By Reducing Pain, Topical Lidocaine Improves Sexual Function

Miriam E. Tucker

October 22, 2014

NATIONAL HARBOR, Maryland — The reduction in pain achieved with self-administered topical lidocaine leads to improvement in other aspects of sexual function in breast cancer survivors with severe menopausal dyspareunia, new data show.

The results were presented here at the North American Menopause Society (NAMS) 2014 Annual Meeting by Martha Goetsch, MD, adjunct assistant professor of ob/gyn at Oregon Health & Science University in Portland. The study was one of three "top scoring" abstracts at NAMS.

Earlier this year, Dr Goetsch presented results at the American College of Obstetricians and Gynecologists meeting, which showed that the application of topical liquid lidocaine to the vulvar vestibule, along with lubricant, allowed for more comfortable intercourse in 46 breast cancer survivors with severe menopausal dyspareunia. That study won first prize for oral abstract at the meeting.

In the updated results presented at NAMS, Dr Goetsch showed that by reducing pain in those women, the low-cost approach also improved sexual desire, arousal, orgasm, enjoyment, and partner concerns.

Sexual dysfunction is present in 50% to 70% of breast cancer survivors, in part because prolonged postmenopausal status is a foundation of anticancer therapy, and these women are discouraged from using estrogen supplementation, Dr Goetsch explained.

"Postmenopausal dyspareunia in breast cancer survivors is a pain condition. There is a dryness condition of atrophy, but there is also a pain condition in the vestibule, and it's treatable. Self-applied low-cost topical therapy...can prevent pain and improve all domains of sexual function, despite continued severe atrophy," she said.

Pending further study, lidocaine might be an option for other women with dyspareunia as well, Dr Goetsch told Medscape Medical News. "This has ramifications for nonsurvivor postmenopausal women. It is relevant for women who could use estrogen but don't want to, not just those for whom it is contraindicated."

"We never handle dyspareunia from the pain point of view. That was a very interesting way to do it," Lila Nachtigall, MD, professor of obstetrics and gynecology at the New York University Langone Medical Center in New York, told Medscape Medical News.

Sexual Function Improves

The study involved 46 postmenopausal women in partnerships of 5 or more years (average, 25 years), who were not taking estrogen and who had moderate or severe dyspareunia, vestibular tenderness, and no pelvic floor myalgia or vulvar dermatoses. All agreed to try penetration twice weekly, either with a tampon or a partner.

The mean age of the women was 56 years, average time since menopause was 8 years, and average time since breast cancer diagnosis was 4.5 years. More than half (52%) had been abstaining from intercourse because of the dyspareunia. At baseline, average intercourse pain score was 8 on a 10-point scale, and sexual distress score was 30.5 (>11 indicates abnormality).

Thee women were randomized to 4% aqueous lidocaine or to placebo with clear liquid saline for 4 weeks; both were applied with saturated cotton balls and Scopettes for 3 minutes before penetration. Silicone lubricants were also used to allow for penetration. The women kept diaries and completed sexual function questionnaires.

At 4 weeks, significant improvements were seen in the lidocaine group on the sexual function questionnaire for subjective arousal (P = .007), cognitive arousal (P = .02), orgasm (P = .01), and pain reduction (P = .003).

In the placebo group, average pain score dropped from 8 to 5, likely because of the lubricant. In the lidocaine group, the score dropped from 8 to 1.

After the 4-week randomized phase, all the women were given open-label topical lidocaine for 8 weeks.

Of the 41 women who completed that 8-week open-label period, 37 consistently had pain scores of 0 or 1, and sexual distress dropped from 30.5 to 14.0 (P < .001). Of the 20 who reported abstaining from sex before the intervention, 17 reported comfortable intercourse.

As treatment time increased and scores improved, differences between the lidocaine and placebo groups decreased; at 12 weeks, only cognitive arousal was different (P = .049). This suggests that those in the placebo group were "catching up" to those in the lidocaine group, Dr Goetsch noted.

The proportion of women in the normal range increased over the 12-week period.

Table. Proportion of Women Scoring in the Normal Range

Domain Baseline, % 12 Weeks, %
Desire 0 12
Enjoyment 2 44
Pain 0 51
Orgasm 20 29
Subjective arousal 7 34
Cognitive arousal 2 29
Partner concerns 65 85

 

Dr Goetsch showed some quotes from patients' diaries: "I feel normal about my body"; "There's dance in the old dame still"; "We feel it's been a gift...pretty much a miracle"; and "We're getting to know each other all over again."

"It's impressive to have a patient who has gone through a lot of history with breast cancer to feel normal about her body," she noted.

Baseline pain score on the sexual function questionnaire did not reflect the duration of a woman's pain, and women with a longer duration of pain improved just as much on all domains as women with a shorter duration of pain. In addition, women taking aromatase inhibitors or selective estrogen-receptor modulators (SERMs) scored no worse or better at baseline, and improved just as much on all domains.

Clinical Considerations

Dr Goetsch noted that for these women, having more sex when it was painful did not reduce dysfunction. "I really think 'use it or lose it' is not a very fair exhortation. It kind of blames the patient if she still has pain.... Severe dysfunction improved with lidocaine even after years of dysfunction, so many did not 'use it' but did not 'lose it' either. We need to re-examine that aphorism," she said.

The 4% aqueous lidocaine product is approved by the US Food and Drug Administration for use on mucosal surfaces, and is available by prescription. A 50 mL bottle costs approximately $8.50.

Dr Goetsch explained that the liquid lidocaine doesn't reduce sensitivity because it is placed on the vestibular mucosa, not the clitoris. Patients reported that it removed the pain but they could still feel, and none of the partners complained of numbness.

"Lidocaine improved arousal and enjoyment.... Arousal is brain-based, and lack of pain allows the usual cues to work," she said.

"Most of us would never have thought of using lidocaine because we would think it would block the whole business," Dr Nachtigall told Medscape Medical News. "I would try it."

North American Menopause Society (NAMS) 2014 Annual Meeting: Abstract S-11. Presented October 17, 2014.

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