29 Jul Sexual Function Improved With Lidocaine Cream in Breast Cancer Survivors
MedicalResearch: What is the background for this study?
Dr. Goetsch: Women who are survivors of breast cancer now number about 3 million in the US. Therapy for breast cancer is anchored in creating a state of postmenopause in which estrogen is eliminated from the system. One of the most difficult symptoms of lack of estrogen is dyspareunia, the term for pain with intercourse. The old term “vulvovaginal atrophy” has been changed to “genitourinary syndrome of menopause” by agreement of two specialty societies. Because of my focus in the gynecologic specialty of vulvar pain, I have felt that this menopausal symptom is more than a condition of atrophy. Additionally, my clinical experience has led me to believe that the exquisite tenderness is located in the vulvar vestibule rather than in the vagina. The vestibule is the inner vulva or entryway before the vagina. This study was devised to answer these hypotheses.
I predicted that the population most likely to represent the worst examples of postmenopausal dyspareunia was the population of women who cannot use estrogen due to being survivors of breast cancer. I treated the problem as a pain problem rather than solely a problem of dryness.
MedicalResearch: What are the main findings?
Dr. Goetsch: I enrolled 46 breast cancer survivors with moderate and severe dyspareunia, and each had tenderness in the vulvar vestibule and not in the vagina. All of the 51 women screened had vestibular tenderness, indicating that this location may typify postmenopausal dyspareunia, and 5 were excluded because of other genital sources of pain. The average pain score for intercourse was 8 on a scale of 0-10. After showing each patient the site of her tenderness, I explained how to apply the study liquid (4% liquid lidocaine) or placebo liquid (saline) for 3 minutes immediately before penetration. They were given silicone lubricant. During the month that they tried penetration twice weekly, the mean score for those using saline/silicone was 5 on a 0-10 score. Those using lidocaine/silicone had a mean score of 1 on a scale of 0-10. After the blinded month they knowingly used liquid lidocaine for 2 more months. The initial Sexual Distress scores were abnormal for the group. Scores using the Sexual Function Questionnaire indicated abnormal scores in most domains of function. By the end of the open-label trial, 90% were having completely comfortable penetrative sex. Distress scores had decreased while sexual function had improved in all domains. Of 20 initial abstainers who completed the study, 85% had resumed comfortable intimacy. The intervention did not change the severe atrophy found in all of these patients. No partners complained of penile numbness.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Goetsch: First, our results point out that the levels of pain in women with postmenopausal dyspareunia can be severe. Additionally, dramatic success in preventing pain was achieved without treating the severe atrophy, and the exquisite mucosal tenderness was localized in the vulvar vestibule. Pain could successfully be prevented by a liquid applied by the patient herself when she needed it. The adage “Use it or lose it” was proven wrong since women improved in all aspects of sexual function. These findings may be relevant to large numbers of women without a history of breast cancer who have postmenopausal dyspareunia despite use of vaginal estrogens because the location of treatment may need to be the vestibule rather than the vagina.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Goetsch: Larger studies need to confirm these results. Survivorship clinics need to explore whether women can be successfully taught this technique by those who may not be vulvar experts. Further studies need to include postmenopausal women who have not had breast cancer to ascertain how generalizable these findings may be. Research could answer whether topical estrogens should be applied to the vulvar vestibule for greatest success in ameliorating the problem of postmenopausal dyspareunia. And finally, research is needed to characterize this vestibular pain condition.
Martha F. Goetsch, MD, MPH (2015). Sexual Function Improved With Lidocaine Cream in Breast Cancer Survivors