The present chapter outlines the sexual aftermath of cancer treatment and strategies for improvement. Sexual dysfunction is underdiagnosed and undertreated after surgery, chemotherapy, radiation, and hormone-modulating therapies. The treatment of genitourinary syndrome of menopause (GSM) is multimodal and includes behavioral modifications, local therapy, and physical therapy. Vaginal estrogen should be first-line treatment for GSM in women with hormone non-responsive cancer. For those with ovarian, endometrial, and breast cancer, vaginal estrogen may be considered with persistent symptoms after regular use of non-hormonal moisturizers. As an alternative, vaginal androgens may be of utility in improving libido and vaginal health. The authors do not endorse the use of compounded formulas due to a lack of formula standardization and a dearth of safety and efficacy data. Vaginal lasers, including CO2 lasers, are discouraged after two sham-controlled randomized trials found they were not effective, and adverse events have been reported in women with cancer. Dyspareunia is common, especially if encountered in the setting of radiation-induced vaginal stenosis. Treatment may involve addressing GSM, serial vaginal dilation, pelvic floor therapy, and/or psychological therapy. In those with low sexual desire, filbanserin and bremelanotide are novel FDA-approved therapies with central mechanisms that may change the landscape for treating female sexual desire disorders.

Improvements in multimodality treatment of anal and colorectal cancer has led to increased numbers of women survivors who experience gynecologic problems in long-term survivorship. The etiology of gynecologic problems after anal and colorectal cancer treatment is complex and multifactorial. Pelvic radiation, surgery and chemotherapy can all cause anatomic, hormonal and psychological changes. Consideration of preventative measures can ideally reduce the risk of vaginal stenosis, dyspareunia, sexual dysfunction, infertility, premature menopause and pelvic pain after therapy. Proactive screening and appropriate treatment of cancer therapy late effects can improve patients’ quality of life during survivorship.

Postpartum women experience many biological, psychological, and relational changes that can greatly impact their sexual function. Women are often ill-informed about what to expect regarding normal sexual function; much of the research is therefore focused on perceived sexual dysfunction. Postpartum care providers should discuss normal sexual changes in the postpartum period, actively elicit sexual health concerns from patients, and provide targeted treatment strategies. (We wish to make it clear that this chapter refers to people with internal reproductive organs as “women.” We acknowledge that this information is relevant for anyone assigned female at birth irrespective of their gender identity.)

A 33-year-old nulligravid woman presents with a complaint of insertional dyspareunia. She has been partnered with the same man for three years and had no issues with coitus until about one year ago. Since that time, she has experienced increasingly severe pain with any attempt at vaginal insertion. She describes the pain as sharp and tearing, occurring when her partner enters her. Because of the pain, she has also experienced diminished arousal and a lack of sexual desire. She denies any vulvar pain in other situations but has a similar sensation with placement of a tampon or sex toy. A trial of topical estrogen worsened her symptoms. Application of lidocaine jelly to the area resulted in improvement of symptoms temporarily, but intercourse without it was persistently painful. Her gynecologic history is notable only for a history of recurrent candida vaginitis, though she has no symptoms currently. She uses a combined oral contraceptive for birth control. She has no significant medical history and has never had surgery. She is a non-smoker and uses alcohol occasionally.