Breast cancer (BC) is the most prevalent cancer among females worldwide [1, 2]. In 2020, there were 2.3 million women diagnosed with BC [1]. According to current statistics, it is estimated that in 2021 there will be 281,550 new cases of female BC [2]. Furthermore, approximately 12.9% of women will be diagnosed with BC during their lifetime [2].

During the last decades, thanks to improvement in BC treatments, survival rates of BC have increased drastically (90.3% in 5 years) [2], and new challenges are appearing to treat Breast Cancer Survivors (BCS). Nowadays, BCS do not only seek to remain free of disease, but there is a demand to do it preserving their quality of life. Therefore, there is a need to focus not only on the survival of the patients, but also on their long-term quality of life.

Evidence shows that BCS have the highest rates of lost disability-adjusted life years (DALYs) among all types of cancer [1]; being sexual dysfunction (SD) one of the main causes [3, 4], being DALYs index a validated health status indicator that evaluates the impact of health interventions in the quality of life of patients. The World Health Organization (WHO) describes sexual health as a “positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” [5]. A healthy sexual function includes sexual activity, free of pain and discomfort, as well as a sexual response with no psychological difficulty experiencing desire, arousal and orgasm [6].

According to Diagnostic and Statistical Manual of Mental Disorders (DSM)-V [7], women can be diagnosed of SD when having persistent symptoms (at least 6 months) that cause a marked personal disturbance and a serious impairment in their sexual lives. SD has been classified into three categories, according to the symptoms experienced: arousal disorder or disfunction in female sexual interest, orgasmic disorder, and penetration disorder or genitopelvic pain. However, for this definition to be complete, it should be considered that SD extends beyond physical symptoms, having serious consequences regarding the psychological health of patients and their sexual quality of life.

The prevalence of SD in BC survivors oscillates between 40–80% [3, 8, 9, 10, 11, 12, 13, 14], clearly higher compared to healthy women [13, 14, 15], and persisting over time, affecting the quality of life of patients through many years [13, 14, 16, 17, 18, 19, 20].

The main symptoms of SD reported by BC patients include difficulties in arousal or excitation [8, 10, 14, 21, 22, 23, 24, 25], decreased sexual desire [8, 9, 10, 14, 21, 23, 25, 26, 27], insufficient lubrication [3, 8, 9, 10, 14, 21, 23, 25] and penetration pain [8, 14, 22, 23, 24, 25].

Although being a frequent problem among BC patients, SD is not usually discussed in the clinical practice [16, 28, 29, 30, 31, 32], since health care providers often feel uncomfortable asking sexual-related issues to patients [16, 32, 33, 34, 35, 36] and furthermore, they do not always have received a proper formation on this field [14, 16, 32, 34]. In addition, patients tend to feel embarrassed to discuss sexual concerns during BC related visits [16, 37]. Some studies reflect that BCS feel that their health care providers are not properly prepared to treat SD issues [16, 38]. As a result, sexual counselling is not usually provided to BC patients [16, 28, 29, 30, 31, 32] and SD remains being an underdiagnosed and undertreated issue for these women [16, 28, 29, 30, 31, 32].

Therefore, the aim of this review is to provide an updated view of how BCS sexual function can be retrained; evaluating how SD is assessed in BC survivors, which specific causes affect sexual function in BCS and potential therapeutic options to palliate SD in BCS.

Observational studies evaluating sexual dysfunction in BCS published until December 2021 were deemed eligible. No limits were set in terms of time of publication or study design. Both prospective and retrospective designs, as well as case series, were acceptable. Interventional studies (randomized-controlled trials (RCT), nonrandomized studies) assessing treatment options in these cohort were included too. Publications with available full text of the article in English language were deemed eligible.

Articles that evaluated non-gynecological cancers were excluded, as well as those focusing on the sexuality of men.

In December 2021, a search on Ovid Medline, Embase, PubMed, Cochrane register of controlled trials (CCTR), Cochrane database of systematic reviews (CDSR), CINAHL and Google scholar for all publications up to date was performed to identify potentially relevant publications related to sexual dysfunction in BC survivors. Search terms used were: “breast cancer”, “sexual health”, “breast cancer survivors”, “sexual dysfunction”, “sexuality”.

New challenges regarding BCS are appearing since the survival have increased drastically during the last decades. There is a huge demand from BCS to focus on maintaining quality of life and avoid secondary effects related to the provided treatments, such as SD.

Evidence shows that over half of BCS experience SD at some point during the treatment or posttreatment. Sexual Dysfunction in BCS present not only a high prevalence, but also a high degree of under-diagnostic in the clinical practice. Sexuality is not usually evaluated during oncological visits, therefore, a great number of women who suffer SD are not diagnosed and thus, not treated.

Patients need to be informed about secondary effects of BC treatments and its possible impact on sexuality. This topic should be easily and openly discussed during visits, and patients may be offered solutions in case they need help or further information.

The authors believe sexual disfunction should be evaluated systematically to all BCS and if possible in the near term, through a validated scale for BCS.

The importance of having a specific scale for BC patients relies on the fact that BC may affect the sexual life of women in a different way from other cancers. Since BCS are usually treated using antiestrogenic treatments worsening all menopause dimension symptoms, and directly causing a physical alteration in women in a sexuality-social-related organ [28, 39].

An ideal scale would need to include all the dimensions of SD. It should also assess other aspects of sexuality beyond physical symptoms and include psychological aspects of sexual function, understanding sexuality from a holistic point of view, not focusing exclusively on coital relationships and vaginal intercourse. Finally, the scale would need to be brief and practical to complete, as well as offer the possibility to be repeated in different visits in order to evaluate the effectiveness of the treatment or strategies used.

Sexual Dysfunction in BCS needs to be understood as the result of the combination of multiple factors: BC is a disease that affects the breasts, which play an essential role in female sexuality and sexual activities, provoking serious impact on the mental health of BC patients and being a common cause of psychological disruption. This disruption has shown to be a constant reminder of the disease, causing women a feeling of insecurity regarding their health status [32]. Furthermore, many women report feeling unattractive and not desirable after BC [14, 32], which is also affected by cultural aspects [32]. In addition, being aware of having SD and self-conscious during sexual activities, can also cause impairments on desire, arousal and difficulty to connect with the partner and enjoy the sexual relationships. All of these promote, in turn, SD [14, 21, 22, 32, 43, 44].

Furthermore, cancer treatments (surgery, chemotherapy, radiation therapy, endocrine therapy) themselves also have a negative effect in the sexual life of women through physical symptoms such as fatigue, joint pain, penetration pain, lack of lubrication, decreased libido and difficulties in arousal.

Despite the high prevalence of SD and its consequences, there are still no clear standardized therapeutic strategies for these patients. Considering the multifactorial nature of SD and its impact on various aspects of the quality of life of patients, proper treatment options may result from the combination of pharmacological and psychological strategies.

The use of vaginal moisturizers combined with psychological therapy focused on sexual aspects should be considered. Moreover, including mechanical stimuli (vibrators, dilators) to the local treatment may be of benefit, although is still of no common use and should be potential investigation target for the future.

Sexual Dysfunction is a multifactorial condition that affects among 40–80% of BCS, causing a decrease in quality of life of these women.

Despite its prevalence, SD remains underdiagnosed and there is scare use of SD assessment scales in regular clinical practice. A regular implementation of a validated scale for its proper assessment would be benefitial for diagnosis screening.

Finally, there is no standardized therapeutic strategies to care for SD in BC survivors. Therapeutic options should be potential investigation targets for the near future, which may evaluate local treatments (vaginal moisturizers, vibrators) combined with psychological interventions.

Addressing this condition might suppose a step forward to achieve a healthy and satisfactory sexual life and, thus, higher quality of life of millions of women worldwide.

EM and HC designed the current investigation. HC and IC performed the research. EM and HC wrote the manuscript. HC, EM, SA and CCB performed the editorial changes. All authors reviewed the final manuscript.

Not applicable.

We would like to express our gratitude to the department of Obstetrics and Gynaecology of the Hospital Clínic de Barcelona for facilitating and promoting research; as well as to all those professionals who helped us during the writing of the present manuscript.

This research received no external funding.

The authors declare no conflict of interest. CCB is serving as one of the Editorial Board and Guest Editors of this journal. We declare that CCB had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to MAMZ.