 days? Well, first of all, you’re not stressed about sex or your partner asking you about it, so you stop avoiding them. And then second, you have all these things you can do to prepare.

(00:33:07):

We call these sexy podcasts, but it’s essentially audio erotica and they’re listed there, Dipsea and Quinn. They’re essentially sexy stories you can listen to, to get in the mood. There is something for everyone on there. I will tell you though, because we do a lot of market research in our OASIS program, I had a patient told me about these. I had them on my phone, and I went to pick my mom up from the airport and it linked to my Bluetooth. I was like, “Mom, I promise this is for work.”

(00:33:38):

There’s also aasect.org where you can type in your zip code and find a sex educator or a counselor in your area. We don’t talk about this, but a lot of patients have a history of sexual trauma. That’s going to make pelvic exams difficult. That’s going to make sexual activity difficult. There are people out there who are really specialized in this.

(00:33:58):

So what’s new? We have new nonhormonal medications for hot flashes, which actually I think I skipped over in my hot flash slide. There are two nonhormonal medications for hot flashes that have come out over the last couple years. One is fezolinetant and the other one is elinzanetant, and they work at your thermostat center in the brain. Our experience in our program is sometimes the prior approval process can be a challenge, but they’re very effective with a really good side effect profile. So talk to your doctor about whether those medications might be helpful for you.

(00:34:34):

Vaginal DHEA and ultralow vaginal estrogen, pelvic floor therapy, and our new devices that you all learned about. And then look for a specialized oncology-minded sex after cancer program in your area. There’s a lot of things also available by telemedicine.

(00:34:48):

What I don’t recommend, save your money: vaginal rejuvenation devices. So when I started this work, I started seeing patients that had had the vaginal laser, and they all have very gentle sounding names. I’m not going to say them, but these devices are marketed to breast cancer survivors during October. You might get a discount. The data on the safety of these devices is not great. They were never FDA approved to be used in the vagina. This technology you can use on the skin of your face for scars, but it was actually fast-tracked through the FDA through a different type of approval process where the FDA actually never had to evaluate whether they were effective or safe. And all the post-market reports have patients who have burns, scarring, and chronic pain. Because I started talking about this — and meanwhile two trials came out showing they had no benefit when compared to a sham, which means they had two groups of patients, some got the laser and some they placed the laser and they turned it on, but they didn’t activate it. So patients actually didn’t know whether they were getting treatments because you’ve all heard of the placebo effect. They found that these devices weren’t even effective.

(00:36:03):

And then I started talking about it and patients started finding me who’d had these procedures, and they can cause significant harm. Some of the patients I’ve seen look like they’ve had pelvic radiation. These devices are not safe, and we can’t predict who’s going to have these bad reactions. We have FDA-approved therapies that are really, really effective. So just save your money.

(00:36:28):

Compounded hormones, I already got on that soapbox. Your hormone levels can get really high. It’s just very unreliable. I think in the cancer space, we just should stick to FDA-approved therapies.

(00:36:38):

And then there’s all kinds of stuff you’ll see on social media. For a while people were asking me about yoni steams and I was like, where you sit on a hot pot and steam your vagina. I’m like, first of all, the vagina is not like a pipe that steam can go through, but also you could really burn yourself. And also I think it’s cultural appropriation to call that yoni steams because if you ask anyone from India, I don’t think that’s what they’re doing.

(00:37:01):

But also you can have these people are like, “Oh, you need to have pelvic weight, so stick this weight in your vagina and you walk around all day.” Also, no. That can worsen your pelvic floor muscle dysfunction.

(00:37:12):

So if you’re going to think about anything where you’re working with the pelvic floor and you’re not sure, ask for a referral to your local pelvic health physical therapist.

(00:37:22):

For partners and caregivers, check in about what feels good. Your body might change. Have conversations about this outside the bedroom. Intimacy does not always mean sex, and sex is not always penetration. This can take a lot of different forms. And sex educators from that website, aasect.org, can also be very helpful.

(00:37:47):

So from now on, all the patients in this room, you’re going to be in charge of the lubricant. You pick out the products, anything that’s touching the vulva and vagina, you’re reading the ingredient list. And sometimes it’s helpful to protect the caregiver role. If your caregiver is also your intimate partner, think about how that can separate a little bit to kind of protect that intimate time. And then couples counseling can be really helpful. Caregiver fear, grief, and fatigue are also real.

(00:38:22):

Our key takeaways: These changes are common. There are medical reasons for this. It is not all in your head and these are treatable.

(00:38:30):

The way to treat them is often much simpler than we think. It’s not a fancy energy-based device. It’s skipping irritants. It’s sometimes subtraction and not adding. It’s moisturize, lubricate, and care for the pelvic floor.

(00:38:45):

Vaginal hormones shouldn’t be a hard no. They should be a discussion. Every provider is different. I’m working on each oncology provider out there one by one. It’s going to take me a while, but ASCO, the American Society of Clinical Oncology has a guideline on this. You can Google it or ask ChatGPT. Print this out, bring it to your appointment and say, “ASCO says that we can talk about vaginal estrogen. So I’d like to know if that’s right for me.” Also know if you’re on aromatase inhibitor that vaginal DHEA might be a good option for you.

(00:39:16):

Desire is complex, treat your pain, but be patient with yourself.

(00:39:20):

And then intimacy matters at every stage for everyone involved.

(00:39:27):

Your goals may shift. Comfort, closeness, touch, and pleasure all count, but intercourse is optional, like I said before. Fatigue can be a real desire buster, so plan for these things. Support your body with all the different things that we talked about, and then quality of life is part of your treatment plan. So if your provider isn’t addressing your side effects, find someone who is going to listen to you. And oftentimes if your primary oncology provider, they usually have maybe a nurse practitioner or PA and they can have a little more extra time where they can chat with you about these things. Find out who in the office might know something and can send you somewhere.

(00:40:07):

And it’s always OK to bring it up first, and you have nothing to lose. And the more uncomfortable you make people with your questions, the more resources they’re going to have for you next time.

(00:40:17):

Speaking of resources, these are some resources that we use and there are some websites for some of the things that I talked about.

Caroline Koffke, RN, BSN, OCN (00:40:25):

Thank you so much, Dr. Rojas. I knew this was going to be an amazing presentation and it exceeded all expectations still somehow.

Kristin Rojas, MD, FACS, FACOG (00:40:33):

Thank you so much for having me.

Caroline Koffke, RN, BSN, OCN (00:40:35):

Oh my goodness. Of course. I have a lot of questions. I know we have a lot of questions. Continue to text them in please because I have two amazing helpers, my colleague Lynn and the leadership volunteer, Bobbi, who will also help us.

(00:40:47):

But I wanted to start because I explain oftentimes that breast cancer is alphabet soup and there’s a lot of things that we’ve talked about. But I wanted to make one clear distinction, if you could make it for us, between hormone therapy and hormone replacement therapy. Can you just clearly define the differences between those two? Maybe give us some examples, some buzzword names.

Kristin Rojas, MD, FACS, FACOG (00:41:11):

Yes. I am on a warpath against the term hormone therapy because it’s extremely confusing. If we’re giving you a pill that blocks estrogen or lowers your estrogen level, that’s a hormone blocker. It’s endocrine therapy or it’s an estrogen blocker. I really don’t like calling that hormone therapy because I think it’s really confusing. So if you’re not sure — that is different, the medication that your oncologist gives you to suppress estrogen or the effects of estrogen, than what we call HRT or hormone replacement therapy.

(00:41:42):

We actually are moving away from the term HRT as well and we’re calling it menopausal hormone therapy, which that’s when we’re giving hormone back to patients where it’s appropriate. And that’s usually when we’re talking about the whole body seeing that estrogen or progesterone.

Caroline Koffke, RN, BSN, OCN (00:41:56):

Thank you. I think my colleague Lynn may have a question for you.

Lynn Folkman (00:41:59):

Yes, I have a question. Are there supplements that are in the CBD or the THC space that are helpful for menopause?

Kristin Rojas, MD, FACS, FACOG (00:42:09):

Oh, I thought you were going to say sex and I was like, yes. But when you said menopause and it’s more complicated.

Lynn Folkman (00:42:17):

Well, actually, why don’t you add your other part too? I think that would be great.

Kristin Rojas, MD, FACS, FACOG (00:42:22):

So first of all, CBD and THC products, please check your local statewide rules on these because it may not apply to everyone. The thing about CBD products is there also might be THC, which is the component in cannabis that gets you high. Sometimes there can be a little bit of THC in CBD products. So if you’re someone who has to give a urine test for work, maybe CBD products aren’t for you at this moment in time.

(00:42:50):

But this is a very interesting and developing space. From a sexual wellness perspective, I do think it’s very interesting to see lubricants and moisturizers that are incorporating CBD because we know there are cannabinoid receptors in the vulva and the vagina that probably help relax the pelvic floor and increase arousal. There’s also CBD gummies that are marketed towards this that have things like ashwagandha, but remember that supplements are not FDA approved. So anything that you’re going to be using, just make sure you let someone on your care team know, at least give them the list of ingredients. But I think they might be helpful.

(00:43:26):

From a hot flashes perspective, that’s really case by case. There are patients who tell me that they’ve really benefited from using different forms of that product. I would stick to FDA first before exploring those options. But if a patient tells me that they’re on it, I always like to make sure it’s documented in case there’s any interactions. But I think it’s a very interesting space and hopefully we’ll have a little bit more regulation in it. Not like regulation preventing it, but regulation as in standardization across all the different treatments so that we’ll know more.

Caroline Koffke, RN, BSN, OCN (00:44:01):

Thank you so much. Thoughts on testosterone for libido? We’re just coming up with really heavy hitting questions.

Kristin Rojas, MD, FACS, FACOG (00:44:09):

It’s a good question. The data on testosterone and libido isn’t even that great. People want it to be this silver bullet that’s going to fix all of your problems. It’s actually not. If someone’s testing your testosterone and telling you your testosterone level is low or your DHEA is low, the lab values that they use for that are also not standardized. So depending on what lab you’re getting that from, it might tell you have a low value and it might be a totally appropriate value for your body.

(00:44:39):

When we’re talking about local vaginal DHEA for painful sex, that is FDA approved and I talked about it today. But systemic testosterone is currently not FDA approved for women. When we give it to women, we kind of eyeball it and say like, “Oh, a 10th of the dose of what we’d give a man.” But we know that there’s a lot of variability in how this is absorbed, how it looks in patients’ bodies. And so for the people with a history of cancer, I like to steer patients away from systemic testosterone because that testosterone is being converted to estrogen in your body. And we don’t know what levels are safe yet for the cancer patients. And then there are also triple-negative breast cancers that have an androgen receptor.

(00:45:28):

I’m going to talk a little bit about testosterone pellets. I think pelleted therapy is not safe. These are not FDA approved, and the levels can be very high. And I’ve seen patients who have such high testosterone, they have a psychotic episode and they need to be admitted to a mental hospital. Their voice deepens. They have clitoromegaly, which is the term for clitoris enlarging. And so it’s the wild west out there. And so I really try to steer our cancer patients towards FDA-approved therapies because we know how it’s going to work in your body.

(00:45:59):

And we have two FDA-approved medications for desire. I can’t believe I probably skipped over them because I couldn’t read the font on my slides here. Two FDA-approved medications for desire. One is flibanserin, it’s called the pink pill. There’s a documentary about it recently that’s fascinating. I would say go watch it. It’s all about how the FDA approves medications for women’s desire. It’s disturbing. When Bob Dole started talking about erectile dysfunction, it was a national emergency. They immediately fast tracked five versions of sildenafil through the FDA and were like, yes, covered by insurance. I learned from the men’s sexual health … Sorry men. Sorry, please forgive me. I learned from the men’s sexual health program people the other day that they have all these great penile implants for patients who have to have those types of surgeries for cancer. And they’re like, “And it’s all covered by Medicare.” And I’m like, “Wow, I can’t get anything approved for our women. That is crazy.”

(00:46:58):

One is flibanserin. It’s a pill you take every night. The biggest thing is if you’re going to drink more than two alcoholic beverages, just skip your pill that night because it can make you sleepy. We use it in patients who are on aromatase inhibitors. Probably more than half of patients respond. So it’s an option. It’s a tool in our toolbox. You do need to take it for at least 2 months before we say whether it’s working or not working. For patients on tamoxifen, it’s a little bit trickier with dosing, so just talk to an expert. Not that it would make tamoxifen less effective, but tamoxifen can increase the side effects of this medication and make you more sleepy.

(00:47:32):

The second medication is an injection you give yourself before sexual activity. And this is how you know that women may not be behind the steering wheel for a lot of these things.

(00:47:43):

Pre-Ozempic, nobody wanted this, but now injections are not so scary. And so some patients are, this is called bremelanotide. Both of these medications are nonhormonal. Bremelanotide also works in the brain. The biggest side effect is nausea and you can only use it eight times per month and it should be about an hour before planned sexual activity.

(00:48:03):

So I tell patients for spontaneous desire, do all the other things I talked about, fixing pain, working on relationship, arousal aids, and then see how things go and we can add one of these pharmacologic agents in.

(00:48:19):

Oh, sorry. I forgot the second half of my sentence. For spontaneous desire, we do flibanserin. If the need is in-the-moment arousal, I think bremelanotide, the injection.

Caroline Koffke, RN, BSN, OCN (00:48:30):

All right. Bobbi, I think you have a question for us.

Roberta Albany (00:48:32):

Yes. Does insurance cover any of these devices?

Kristin Rojas, MD, FACS, FACOG (00:48:39):

Actually, if you can get creative with your FSA account, I think you can do these things where you get a Truemed letter of medical necessity. And some of these devices, I know MV.Health offers this. Sometimes it requires an extra step, but I think some of these devices are FSA eligible. In our OASIS program, we give the dilators to the patients and it goes through their insurance. So I know there is a route that way. And probably through a pelvic health PT, they probably have a lot of insight onto that as well. But the vibratory arousal aids, I think on MV.Health, and I’m sure this is on other websites as well, because those are geared as medical devices, even though we know that they serve a lot of needs, that they can also potentially go under insurance, probably depending on who’s prescribing them.

Caroline Koffke, RN, BSN, OCN (00:49:36):

Can I talk a little bit about the algorithm and the things that get pushed to us to buy?

Kristin Rojas, MD, FACS, FACOG (00:49:41):

Oh, the social media algorithm.

Caroline Koffke, RN, BSN, OCN (00:49:42):

The social media algorithm. And especially as you said this month, things get a little bit wild and crazy. Someone’s algorithm is pushing them vaginal red light devices.

Kristin Rojas, MD, FACS, FACOG (00:49:52):

Oh, that’s interesting because I was really excited about the face red light. I got one of the masks. It scares everyone and my dog. But in reading about this, I learned that it has to be a certain distance from the skin. It has to be a very specific wavelength. And when I’m thinking about the vagina, it’s not really, it’s like internal device, so I’m not sure the same qualities apply. I think anything that goes in the vagina, not anything, but these types of devices that can gently stretch the tissues all probably help. I don’t know that the red light component is needed. I know that there are some celebrities touting them, but I would say basics probably do work, are proven to work very well. And so I’m just not sure about red light.

(00:50:39):

Personally, or when I’m thinking about my patients, anything with an energy component, I get a little nervous about, although I guess arousal aids, vibratory devices also have energy.

(00:50:52):

But yeah, I’m not sure that they’re that effective. I think the basic dilators and aids are probably as effective.

Caroline Koffke, RN, BSN, OCN (00:51:01):

Lynn?

Lynn Folkman (00:51:02):

Yes. Can you please talk about vaginal estrogen and TNBC?

Kristin Rojas, MD, FACS, FACOG (00:51:08):

Yes. So that is a very case … Oh, the question was vaginal estrogen and triple-negative breast cancer. And so patients with triple-negative breast cancer typically aren’t prescribed estrogen-blocking medications, but they can still experience these symptoms.

(00:51:29):

Breast cancers can change when they recur. Breast cancer can turn from estrogen receptor-positive to estrogen receptor-negative, and that’s more common than the other way around. So I feel pretty comfortable as an expert giving patients with triple-negative breast cancer vaginal estrogen, especially I just say the same components apply to our estrogen receptor-positive patients. We start with a good foundation of vulvar health, eliminating things that are wrecking the microbiome, and then improve the tissue quality and then add in our vaginal hormone of choice and then address the pelvic floor. So in my mind, I don’t think of it differently in that way. And in fact, I kind of feel like it should be less complicated.

Caroline Koffke, RN, BSN, OCN (00:52:20):

You talked about venlafaxine for hot flashes. Is that something that someone could add if they’re already on an antidepressant regimen or how would you maneuver that?

Kristin Rojas, MD, FACS, FACOG (00:52:32):

That’s a great question. So technically it is in the … Sorry, vagina. Sorry. Antidepressants. Technically it is in the antidepressant category. So in adding anything like that, you would want to check with your prescribers because there are certain interactions. Sometimes you can be on a medication like bupropion.

(00:52:50):

Speaking of antidepressants and libido busters, SSRIs are the biggest offenders. SNRIs, which is venlafaxine, tend to have less effects on orgasm and desire.

(00:53:02):

Bupropion is a different medication class, which actually does not have sexual side effects, but it’s not great for patients with a lot of anxiety. But I know that we can use medication like bupropion with an SSRI. So I would say any type of combination of different type of antidepressants, make sure that your psychiatrist or your prescriber knows what’s going on because it probably matters by dose, et cetera.

Caroline Koffke, RN, BSN, OCN (00:53:28):

Thank you. Lynn, back to you.

Lynn Folkman (00:53:30):

Thank you. What are some nutritional tips to improve and enhance vaginal microbiome?

Kristin Rojas, MD, FACS, FACOG (00:53:39):

So I think. well, I don’t I think. We know that the gut microbiome and the vaginal microbiome are really related. I do research on the gut microbiome and opioids, and so I’m very excited about microbiome stuff, sorry. So the microbiome is a balance of good and bad bacteria. It’s on your skin, it’s in your mouth, it’s in your gut, it’s everywhere. And what we don’t want to do is deplete the good bacteria that also help fight infection. So in your gut, that means eating a lot of things that good bacteria like: vegetables. Specifically a lot of fiber products. So the more plant-based your diet, the healthier your microbiome. If your gut microbiome is healthy, your vaginal microbiome tends to be healthy as well.

(00:54:24):

I think when we’re talking about things like recurrent infections, so there are some patients who have poorly controlled diabetes who are more likely to develop intravaginal infections like yeast infections, recurrent bladder infections. So I do think it’s all intimately linked. I don’t think that you need a special supplement for vaginal health. People ask me a lot about vaginal probiotics. I think just having a healthy diet is probably the best thing and avoiding things that are going to wreck your microbiome.

(00:54:49):

But this is also another reason to talk about vaginal estrogen because we know vaginal estrogen does bring back good bacteria in the vagina that help fight infection. So patients who have recurrent bladder infections oftentimes really, really benefit from vaginal estrogen because the good bacteria, also known as lactobacilli, help fight bladder infections. So sometimes when I’m trying to make a case for starting a patient on vaginal estrogen to their oncologist, if they have recurrent bladder infections, then it’s kind of like a no-brainer because I know that bladder infections can spread to your kidneys, can put you in the hospital, can threaten your life. And we know that vaginal estrogen decreases your risk of dying from an infection like that.

(00:55:28):

And so sometimes it’s a good, a little extra piece of evidence to support the need for vaginal estrogen, at least temporarily. And I tell people who are telling providers like, “OK, we’re going to give her vaginal estrogen for a little while. We’re going to replete the vaginal microbiome and then we’ll reassess once symptoms get better and we can sometimes taper patients off if it’s making everybody uncomfortable.”

Caroline Koffke, RN, BSN, OCN (00:55:53):

Piggybacking off of the infection concerns, someone had heard that using coconut oil, which I know you had suggested as a possible, could maybe increase risk of UTI or yeast infections. Is there data behind that?

Kristin Rojas, MD, FACS, FACOG (00:56:05):

Actually, there’s data to the opposite. I actually heard a speaker talk about this. Actually, I’m being live streamed. I’m just remembering. And I disagreed with what that speaker said. Let’s just say that. There’s data on coconut oil in the vagina. It’s actually a natural antimicrobial antifungal. OK? Someone once said, and I think it has made its way through channels that placing coconut oil in the vagina would make it turn rancid. And I’m like, first of all, nobody knows what rancid means. Second of all, you don’t place … The vagina doesn’t turn things like curdle milk. And that I think is ignorance and why we have entire aisles in the supermarket telling us our vagina should smell like peach blossoms because someone’s saying that it’s going to turn things.

Caroline Koffke, RN, BSN, OCN (00:57:03):

Those are your thoughts?

Kristin Rojas, MD, FACS, FACOG (00:57:04):

Those are my thoughts. I’m going to get a nasty email after this.

Caroline Koffke, RN, BSN, OCN (00:57:11):

We can only hope. That means you’ve done a good job.

Kristin Rojas, MD, FACS, FACOG (00:57:13):

I didn’t name names. Let’s just say that.

Caroline Koffke, RN, BSN, OCN (00:57:14):

And we love that. All right, Bobbi.

Roberta Albany (00:57:17):

Someone wants to know a lot of what you talked about with women on HRT intersects a lot with bodily changes that female-to-male, trans men, masculine people go through when on HRT to transition. It’s a small population, but was curious about how breast cancer treatment affects trans men, masculine who take testosterone. Do you know of any doctors or studies on this?

Kristin Rojas, MD, FACS, FACOG (00:57:47):

Yes. Great question and actually a talk on its own that deserves a whole hour. And so you’re right. Some of these themes do cross between these two worlds. There are guidelines from the American College of Radiologists on what the breast cancer risk is for patients who are trans men and trans women who have either had top surgery or are on hormones. If you have had top surgery, it’s important to know that top surgery is not an oncologic mastectomy. So you may still have breast tissue, so you need to make sure all of your team knows all these things and you might still need breast cancer screening after the age of 40. For patients who are on hormones who are trans women, their risk of breast cancer is still very low, but it depends on their family history and whether they have say a BRCA mutation.

(00:58:53):

And so I think it’s a very, very individualized discussion, but there are guidelines on this that you can read through in the American College of Radiologists. And radiologists also should know these guidelines too because it has to do with how we should be screening those patients and at what age we should start.

Caroline Koffke, RN, BSN, OCN (00:59:09):

You mentioned a lot of washes that we should be avoiding. What should we be using to wash the vaginal area and are there any recommended brands or products?

Kristin Rojas, MD, FACS, FACOG (00:59:19):

So the vulva is the outside and the vagina is the inside. OK? And in the United States, we don’t get great sex education. So I always start there so we’re all on the same page, but the hair-bearing area is skin like the rest of your body. So you wash it like the rest of your body. The area that does not have hair more internally is a different type of skin than the rest of your body. It’s non-keratinized squamous mucosa. It’s the same kind that you have in your mouth. And so it is a balance of good and bad bacteria. These discussions are very individualized and depend on a patient’s symptoms. So anyone with burning and stinging, that’s telling me that they’re having a reaction to something and I really try to back off of those things and tell them water only for the non-hair-bearing area, coconut oil, and the outside part you can wash the rest of your body.

(01:00:10):

It really is an individual discussion. But people who have burning and stinging, I really try to convince them to start there and write back to me. And everyone’s like, “Oh my gosh, the burning and stinging is gone.” I’m like, “I know, you’re putting chemicals on your vaginal mucosa.”

(01:00:29):

Those chemicals are also being absorbed. So I don’t endorse a specific brand or product for that area.

Caroline Koffke, RN, BSN, OCN (01:00:37):

Bobbi.

Roberta Albany (01:00:39):

Can neuropathy affect the pelvic floor?

Kristin Rojas, MD, FACS, FACOG (01:00:43):

Definitely. Neuropathy can affect the entire body. Yeah. And I actually, for outside the breast cancer space, I have a patient in OASIS with … Well, there might be a patient somewhere who could have GYN cancer and had a sentinel node biopsy in the pelvis, and you can have nerve damage to the nerves in the pelvis that can affect sexual function. Nerves are a really component part of this. And so surgery, radiation to the pelvis and neuropathy could certainly impact this.

(01:01:19):

If there’s ever a question about whether there might be a nerve component, if it’s pain, I would definitely see a specialized GYN who specializes in something called vestibulodynia because that’s another issue that affects the vulva and the vagina that’s very painful, that’s caused from abnormal nerves firing in the area. So they may have some helpful insight, but it’s probably very patient specific.

Caroline Koffke, RN, BSN, OCN (01:01:47):

People are on Amazon.

Kristin Rojas, MD, FACS, FACOG (01:01:51):

On what?

Caroline Koffke, RN, BSN, OCN (01:01:52):

Amazon.

Kristin Rojas, MD, FACS, FACOG (01:01:52):

Oh, OK.

Caroline Koffke, RN, BSN, OCN (01:01:53):

Wondering about vaginal suppositories because of your amazing talk today. And you had said to avoid products containing glycerin.

Kristin Rojas, MD, FACS, FACOG (01:02:01):

Oh, do they have glycerin?

Caroline Koffke, RN, BSN, OCN (01:02:02):

It sounds like hyaluronic vaginal suppository Reverie is popular and it contains semi-synthetic glycerides. Does that have the same effect as glycerin?

Kristin Rojas, MD, FACS, FACOG (01:02:13):

Oh my.

Caroline Koffke, RN, BSN, OCN (01:02:16):

People are ready to follow your instructions.

Kristin Rojas, MD, FACS, FACOG (01:02:19):

Wow, you guys. I saw Dr. Gary getting a lot of hard questions and I was mentally preparing.

(01:02:25):

OK. I would say a hyaluronic acid moisturizer, the most important thing is we avoid things with artificial fragrance because those are the biggest offenders. Generally speaking, we try to steer away from other long name chemicals, but there might be some products with a component of glycerin and you can always buy one box and try it and see if your symptoms get better. If it doesn’t work, try something else. But if you’re noticing that you’re placing a suppository and you’re still feeling irritated, then I’d really say let’s do coconut oil because it’s the most bland emollient that can protect the skin and kind of reset that inflammation cycle.

(01:03:12):

Yeah, but I would need to look more into that, I think. Yeah.

Caroline Koffke, RN, BSN, OCN (01:03:17):

And that is a great answer.

(01:03:20):

I think a couple things. One, you are such a wealth of knowledge. I wish everyone could just come to your OASIS clinic. I think the whole world could benefit. So if we could just clone you, that would be wonderful.

Kristin Rojas, MD, FACS, FACOG (01:03:31):

I’m working on training more of me.

Caroline Koffke, RN, BSN, OCN (01:03:33):

Please continue that great work. Please continue that great work. Also, you can always just send, this is recorded, right? It’ll be on our website. Just passive aggressively send this video to your oncologist and say, “I would love for you to learn something today. Learn something from Dr. Rojas.”

Kristin Rojas, MD, FACS, FACOG (01:03:54):

Tell your oncologist I’m a breast surgeon. I had my GYN hat on today, but I actually do treat breast cancer. So I’m an expert in this data. So yes, sorry to interrupt.

Caroline Koffke, RN, BSN, OCN (01:04:04):

No, you really are amazing. She’s incredible. So just again, it will be online. You can re-watch it when you’re like, “What was step 1 versus step 2? I washed the inside accidentally. Oh my goodness.” So we’re so thankful for that. We are so thankful for you and to have this as content forever.

(01:04:23):

To our Q&A moderators, thank you so much. And also to the audience for sending in some really incredible questions. We’re so thankful. Thank you for joining us today.

Kristin Rojas, MD, FACS, FACOG (01:04:33):

Thank you so much for having me. And just talk to your team and build your team, make sure they listen to you and know that we have a lot of options.

Caroline Koffke, RN, BSN, OCN (01:04:42):

Absolutely.