More Than Just “Vaginal Dryness”: Sexual Dysfunction Correlates with Genitourinary Anatomy Disruptions in Female Cancer Survivors

More Than Just “Vaginal Dryness”: Sexual Dysfunction Correlates with Genitourinary Anatomy Disruptions in Female Cancer Survivors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article More Than Just “Vaginal Dryness”: Sexual Dysfunction Correlates with Genitourinary Anatomy Disruptions in Female Cancer Survivors Erin Kobiella, Sanjana Satish, Fay Pon, Lia Jueng, Chloe Shields, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7143576/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Nov, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract PURPOSE To correlate genitourinary exam (GU) findings to patient-reported sexual dysfunction in female cancer survivors. METHODS This retrospective cohort study included female cancer patients seen at a South Florida sexual health after cancer program. GU anatomy disruptions and patient-reported sexual dysfunction were evaluated by Adapted Vulvovaginal Exam Score (AVES) and Female Sexual Function Index (FSFI), respectively. Multivariate analyses compared, FSFI scores between patients with AVES > 3 vs. 0–3, (AVES > 3 corresponds to more abnormal GU exam). Adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) were calculated. RESULTS AVES was calculated for 162 female patients treated between 2020–2022. Median age was 46; 57% were Hispanic, and 79% had breast cancer. Common symptoms included vaginal dryness (55%) and dyspareunia (45%). Of 108 women with FSFI scores, 97% met criteria for female sexual dysfunction (FSD). 23% were found to have vaginal stenosis, and 42% had a narrowed vaginal introitus. Those with AVES > 3 had significantly lower FSFI lubrication, orgasm, satisfaction, and pain domain scores. Any endocrine therapy use was associated with worse AVES scores (aOR 0.20, 95% CI 0.05–0.80, p = 0.024), an association strongest with aromatase inhibitor (AIs) use. Low satisfaction scores < 3.6 were nearly three times more likely to have abnormal GU exams (aOR = 2.81; 95% CI: 1.03–7.65; p = 0.044). CONCLUSION FSD in female cancer survivors is associated with previously unreported GU exam disruptions that can limit or prevent sexual activity through pain and worsened sexual satisfaction. Ongoing work evaluates targeted interventions to improve symptoms and quality of life for this growing survivor population. cancer sexual dysfunction genitourinary syndrome of menopause menopause survivorship Figures Figure 1 Figure 2 Introduction As a result of advancements in targeted therapies, the number of cancer survivors in the United States is expected to exceed 20 million by 2026 with approximately 10.3 million survivors predicted to be women [ 1 ]. Adding to the challenges that survivors face, many cite sexuality as a major concern and unmet need [ 1 , 2 ]. Female sexual dysfunction (FSD) is reported in women with all cancer types, including breast, gynecologic, hematologic, colorectal, and head and neck cancers [ 1 – 3 ]. Women with cancer are estimated to have a 2.7- to 3.5-fold increased risk of developing sexual dysfunction compared to women without cancer [ 3 ]. In patients with breast cancer, the prevalence of FSD is estimated to be 50–75% [ 2 , 4 ]. Additionally, an estimated 43% of gynecologic cancer survivors report sexual dysfunction [ 5 ], whereas patients with cervical cancer experience sexual dysfunction at an even higher rate of 80% [ 6 ]. Sexual difficulties also occur in up to 75% of female patients who are treated for colorectal cancer [ 7 ], and 85% of female patients with anal cancer report symptoms of sexual dysfunction, particularly dyspareunia in up to 65% of these patients [ 8 ]. Those with an elevated risk for malignancy due to genetic predisposition syndromes also report high rates of negative sexual side effects after risk-reducing surgeries [ 9 ], and iatrogenic estrogen suppression related to preventive therapies can incite or worsen menopausal symptoms. Lastly, those with hematologic malignancies have an increased risk of immune-mediated vulvar disorders such as vulvovaginal graft-versus-host disease (GVHD) and lichen sclerosis [ 10 ]. Negative disruptions to female sexual health can be the sequelae of any type of malignancy, not just breast and gynecologic types. Despite the high rates of distressing sexual symptoms in female cancer survivors, sexual dysfunction remains critically undertreated. Most commonly, female cancer survivors experience treatment-induced genitourinary syndrome of menopause (GSM), which can include symptoms of vaginal dryness, dyspareunia, diminished libido, poor arousal, and difficulties with orgasm. Chemotherapy, pelvic radiation, bilateral salpingo-oophorectomy (BSO), and estrogen suppression increase the risk of GSM [ 11 ], and premenopausal patients who receive chemotherapy and experience premature iatrogenic menopause may be unprepared for these abrupt changes that impact their quality of life [ 12 ]. Although genitourinary exams are recommended for cancer survivors who present for evaluation of sexual concerns, few studies detail the anatomic disruptions encountered during the exams of female survivors and the effect such changes have on the patient’s sexual well-being and overall quality of life. Therefore, the objective of the current study was to describe genitourinary exam findings in a diverse population of female cancer survivors and correlate these findings to patient-reported sexual dysfunction. Methods This retrospective cohort study included female cancer patients presenting to a sexual health after cancer program at an NCI-designated cancer center in South Florida between November 2020 and June 2022. The study was approved by the University of Miami Institutional Review Board, and research was conducted according to the principles of the Declaration of Helsinki. Informed consent was obtained from all individual participants. The MUSIC™ ( M enopause, U rogenital, S exual Health and I ntimacy C linic) Sexual Health After Cancer Program provides a safe space where stigmatized topics such as sexual well-being can be discussed and treated. Patients referred to the MUSIC™ Program receive a one-on-one clinic visit with a subspecialized board-certified women’s health specialist to discuss symptoms related to sexual wellness. Patients also undergo a complete physical exam and receive a personalized treatment plan. All intake paperwork in the Program is available in English and Spanish. Electronic medical records were queried for demographic data, clinical history, cancer diagnoses and treatment, and patient-reported sexual health symptoms (e.g., vaginal dryness, painful sex, low desire). Information pertaining to sexual health was collected, including sexual activity frequency before and after cancer treatment, pain associated with sex, orgasm difficulties, genitourinary (GU) exam findings, and treatment plan after the first program visit. As part of the intake paperwork, Female Sexual Function Index (FSFI) was administered in English and Spanish at the first visit to measure patient-reported sexual function. The FSFI is a 19-item Likert scale questionnaire that assesses female sexual functioning through six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI was validated for use in gynecologic and cervical cancer populations in 2012 [ 13 ] and breast cancer populations in 2015 [ 14 ]. The maximum FSFI score is 36, and a total FSFI score ≤ 26.0 indicates female sexual dysfunction [ 15 ]. Of note, desire domain scores < 5.0 are indicative of hypoactive sexual desire disorder [ 16 ]. Total scores and domain scores were calculated. An Adapted Vulvovaginal Exam Score (AVES) was calculated for each patient who underwent a genitourinary (GU) exam. This score was developed from the Vagina; Health Assessment described in the supplementary material of a previous publication [ 17 ] and measures the integrity of the vaginal rugae, vascularity, epithelial integrity, elasticity, and vaginal moisture. For each individual exam finding, a score of 0 corresponds to no disruption, a score of 1 indicates mild disruption, and a score of 2 indicates severe disruption. For measurement of vaginal shortening, 6 cm was considered normal. Based on the distribution of scores in this population, the AVES cutoff point for severe exam disruption was established at the first quartile. Subsequently, AVES 0–3 correlated to a normal GU exam, whereas AVES greater than 3 correlated to severe GU exam disruptions. The prevalence of vaginal stenosis in this sample was also determined based on the presence of vaginal shortening, vaginal agglutination, and/or vaginal adhesions/scarring on genitourinary exam. Data was collected and stored using the REDCap (Research Electronic Data Capture) tool. REDCap is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources [18, 19]. Demographic, clinical, and treatment characteristics and patient-reported symptoms were summarized with descriptive statistics. Chi-square test for association and Fisher’s exact test, if applicable, were employed to correlate AVES groups to patient characteristics. Mean FSFI total and domain scores were compared between AVES groups (0–3 vs. >3) using student’s t-test. Domain score cutoffs were used based on previously published studies. Multivariable binary logistic regression model was fit for high AVES (> 3) with reference group of low-AVES (0–3) by incorporating clinically relevant variables in the model as covariates. Adjusted odds ratios (aOR) and corresponding 95% confidence intervals along with p-values are calculated. Data management and statistical analysis were performed with SAS version 9.4 for Windows (SAS Institute Inc., Cary, NC). Results Demographics Between November 2020 and June 2022, 162 female cis-gender patients were evaluated, and AVES was calculated for 139 patients (86%). Overall, the mean age was 46 years (range: 19-70), and most patients were under 50 years old (63%). Many patients were White (84%) and/or Hispanic (57%). Most patients reported English as their primary language (74%), and a significant proportion of patients reported a primary language of Spanish (26%). One-quarter of the population reported current or previous tobacco use, and one-quarter of patients had Medicare or Medicaid for insurance coverage (27%). Most patients had breast cancer (79%), followed by gynecologic cancer (9%). A small number of patients had a history of gastrointestinal (GI) malignancy (2%), hematologic malignancy (8%), or other cancer subtypes such as lymphoma, renal malignancies, and pseudomyxoma peritonei (1.4%). There were no significant differences in AVES groups (0-3 and >3) by race, ethnicity, primary language, smoking status, insurance, cancer type or stage, although there was a trend towards a greater proportion of patients > 50 to have more higher AVES score (more abnormal GU exams), as shown in Table 1. Table 1. Demographic and clinical characteristics of the study population by AVES exam group AVES 0-3 >3 Characteristic N (%)* N (%) N (%) P-value ‡ Cis-gender female 139 (100) 50 (36) 89 (64) - Age at diagnosis 0.053 > 50 50 (36) 13 (26) 37 (74) <50 Mean (SD) Min, Max 87 (63) 46 (11) 19, 70 37 (43) - - 50 (57) - - Race 0.650 White 116 (84) 43 (37) 73 (63) Black/Other 16 (12) 5 (31) 11 (69) Ethnicity 0.154 Hispanic 79 (57) 32 (40) 47 (60) Non-Hispanic 56 (40) 16 (29) 40 (71) Primary Language 0.672 English 103 (74) 36 (35) 67 (65) Spanish 36 (26) 14 (39) 22 (61) Smoking Status 0.832 Never 102 (73) 37 (36) 65 (64) Former/Current 35 (25) 12 (34) 23 (66) Unknown 2 (1) - - Insurance Type 0.764 Private 87 (63) 31 (36) 56 (64) Medicare/Medicaid 38 (27) 15 (40) 23 (60) Other 14 (10) 4 (29) 10 (71) Menopausal at Diagnosis 0.045 Premenopausal 87 (63) - - Postmenopausal 46 (33) 11 (24) 35 (76) Cancer Type 0.096 Breast 110 (79) 45 (41) 65 (59) Gynecologic 13 (9) 1 (8) 12 (92) Leukemia 11 (8) 3 (27) 8 (73) Gastrointestinal 3 (2) - 3 (100) Other 2 (1) 1 (50) 1 (50) Clinical Tumor Stage 0.233 DCIS-Stage II 67 (48) 29 (43) 38 (57) Stage III-IV 18 (13) 5 (28) 13 (72) Unknown 54 (39) - - Hysterectomy performed 1 54 (34) 13 (28) 33 (72) 0.193 Bilateral Oophorectomy 1 52 (33) 12 (27) 32 (73) 0.134 Treatment received † Endocrine Therapy Tamoxifen only Tamoxifen + AI or AI only 3 93 (67) 21 (22) 72 (78) 39 (42) 14 (67) 25 (35) 54 (58) 7 (33) 47 (65) 0.011 Chemotherapy 103 (74) 33 (32) 70 (68) 0.102 Radiation 86 (62) 29 (34) 57 (66) 0.334 Immunotherapy 18 (13) 7 (39) 11 (61) 0.735 Surgery 2 124 (89) 46 (37) 78 (63) 0.427 Surgery and Chemotherapy 89 (64) 29 (33) 60 (67) 0.406 Surgery and Endocrine 32 (23) 16 (50) 16 (50) 0.406 Other 9 (6) 2 (22) 7 (78) 0.406 Type of Surgery 0.049 Mastectomy 68 (49) 30 (44) 38 (56) Lumpectomy 39 (28) 15 (38) 24 (62) Hysterectomy 13 (9) 1 (8) 12 (92) Other 4 (3) - 4 (100) FSFI Scores Total Median (IQR) Desire Median (IQR) Arousal Median (IQR) Lubrication Median (IQR) Orgasm Median (IQR) Satisfaction Median (IQR) Pain Median (IQR) 9.85 1.80 1.83 1.20 1.20 2.00 1.20 14.00 1.20 2.10 1.80 2.80 2.80 1.60 7.20 1.80 1.50 1.05 0.60 1.20 0.20 0.004 0.844 0.163 0.023 0.003 0.012 0.004 FSFI Satisfaction Score <3.6 N (%) N (%) N (%) 3.6 27 (19) 16 (59) 11 (41) Unknown 36 (26) - - Changes to Penetrative Sex (n=66) Possible but uncomfortable Possible but painful Impossible due to pain 14 (16) 41 (62) 11 (18) 8 (57) 24 (41) 4 (36) 6 (43) 35 (59) 7 (64) 0.369 Ability to Orgasm (n=63) Unchanged More difficult Impossible 26 (41) 26 (41) 11 (18) 6 (23) 19 (73) 6 (55) 20 (77) 7 (27) 5 (46) <0.001 Presenting symptoms Vaginal dryness Painful sex Low desire Hot flashes 57 (55) 46 (45) 37 (36) 23 (22) - - - - - - - - - Genitourinary exam findings (n=139) 4 Vaginal dryness Loss of elasticity Loss of vascularity/pallor Loss of vaginal rugae Vaginal agglutination Vaginal scarring/adhesions Vaginal shortening Vaginal stenosis (presence of agglutination, scarring/adhesions, and/or shortening) 116 (83) 112 (81) 106 (76) 100 (74) 14 (10) 13 (9) 27 (19) 34 (23) - - - - - - - - - - - - - - - - - DCIS: Ductal Carcinoma In-Situ; AVES: Adapted Vulvovaginal Exam Score 1 History of surgery reported at time of first MUSIC visit for ANY reason (not necessarily cancer treatment) 2 Surgery done for cancer treatment purposes * Some percentages do not add up to 100% due to non-response, unknown or missing values 3 AI = Aromatase inhibitor (anastrozole, letrozole, exemestane) 4 Patients could have more than one exam finding † Same patient can be in multiple treatment categories ‡ P-values are calculated either with chi-square test for association or Fisher’s exact test, excluding unknown values. Presenting Symptoms, Menopausal Status, and Genitourinary Exam Findings The most common presenting symptoms were vaginal dryness (55%), dyspareunia (45%), low sexual desire (36%), and bothersome hot flashes (22%) (Table 1). At presentation, nearly 1 in 5 women disclosing penetrative sexual activity changes (n=66) reported that penetration was impossible. Furthermore, of those who reported changes to orgasm (n=63), 41% disclosed that orgasm was more difficult to achieve, and 18% reported that orgasm was impossible. At the time of cancer diagnosis, the majority of patients were pre-menopausal (63%). Out of all menopausal patients (n=46), 76% were found to have AVES >3 (p=0.045) (Table 1). Vulvovaginal Exam Findings Of those who underwent a GU exam (n=139), most patients had vaginal dryness (83%), loss of elasticity (81%), loss of rugae (74%), and loss of vascularity/pallor (76%). Vaginal agglutination was observed in 10% of patients, 19% had vaginal shortening, and 9% had vaginal scarring/adhesions (Figure 2). Overall, the rate of vaginal stenosis in this sample was 23% (Figure 1). Cancer Treatment, AVES Scores, and FSFI Most patients were prescribed endocrine therapy as part of their cancer treatment (67%), including tamoxifen and aromatase inhibitors (AIs). A greater proportion of patients who were prescribed endocrine therapy were found to have AVES >3 (p=0.011). When analyzed by endocrine therapy type, more patients with a history of AI use had AVES >3 (65%) compared to patients who prescribed tamoxifen only (33%) (Table 1). 108 patients completed the FSFI. Nearly every patient (n=106, 98%) scored lower than 26.0 on the FSFI scale, suggesting a high prevalence of sexual dysfunction or lack of sexual activity. The mean FSFI score was 10.8 (SD 7.4). AVES >3 was associated with lower FSFI scores in the lubrication, orgasm, satisfaction, and pain domains, as well as in total (Figure 2). There were no statistically significant differences between AVES categories with respect to the FSFI desire and arousal domains. Additional analyses did not reveal an association between lower desire and arousal domain scores in patients with a history of endocrine therapy or specifically, of aromatase inhibitor use (Supplemental Table 1). Multivariate Analysis Multivariate analyses to determine the association of patient and treatment factors with abnormal GU exam at presentation (higher AVES) adjusted for language, smoking status, insurance, surgery, chemotherapy, radiation therapy and immunotherapy confirmed that endocrine therapy receipt was associated with higher AVES scores, as those never prescribed endocrine therapy were less likely to have severe exam disruptions (aOR 0.05, 95% CI 0.00-0.75, p=0.030). Furthermore, FSFI domain pain scores were inversely associated with high AVES, denoting that normal (higher) pain domain score was associated with a normal GU exam (lower AVES) (aOR 0.67; 95%CI 0.48-0.95; p=0.023) (Table 2). An additional multivariate analysis further exploring the association of FSFI satisfaction domain scores with high AVES found that women with poor FSFI satisfaction domain score (<3.6) were nearly three times more likely to have worse AVES scores (aOR 2.81; 95%CI 1.03-7.65; p=0.044) (Table 3). Table 2. Factors associated with abnormal GU exam, where aOR<1 is associated with normal AVES (0-3) Covariates Adjusted OR 95% CI p-value Age ≥ 50 2.62 0.39-17.52 0.320 Race (White) 1.78 0.24-13.19 0.573 Ethnicity (Non-Hispanic/Latinx) 1.95 0.42-8.94 0.391 Menopausal at Diagnosis 1.40 0.18-11.07 0.749 Any Endocrine Therapy Use FSFI Desire Domain FSFI Lubrication Domain FSFI Orgasm Domain FSFI Pain Domain 0.05 1.14 1.26 0.57 0.67 0.0-0.75 0.54-2.39 0.67-2.37 0.31-1.04 0.48-0.95 0.030* 0.733 0.475 0.066 0.023* FSFI Satisfaction Domain 0.70 0.44-1.11 0.131 Adjusted for language, smoking status, surgery, chemotherapy, radiation therapy and immunotherapy receipt * Denotes statistically significant association AVES: Adapted Vulvovaginal Exam Score FSFI: Female Sexual Function Index Table 3. Factors associated with abnormal GU exam, where aOR>1 is associated with abnormal AVES (>3) Covariates Category Adjusted OR 95% CI p-value Age (years) <50 vs ≥50 0.75 0.20-2.80 0.667 Race All Others vs White 0.60 0.14-2.64 0.503 Ethnicity Hispanic vs Non-Hispanic 0.52 0.18-1.47 0.217 Menopause Status at Diagnosis No vs Yes 0.53 0.13-2.19 0.380 Endocrine Therapy Yes vs. No 0.20 0.05-0.80 0.024* FSFI Satisfaction <3.6 vs 3.6+ 2.81 1.03-7.65 0.044* Adjusted for language, smoking status, insurance, surgery, chemotherapy, radiation therapy and immunotherapy * Denotes statistically significant association with abnormal GU exam AVES: Adapted Vulvovaginal Exam Score FSFI: Female Sexual Function Index Discussion Our study is the first to correlate anatomic genitourinary exam disruptions to patient-reported sexual function in a diverse cohort of female cancer patients. In this population, patients reported a variety of sexual side effects from treatment, including vaginal dryness, decreased sexual desire, hot flashes, and dyspareunia. Changes to orgasm and increased pain with penetrative sex were common. Higher AVES scores, corresponding to more severe genitourinary exam disruptions, were associated with more sexual-related pain. Notably, low desire was not associated with worse AVES, suggesting that GU exam changes may not predict or explain changes to sexual desire after cancer treatment. This finding is in line with the hypothesis that sexual desire has both biological and psychological components, since the adverse effects of a cancer diagnosis and treatment may manifest in ways other than physical changes, such as emotional, mental, and psychological changes that affect sexual functioning [20]. Lastly, cancer patients with a history of endocrine therapy were more likely to have abnormal GU exams when compared to those without a history of endocrine therapy use. This finding was more pronounced in patients with a history of aromatase inhibitor use, which has not previously been characterized in a diverse population of cancer survivors. Elements of vaginal stenosis were identified in one-quarter of patients in this study. Previous studies characterized prevalence rates of vaginal stenosis after pelvic radiation therapy between 50% and 80% [21]. The current cohort differs from these populations because very few patients received pelvic radiation and most only received breast radiation, which highlights that iatrogenic estrogen suppression without pelvic radiation can seriously disrupt vaginal anatomy. Previously, vaginal stenosis in breast cancer patients on endocrine therapy has only been reported in one study [22]. Breast medical and surgical oncologists should be aware of this complication of treatment as it is oftentimes overlooked and can be treated when promptly identified. Elements of the female pelvic exam have been previously correlated to patient-reported sexual function outcomes. Eaton et al. found that the 4-item Vaginal Assessment Scale (VAS), a patient-reported measurement of vaginal symptoms, correlated with pain on exam [ 17 ], while Hwang et al. reported that pelvic floor muscle strength is positively associated with high desire, arousal, and satisfaction domains as well as total FSFI scores [23]. Notably, this study demonstrated a consistent inverse relationship between AVES and FSFI scores and is the first to directly correlate objective genitourinary exam disruptions to FSFI scores. The current study is unique in that it represents a diverse patient population with 57% Hispanic patients, identifies the relationship between FSFI score and genitourinary exam findings, and describes the prevalence of vaginal stenosis in a population of predominantly breast cancer patients. There were no significant differences identified among various demographic measures between the low and high AVES groups, but this could be attributed to sample size and the inclusion of patients with different sites of malignancy and therefore treatment protocol receipt. Additionally, while breast cancer and gynecologic cancer patients were well-represented, the population included a smaller proportion of patients with more rare cancers such as gastrointestinal and hematologic malignancies. Although the most symptomatic patients are more likely to be seen in the sexual survivorship program, which could lead to selection bias in our sample, providers should be prepared to offer targeted mitigation strategies to patients experiencing sexual function with treatment especially if a dedicated specialty program is not available. While the FSFI is well-validated and commonly used to assess sexual functioning in female cancer survivors, the questionnaire does not adequately represent women who were not sexually inactive within the past four weeks. In the survey, 15 of the 19 items include a “no sexual activity” or “did not attempt intercourse” response, which is assigned a score of zero [ 13 ]. However, these questions do not distinguish whether the absence of sexual activity was due to the lowest level of sexual functioning or a lack of a sexual partner, preference to not engage in penetrative sex, or other factors unrelated to changes secondary to cancer treatment, which may impact the analysis of FSFI response data [24, 25]. The current study included all participants who returned a FSFI survey, regardless of whether the participant was currently sexually active or not. To circumvent this issue, median scores were compared instead of means in Table 1 , and analyses specific to each domain including Desire and Satisfaction were included. Our ongoing work considers the number of “0” responses when analyzing total FSFI responses and employs other methods to assess sexual dysfunction that include sexually inactive women, such as the Female Sexual Distress Scale [26]. Future studies should seek to understand why women with cancer choose to not engage in sexual activity and consider this reasoning during comparative analyses. Any practitioner who treats patients with cancer, including but not limited to breast cancer, should be aware of the potential for sexual dysfunction during and after treatment. In order to optimize screening and referral strategies, brief sexual symptom questionnaires can be employed in this clinical setting [27]. Best practices for discussing and treating these concerns for providers who may not be comfortable discussing these sensitive topics are described in a recent publication directed towards breast surgical oncologists who encounter symptomatic breast cancer patients on endocrine suppression [28]. Patients themselves should also be gently encouraged to have open discussions about their symptoms in order to bring them to the attention of their oncologic team. Failing to recognize and treat these quality-of-life concerns may impact treatment compliance and therefore oncologic outcome. Declarations Conflicts of Interest and Funding Dr. Rojas has received speaker honoraria from Pacira Pharmaceuticals (2023) for a presentation highlighting perioperative multimodal analgesia strategies and has served in an advisory role for Merck and Novartis (2024). Dr. Rojas receives funding from the NCI Early-Stage Surgeon Scientist Program (ESSP) NIH/NCI P30 CCSG Supplement Grant (AWD-005240 | GR023102), 2023-2026. Ethics Approval Approval for the current study was granted by University of Miami Institutional Review Board. The research was conducted in accordance with the ethical standards set forth by the Declaration of Helsinki. Consent to Participate Informed consent was obtained from all individual participants included in the study. Only de-identified patient data is included in the present study. Data Availability The data that support the findings of this study are stored in the University of Miami RedCap database and are available from the corresponding author upon reasonable request. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Erin Kobiella, Sanjana Satish, Fay Pon, Lia Jeung, Chloe Shields, Melissa Curran, Tizeta Wolde, Jessica Moore, Samantha Greenseid, Tulay Koru-Sengul, Wei Zhao, Frank Penedo, and Kristin Rojas. The manuscript was drafted by Erin Kobiella, Sanjana Satish, Kristin Rojas and the final manuscript was completed by Erin Kobiella and Kristin Rojas. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. 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Prevalence of sexual dysfunction in women with cervical cancer: a systematic review and meta analysis. Psychology, Health & Medicine , 28 (2), 494–508. https://doi.org/10.1080/13548506.2022.2110270 Canty, J., Stabile, C., Milli, L., Seidel, B., Goldfrank, D., & Carter, J. (2019). Sexual Function in Women with Colorectal/Anal Cancer. Sexual Medicine Reviews , 7 (2), 202–222. https://doi.org/10.1016/j.sxmr.2018.12.001 Mejia-Gomez, J., Petrovic, I., Doherty, M., Kennedy, E., Wolfman, W., Jacobson, M., Brezden, C., Philippopoulos, E., & Lukovic, J. (2023). Sexual dysfunction in female patients with anal cancer treated with curative intent: A systematic review of the literature. Radiotherapy and Oncology , 178 , 109437. https://doi.org/10.1016/j.radonc.2022.109437 Gahm, J., Wickman, M., & Brandberg, Y. (2010). Bilateral prophylactic mastectomy in women with inherited risk of breast cancer—prevalence of pain and discomfort, impact on sexuality, quality of life and feelings of regret two years after surgery. Breast , 19 (6), 462–469. https://doi.org/10.1016/j.breast.2010.05.003 Machado, A. M. N., Hamerschlak, N., Rodrigues, M., Piccinato, C. A., Podgaec, S., & Mauad, L. M. Q. (2019). Female genital tract chronic graft-versus-host disease: A narrative review. Hematology, Transfusion and Cell Therapy , 41 (1), 69–75. https://doi.org/10.1016/j.htct.2018.06.005 Faubion, S. S., MacLaughlin, K. L., Long, M. E., Pruthi, S., & Casey, P. M. (2015). Surveillance and Care of the Gynecologic Cancer Survivor. Journal of Women's Health , 24 (11), 899–906. https://doi.org/10.1089/jwh.2014.5127 Melissant, H. C., Jansen, F., Schutte, L. E. R., Lissenberg-Witte, B. I., Buter, J., Leemans, C. R., Sprangers, M. A., Vergeer, M. R., Laan, E. T. M., & Verdonck de Leeuw, I. M. (2018). The course of sexual interest and enjoyment in head and neck cancer patients treated with primary (chemo)radiotherapy. Oral Oncology , 83 , 120–126. https://doi.org/10.1016/j.oraloncology.2018.06.016 Baser, R. E., Li, Y., & Carter, J. (2012). Psychometric validation of the Female Sexual Function Index (FSFI) in cancer survivors. Cancer , 118 (18), 4606–4618. https://doi.org/10.1002/cncr.26739 Bartula, I., & Sherman, K. A. (2015). The Female Sexual Functioning Index (FSFI): evaluation of acceptability, reliability, and validity in women with breast cancer. Supportive Care Cancer , 23 (9), 2633–2641. https://doi.org/10.1007/s00520 0152623-y. Wiegel, M., Meston, C., & Rosen, R. (2005). The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. Journal of Sex & Marital Therapy , 31 (1), 1–20. https://doi.org/10.1080/00926230590475206 . Gerstenberger, E. P., Rosen, R. C., Brewer, J. V., Meston, C. M., Brotto, L. A., Wiegel, M., & Sand, M. (2010). Sexual desire and the female sexual function Additional Declarations Competing interest reported. Dr. Rojas has received speaker honoraria from Pacira Pharmaceuticals (2023) for a presentation highlighting perioperative multimodal analgesia strategies and has served in an advisory role for Merck and Novartis (2024). Dr. Rojas receives funding from the NCI Early-Stage Surgeon Scientist Program (ESSP) NIH/NCI P30 CCSG Supplement Grant (AWD-005240 | GR023102), 2023-2026. Supplementary Files TabS1.jpg Cite Share Download PDF Status: Published Journal Publication published 13 Nov, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 08 Sep, 2025 Reviews received at journal 08 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers invited by journal 26 Aug, 2025 Editor assigned by journal 26 Aug, 2025 Submission checks completed at journal 27 Jul, 2025 First submitted to journal 16 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7143576","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509242543,"identity":"bdf702b4-7f5a-4655-af7b-4e7fbfbe1f5c","order_by":0,"name":"Erin Kobiella","email":"","orcid":"","institution":"University of Miami Miller Medical School","correspondingAuthor":false,"prefix":"","firstName":"Erin","middleName":"","lastName":"Kobiella","suffix":""},{"id":509242544,"identity":"03c10a48-f5dc-481c-b2cc-6fee9e528a1f","order_by":1,"name":"Sanjana Satish","email":"","orcid":"","institution":"University of Pennsylvania Perelman School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sanjana","middleName":"","lastName":"Satish","suffix":""},{"id":509242545,"identity":"1854ba28-8de6-4d94-a9d4-ad8243133c46","order_by":2,"name":"Fay Pon","email":"","orcid":"","institution":"University of Miami Miller Medical School","correspondingAuthor":false,"prefix":"","firstName":"Fay","middleName":"","lastName":"Pon","suffix":""},{"id":509242546,"identity":"459a408a-cb25-47ec-b76e-6491104176f1","order_by":3,"name":"Lia Jueng","email":"","orcid":"","institution":"University of Miami Miller Medical School","correspondingAuthor":false,"prefix":"","firstName":"Lia","middleName":"","lastName":"Jueng","suffix":""},{"id":509242547,"identity":"45aba0ed-8116-40e5-ab94-88acbb7dcae9","order_by":4,"name":"Chloe Shields","email":"","orcid":"","institution":"University of Miami Miller Medical School","correspondingAuthor":false,"prefix":"","firstName":"Chloe","middleName":"","lastName":"Shields","suffix":""},{"id":509242548,"identity":"25064f86-f922-4182-ac1c-bdf8788b42ee","order_by":5,"name":"Melissa Curran","email":"","orcid":"","institution":"University of Miami Miller Medical School","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"","lastName":"Curran","suffix":""},{"id":509242549,"identity":"d7a43d05-a6fa-48df-947d-6ab26972ff3a","order_by":6,"name":"Tizeta Wolde","email":"","orcid":"","institution":"University of Miami Miller Medical School","correspondingAuthor":false,"prefix":"","firstName":"Tizeta","middleName":"","lastName":"Wolde","suffix":""},{"id":509242550,"identity":"ebd710e7-c32f-4ee6-ba8d-1891f5241ae0","order_by":7,"name":"Jessica F. Moore","email":"","orcid":"","institution":"University of Miami Miller School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"F.","lastName":"Moore","suffix":""},{"id":509242551,"identity":"766a12c3-f33d-48b0-aaf8-a078ac54b0e7","order_by":8,"name":"Samantha Greenseid","email":"","orcid":"","institution":"University of Miami Miller Medical School","correspondingAuthor":false,"prefix":"","firstName":"Samantha","middleName":"","lastName":"Greenseid","suffix":""},{"id":509242552,"identity":"37a10632-9ebc-4f8c-8544-f5e7864932f6","order_by":9,"name":"Tulay Koru-Sengul","email":"","orcid":"","institution":"University of Miami Miller School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tulay","middleName":"","lastName":"Koru-Sengul","suffix":""},{"id":509242553,"identity":"df3efade-84fd-48a6-9351-5227089110f5","order_by":10,"name":"Wei Zhao","email":"","orcid":"","institution":"University of Miami Miller School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Zhao","suffix":""},{"id":509242554,"identity":"3244053e-a043-4f2b-a8cb-60858bb972fc","order_by":11,"name":"Frank Penedo","email":"","orcid":"","institution":"University of Miami Miller School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Penedo","suffix":""},{"id":509242555,"identity":"92cee0fe-1207-4492-a298-bbfd1fbd8b47","order_by":12,"name":"Kristin E. Rojas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACCSA2YGCwAVIJYMQDESCsJY1ELUBwGKIFCvBrkZx9+EDBjz/no/nZE1g3PKjZJsPA3rxNAp8Wab60BMPettu5M3sesN1IOHabh4HnWBleLXI8PAYGvA23czfcSABqYQNqkcgxI6jF8M+fc7n7wVr+AbXIv8GvRRqoxZiH7UDuBgmglsQ2kC08+LVI9rAlGMu2JefOOPOw7UZi320eNp60Ygt8WiTOMB8zfPPHLre/PfnYzR/fbtvzsx/eeAOfFiBgg0YDYwOES0A5CDA/IELRKBgFo2AUjGQAAHxqSF89g2YlAAAAAElFTkSuQmCC","orcid":"","institution":"University of Miami Miller School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Kristin","middleName":"E.","lastName":"Rojas","suffix":""}],"badges":[],"createdAt":"2025-07-16 22:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7143576/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7143576/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-025-10046-2","type":"published","date":"2025-11-13T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90616648,"identity":"98d7a480-e36c-415a-b3e3-55cdbd167ac3","added_by":"auto","created_at":"2025-09-04 18:45:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":221215,"visible":true,"origin":"","legend":"\u003cp\u003eGenitourinary exam findings.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7143576/v1/cb522d00e9cec2b30e77285e.png"},{"id":90615959,"identity":"161456aa-8056-4ef4-a2d5-1ac4fa7ac670","added_by":"auto","created_at":"2025-09-04 18:37:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50039,"visible":true,"origin":"","legend":"\u003cp\u003eTotal and domain FSFI score analyzed by AVES score groups, n=108.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7143576/v1/7000fd9b5ed38dd50fd56d0b.png"},{"id":96105106,"identity":"126c44f6-23f6-4b24-9c0f-c78a4af1942a","added_by":"auto","created_at":"2025-11-17 16:08:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1246615,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7143576/v1/c3fc2de2-7487-444c-b943-baa968cbeb4e.pdf"},{"id":90615958,"identity":"84d54c1d-2f1e-471e-b025-305e0b3be17e","added_by":"auto","created_at":"2025-09-04 18:37:06","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":62911,"visible":true,"origin":"","legend":"","description":"","filename":"TabS1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7143576/v1/4acf0e8a71c80ee4eec6ab88.jpg"}],"financialInterests":"Competing interest reported. Dr. Rojas has received speaker honoraria from Pacira Pharmaceuticals (2023) for a presentation highlighting perioperative multimodal analgesia strategies and has served in an advisory role for Merck and Novartis (2024). \nDr. Rojas receives funding from the NCI Early-Stage Surgeon Scientist Program (ESSP) NIH/NCI P30 CCSG Supplement Grant (AWD-005240 | GR023102), 2023-2026.","formattedTitle":"More Than Just “Vaginal Dryness”: Sexual Dysfunction Correlates with Genitourinary Anatomy Disruptions in Female Cancer Survivors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs a result of advancements in targeted therapies, the number of cancer survivors in the United States is expected to exceed 20\u0026nbsp;million by 2026 with approximately 10.3\u0026nbsp;million survivors predicted to be women [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Adding to the challenges that survivors face, many cite sexuality as a major concern and unmet need [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFemale sexual dysfunction (FSD) is reported in women with all cancer types, including breast, gynecologic, hematologic, colorectal, and head and neck cancers [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Women with cancer are estimated to have a 2.7- to 3.5-fold increased risk of developing sexual dysfunction compared to women without cancer [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In patients with breast cancer, the prevalence of FSD is estimated to be 50\u0026ndash;75% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additionally, an estimated 43% of gynecologic cancer survivors report sexual dysfunction [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], whereas patients with cervical cancer experience sexual dysfunction at an even higher rate of 80% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Sexual difficulties also occur in up to 75% of female patients who are treated for colorectal cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and 85% of female patients with anal cancer report symptoms of sexual dysfunction, particularly dyspareunia in up to 65% of these patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Those with an elevated risk for malignancy due to genetic predisposition syndromes also report high rates of negative sexual side effects after risk-reducing surgeries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and iatrogenic estrogen suppression related to preventive therapies can incite or worsen menopausal symptoms. Lastly, those with hematologic malignancies have an increased risk of immune-mediated vulvar disorders such as vulvovaginal graft-versus-host disease (GVHD) and lichen sclerosis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Negative disruptions to female sexual health can be the sequelae of any type of malignancy, not just breast and gynecologic types. Despite the high rates of distressing sexual symptoms in female cancer survivors, sexual dysfunction remains critically undertreated.\u003c/p\u003e\u003cp\u003eMost commonly, female cancer survivors experience treatment-induced genitourinary syndrome of menopause (GSM), which can include symptoms of vaginal dryness, dyspareunia, diminished libido, poor arousal, and difficulties with orgasm. Chemotherapy, pelvic radiation, bilateral salpingo-oophorectomy (BSO), and estrogen suppression increase the risk of GSM [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and premenopausal patients who receive chemotherapy and experience premature iatrogenic menopause may be unprepared for these abrupt changes that impact their quality of life [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although genitourinary exams are recommended for cancer survivors who present for evaluation of sexual concerns, few studies detail the anatomic disruptions encountered during the exams of female survivors and the effect such changes have on the patient\u0026rsquo;s sexual well-being and overall quality of life. Therefore, the objective of the current study was to describe genitourinary exam findings in a diverse population of female cancer survivors and correlate these findings to patient-reported sexual dysfunction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective cohort study included female cancer patients presenting to a sexual health after cancer program at an NCI-designated cancer center in South Florida between November 2020 and June 2022. The study was approved by the University of Miami Institutional Review Board, and research was conducted according to the principles of the Declaration of Helsinki. Informed consent was obtained from all individual participants. The MUSIC\u0026trade; (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eM\u003c/span\u003eenopause, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eU\u003c/span\u003erogenital, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eS\u003c/span\u003eexual Health and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eI\u003c/span\u003entimacy \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eC\u003c/span\u003elinic) Sexual Health After Cancer Program provides a safe space where stigmatized topics such as sexual well-being can be discussed and treated. Patients referred to the MUSIC\u0026trade; Program receive a one-on-one clinic visit with a subspecialized board-certified women\u0026rsquo;s health specialist to discuss symptoms related to sexual wellness. Patients also undergo a complete physical exam and receive a personalized treatment plan. All intake paperwork in the Program is available in English and Spanish.\u003c/p\u003e\u003cp\u003eElectronic medical records were queried for demographic data, clinical history, cancer diagnoses and treatment, and patient-reported sexual health symptoms (e.g., vaginal dryness, painful sex, low desire). Information pertaining to sexual health was collected, including sexual activity frequency before and after cancer treatment, pain associated with sex, orgasm difficulties, genitourinary (GU) exam findings, and treatment plan after the first program visit.\u003c/p\u003e\u003cp\u003eAs part of the intake paperwork, Female Sexual Function Index (FSFI) was administered in English and Spanish at the first visit to measure patient-reported sexual function. The FSFI is a 19-item Likert scale questionnaire that assesses female sexual functioning through six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI was validated for use in gynecologic and cervical cancer populations in 2012 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and breast cancer populations in 2015 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The maximum FSFI score is 36, and a total FSFI score\u0026thinsp;\u0026le;\u0026thinsp;26.0 indicates female sexual dysfunction [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Of note, desire domain scores\u0026thinsp;\u0026lt;\u0026thinsp;5.0 are indicative of hypoactive sexual desire disorder [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Total scores and domain scores were calculated.\u003c/p\u003e\u003cp\u003eAn Adapted Vulvovaginal Exam Score (AVES) was calculated for each patient who underwent a genitourinary (GU) exam. This score was developed from the Vagina; Health Assessment described in the supplementary material of a previous publication [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and measures the integrity of the vaginal rugae, vascularity, epithelial integrity, elasticity, and vaginal moisture. For each individual exam finding, a score of 0 corresponds to no disruption, a score of 1 indicates mild disruption, and a score of 2 indicates severe disruption. For measurement of vaginal shortening, \u0026lt;\u0026thinsp;4 cm was defined as severe, 4\u0026ndash;6 cm was moderate, and \u0026gt;\u0026thinsp;6 cm was considered normal. Based on the distribution of scores in this population, the AVES cutoff point for severe exam disruption was established at the first quartile. Subsequently, AVES 0\u0026ndash;3 correlated to a normal GU exam, whereas AVES greater than 3 correlated to severe GU exam disruptions. The prevalence of vaginal stenosis in this sample was also determined based on the presence of vaginal shortening, vaginal agglutination, and/or vaginal adhesions/scarring on genitourinary exam.\u003c/p\u003e\u003cp\u003eData was collected and stored using the REDCap (Research Electronic Data Capture) tool. REDCap is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources [18, 19].\u003c/p\u003e\u003cp\u003eDemographic, clinical, and treatment characteristics and patient-reported symptoms were summarized with descriptive statistics. Chi-square test for association and Fisher\u0026rsquo;s exact test, if applicable, were employed to correlate AVES groups to patient characteristics. Mean FSFI total and domain scores were compared between AVES groups (0\u0026ndash;3 vs. \u0026gt;3) using student\u0026rsquo;s t-test. Domain score cutoffs were used based on previously published studies. Multivariable binary logistic regression model was fit for high AVES (\u0026gt;\u0026thinsp;3) with reference group of low-AVES (0\u0026ndash;3) by incorporating clinically relevant variables in the model as covariates. Adjusted odds ratios (aOR) and corresponding 95% confidence intervals along with p-values are calculated. Data management and statistical analysis were performed with SAS version 9.4 for Windows (SAS Institute Inc., Cary, NC).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eDemographics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBetween November 2020 and June 2022, 162 female cis-gender patients were evaluated, and AVES was calculated for 139 patients (86%). Overall, the mean age was 46 years (range: 19-70), and most patients were under 50 years old (63%). Many patients were White (84%) and/or Hispanic (57%). Most patients reported English as their primary language (74%), and a significant proportion of patients reported a primary language of Spanish (26%). One-quarter of the population reported current or previous tobacco use, and one-quarter of patients had Medicare or Medicaid for insurance coverage (27%). Most patients had breast cancer (79%), followed by gynecologic cancer (9%). \u0026nbsp;A small number of patients had a history of gastrointestinal (GI) malignancy (2%), hematologic malignancy (8%), or other cancer subtypes such as lymphoma, renal malignancies, and pseudomyxoma peritonei (1.4%). There were no significant differences in AVES groups (0-3 and \u0026gt;3) by race, ethnicity, primary language, smoking status, insurance, cancer type or stage, although there was a trend towards a greater proportion of patients \u003cu\u003e\u0026gt;\u003c/u\u003e 50 to have more higher AVES score (more abnormal GU exams), as shown in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographic and clinical characteristics of the study population by AVES exam group\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 353px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 248px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAVES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 353px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0-3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u0026Dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCis-gender female\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e139 (100)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e50 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e89 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e-\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.053\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e50\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e50 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e13 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e37 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026lt;50\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003cp\u003eMin, Max\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e87 (63)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46 (11)\u003c/p\u003e\n \u003cp\u003e19, 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e37 (43)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e50 (57)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.650\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e116 (84)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e43 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e73 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eBlack/Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e16 (12)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e11 (69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.154\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e79 (57)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e32 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e47 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eNon-Hispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e56 (40)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e16 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e40 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Language\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.672\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e103 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e36 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e67 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eSpanish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e36 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e14 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e22 (61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking Status\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.832\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e102 (73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e37 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e65 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eFormer/Current\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e35 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e12 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e23 (66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance Type\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.764\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e87 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e31 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e56 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eMedicare/Medicaid\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e38 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e15 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e23 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e14 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e10 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMenopausal at Diagnosis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.045\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003ePremenopausal \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e87 (63) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003ePostmenopausal \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e46 (33)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e11 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e35 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer Type\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.096\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eBreast \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e110 (79)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e45 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e65 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eGynecologic \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e13 (9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e1 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e12 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eLeukemia \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e11 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e8 (73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eGastrointestinal \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e3 (2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eOther \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e2 (1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e1 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e1 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Tumor Stage\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.233\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eDCIS-Stage II\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e67 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e29 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e38 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eStage III-IV\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e18 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e13 (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eUnknown\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e54 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHysterectomy performed\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e54 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e13 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e33 (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBilateral Oophorectomy\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e52 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e12 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e32 (73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment received\u003c/strong\u003e\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eEndocrine Therapy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Tamoxifen only\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Tamoxifen + AI or AI only\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e93 (67)\u003c/p\u003e\n \u003cp\u003e21 (22)\u003c/p\u003e\n \u003cp\u003e72 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e39 (42)\u003c/p\u003e\n \u003cp\u003e14 (67)\u003c/p\u003e\n \u003cp\u003e25 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e54 (58)\u003c/p\u003e\n \u003cp\u003e7 (33)\u003c/p\u003e\n \u003cp\u003e47 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eChemotherapy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e103 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e33 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e70 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.102\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eRadiation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e86 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e29 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e57 (66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.334\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eImmunotherapy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e18 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e7 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e11 (61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.735\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 254px;\"\u003e\n \u003cp\u003eSurgery\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e124 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e46 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e78 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.427\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eSurgery and Chemotherapy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e89 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e29 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e60 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.406\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eSurgery and Endocrine \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e32 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e16 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e16 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.406\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e9 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e7 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.406\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Surgery\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.049\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eMastectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e68 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e30 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e38 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eLumpectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e39 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e15 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e24 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eHysterectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e13 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e1 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e12 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e4 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e4 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFSFI Scores\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTotal Median (IQR)\u003c/p\u003e\n \u003cp\u003eDesire Median (IQR)\u003c/p\u003e\n \u003cp\u003eArousal Median (IQR)\u003c/p\u003e\n \u003cp\u003eLubrication Median (IQR)\u003c/p\u003e\n \u003cp\u003eOrgasm Median (IQR)\u003c/p\u003e\n \u003cp\u003eSatisfaction Median (IQR)\u003c/p\u003e\n \u003cp\u003ePain Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.85\u003c/p\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e14.00\u003c/p\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003cp\u003e2.10\u003c/p\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003cp\u003e1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e7.20\u003c/p\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003cp\u003e0.844\u003c/p\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFSFI Satisfaction Score \u0026lt;3.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u0026lt;3.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e76 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e26 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e50 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.023\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e3.6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e27 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e16 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e11 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003eUnknown\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e36 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChanges to Penetrative Sex (n=66)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePossible but uncomfortable\u003cbr\u003e\u0026nbsp;Possible but painful\u003cbr\u003e\u0026nbsp;Impossible due to pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;14 (16)\u003cbr\u003e\u0026nbsp;41 (62)\u003cbr\u003e\u0026nbsp;11 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (57)\u003c/p\u003e\n \u003cp\u003e24 (41)\u003c/p\u003e\n \u003cp\u003e4 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (43)\u003c/p\u003e\n \u003cp\u003e35 (59)\u003c/p\u003e\n \u003cp\u003e7 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0.369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbility to Orgasm (n=63)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUnchanged\u003cbr\u003e\u0026nbsp;More difficult\u003cbr\u003e\u0026nbsp;Impossible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;26 (41)\u003cbr\u003e\u0026nbsp;26 (41)\u003cbr\u003e\u0026nbsp;11 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (23)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;19 (73)\u003c/p\u003e\n \u003cp\u003e6 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (77)\u003c/p\u003e\n \u003cp\u003e7 (27)\u003c/p\u003e\n \u003cp\u003e5 (46)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresenting symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eVaginal dryness\u003c/p\u003e\n \u003cp\u003ePainful sex\u003c/p\u003e\n \u003cp\u003eLow desire\u003c/p\u003e\n \u003cp\u003eHot flashes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57 (55)\u003c/p\u003e\n \u003cp\u003e46 (45)\u003c/p\u003e\n \u003cp\u003e37 (36)\u003c/p\u003e\n \u003cp\u003e23 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 254px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGenitourinary exam findings (n=139)\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eVaginal dryness\u003c/p\u003e\n \u003cp\u003eLoss of elasticity\u003c/p\u003e\n \u003cp\u003eLoss of vascularity/pallor\u003c/p\u003e\n \u003cp\u003eLoss of vaginal rugae\u003c/p\u003e\n \u003cp\u003eVaginal agglutination\u003c/p\u003e\n \u003cp\u003eVaginal scarring/adhesions\u003c/p\u003e\n \u003cp\u003eVaginal shortening\u003c/p\u003e\n \u003cp\u003eVaginal stenosis (presence of agglutination, scarring/adhesions, and/or shortening)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e116 (83)\u003c/p\u003e\n \u003cp\u003e112 (81)\u003c/p\u003e\n \u003cp\u003e106 (76)\u003c/p\u003e\n \u003cp\u003e100 (74)\u003c/p\u003e\n \u003cp\u003e14 (10)\u003c/p\u003e\n \u003cp\u003e13 (9)\u003c/p\u003e\n \u003cp\u003e27 (19)\u003c/p\u003e\n \u003cp\u003e34 (23)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDCIS: Ductal Carcinoma In-Situ; AVES: Adapted Vulvovaginal Exam Score\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e History of surgery reported at time of first MUSIC visit for ANY reason (not necessarily cancer treatment)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eSurgery done for cancer treatment purposes\u003c/p\u003e\n\u003cp\u003e* Some percentages do not add up to 100% due to non-response, unknown or missing values\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eAI = Aromatase inhibitor (anastrozole, letrozole, exemestane)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u0026nbsp;\u003c/sup\u003ePatients could have more than one exam finding\u003c/p\u003e\n\u003cp\u003e\u0026dagger; Same patient can be in multiple treatment categories\u003c/p\u003e\n\u003cp\u003e\u0026Dagger; P-values are calculated either with chi-square test for association or Fisher\u0026rsquo;s exact test, excluding unknown values.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePresenting Symptoms, Menopausal Status, and Genitourinary Exam Findings\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe most common presenting symptoms were vaginal dryness (55%), dyspareunia (45%), low sexual desire (36%), and bothersome hot flashes (22%) (Table 1). At presentation, nearly 1 in 5 women disclosing penetrative sexual activity changes (n=66) reported that penetration was impossible. Furthermore, of those who reported changes to orgasm (n=63), 41% disclosed that orgasm was more difficult to achieve, and 18% reported that orgasm was impossible. At the time of cancer diagnosis, the majority of patients were pre-menopausal (63%). Out of all menopausal patients (n=46), 76% were found to have AVES \u0026gt;3 (p=0.045) (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVulvovaginal Exam Findings\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf those who underwent a GU exam (n=139), most patients had vaginal dryness (83%), loss of elasticity (81%), loss of rugae (74%), and loss of vascularity/pallor (76%). Vaginal agglutination was observed in 10% of patients, 19% had vaginal shortening, and 9% had vaginal scarring/adhesions (Figure 2). Overall, the rate of vaginal stenosis in this sample was 23% (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCancer Treatment, AVES Scores, and FSFI\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost patients were prescribed endocrine therapy as part of their cancer treatment (67%), including tamoxifen and aromatase inhibitors (AIs). A greater proportion of patients who were prescribed endocrine therapy were found to have AVES \u0026gt;3 (p=0.011). When analyzed by endocrine therapy type, more patients with a history of AI use had AVES \u0026gt;3 (65%) compared to patients who prescribed tamoxifen only (33%) (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e108 patients completed the FSFI. Nearly every patient (n=106, 98%) scored lower than 26.0 on the FSFI scale, suggesting a high prevalence of sexual dysfunction or lack of sexual activity. The mean FSFI score was 10.8 (SD 7.4). AVES \u0026gt;3 was associated with lower FSFI scores in the lubrication, orgasm, satisfaction, and pain domains, as well as in total (Figure 2). There were no statistically significant differences between AVES categories with respect to the FSFI desire and arousal domains. Additional analyses did not reveal an association between lower desire and arousal domain scores in patients with a history of endocrine therapy or specifically, of aromatase inhibitor use (Supplemental Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMultivariate Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMultivariate analyses to determine the association of patient and treatment factors with abnormal GU exam at presentation (higher AVES) adjusted for language, smoking status, insurance, surgery, chemotherapy, radiation therapy and immunotherapy confirmed that endocrine therapy receipt was associated with higher AVES scores, as those never prescribed endocrine therapy were less likely to have severe exam disruptions (aOR 0.05, 95% CI 0.00-0.75, p=0.030). Furthermore, FSFI domain pain scores were inversely associated with high AVES, denoting that normal (higher) pain domain score was associated with a normal GU exam (lower AVES) (aOR 0.67; 95%CI 0.48-0.95; p=0.023) (Table 2). An additional multivariate analysis further exploring the association of FSFI satisfaction domain scores with high AVES\u0026nbsp;found that women with poor FSFI satisfaction domain score (\u0026lt;3.6) were nearly three times more likely to have worse AVES scores (aOR 2.81; 95%CI 1.03-7.65; p=0.044) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Factors associated with abnormal GU exam, where aOR\u0026lt;1 is associated with normal AVES (0-3)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCovariates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eAge \u0026ge; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e2.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e0.39-17.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eRace (White)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e0.24-13.19\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.573\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eEthnicity (Non-Hispanic/Latinx)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e0.42-8.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.391\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eMenopausal at Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e0.18-11.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.749\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eAny Endocrine Therapy Use\u003c/p\u003e\n \u003cp\u003eFSFI Desire Domain\u003c/p\u003e\n \u003cp\u003eFSFI Lubrication Domain\u003c/p\u003e\n \u003cp\u003eFSFI Orgasm Domain\u003c/p\u003e\n \u003cp\u003eFSFI Pain Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003cp\u003e1.26\u003c/p\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e0.0-0.75\u003c/p\u003e\n \u003cp\u003e0.54-2.39\u003c/p\u003e\n \u003cp\u003e0.67-2.37\u003c/p\u003e\n \u003cp\u003e0.31-1.04\u003c/p\u003e\n \u003cp\u003e0.48-0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.030*\u003c/p\u003e\n \u003cp\u003e0.733\u003c/p\u003e\n \u003cp\u003e0.475\u003c/p\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003cp\u003e0.023*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eFSFI Satisfaction Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e0.44-1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 630px;\"\u003e\n \u003cp\u003eAdjusted for language, smoking status, surgery, chemotherapy, radiation therapy and immunotherapy receipt\u003c/p\u003e\n \u003cp\u003e* Denotes statistically significant association\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAVES: Adapted Vulvovaginal Exam Score\u003c/p\u003e\n\u003cp\u003eFSFI: Female Sexual Function Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Factors associated with abnormal GU exam, where aOR\u0026gt;1 is associated with abnormal AVES (\u0026gt;3)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCovariates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026lt;50 vs \u0026ge;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.75\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.20-2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.667\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eAll Others vs White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.14-2.64\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.503\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eHispanic vs Non-Hispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.18-1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eMenopause Status at Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eNo vs Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.13-2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.380\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eEndocrine Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eYes vs. No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.05-0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.024*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eFSFI Satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026lt;3.6 vs 3.6+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e1.03-7.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.044*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 630px;\"\u003e\n \u003cp\u003eAdjusted for language, smoking status, insurance, surgery, chemotherapy, radiation therapy and immunotherapy\u003c/p\u003e\n \u003cp\u003e* Denotes statistically significant association with abnormal GU exam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAVES: Adapted Vulvovaginal Exam Score\u003c/p\u003e\n\u003cp\u003eFSFI: Female Sexual Function Index\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study is the first to correlate anatomic genitourinary exam disruptions to patient-reported sexual function in a diverse cohort of female cancer patients. In this population, patients reported a variety of sexual side effects from treatment, including vaginal dryness, decreased sexual desire, hot flashes, and dyspareunia. Changes to orgasm and increased pain with penetrative sex were common. Higher AVES scores, corresponding to more severe genitourinary exam disruptions, were associated with more sexual-related pain. Notably, low desire was not associated with worse AVES, suggesting that GU exam changes may not predict or explain changes to sexual desire after cancer treatment. This finding is in line with the hypothesis that sexual desire has both biological and psychological components, since the adverse effects of a cancer diagnosis and treatment may manifest in ways other than physical changes, such as emotional, mental, and psychological changes that affect sexual functioning [20]. Lastly, cancer patients with a history of endocrine therapy were more likely to have abnormal GU exams when compared to those without a history of endocrine therapy use. This finding was more pronounced in patients with a history of aromatase inhibitor use, which has not previously been characterized in a diverse population of cancer survivors.\u003c/p\u003e\u003cp\u003eElements of vaginal stenosis were identified in one-quarter of patients in this study. Previous studies characterized prevalence rates of vaginal stenosis after pelvic radiation therapy between 50% and 80% [21]. The current cohort differs from these populations because very few patients received pelvic radiation and most only received breast radiation, which highlights that iatrogenic estrogen suppression without pelvic radiation can seriously disrupt vaginal anatomy. Previously, vaginal stenosis in breast cancer patients on endocrine therapy has only been reported in one study [22]. Breast medical and surgical oncologists should be aware of this complication of treatment as it is oftentimes overlooked and can be treated when promptly identified.\u003c/p\u003e\u003cp\u003eElements of the female pelvic exam have been previously correlated to patient-reported sexual function outcomes. Eaton et al. found that the 4-item Vaginal Assessment Scale (VAS), a patient-reported measurement of vaginal symptoms, correlated with pain on exam [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], while Hwang et al. reported that pelvic floor muscle strength is positively associated with high desire, arousal, and satisfaction domains as well as total FSFI scores [23]. Notably, this study demonstrated a consistent inverse relationship between AVES and FSFI scores and is the first to directly correlate objective genitourinary exam disruptions to FSFI scores.\u003c/p\u003e\u003cp\u003eThe current study is unique in that it represents a diverse patient population with 57% Hispanic patients, identifies the relationship between FSFI score and genitourinary exam findings, and describes the prevalence of vaginal stenosis in a population of predominantly breast cancer patients. There were no significant differences identified among various demographic measures between the low and high AVES groups, but this could be attributed to sample size and the inclusion of patients with different sites of malignancy and therefore treatment protocol receipt. Additionally, while breast cancer and gynecologic cancer patients were well-represented, the population included a smaller proportion of patients with more rare cancers such as gastrointestinal and hematologic malignancies. Although the most symptomatic patients are more likely to be seen in the sexual survivorship program, which could lead to selection bias in our sample, providers should be prepared to offer targeted mitigation strategies to patients experiencing sexual function with treatment especially if a dedicated specialty program is not available.\u003c/p\u003e\u003cp\u003eWhile the FSFI is well-validated and commonly used to assess sexual functioning in female cancer survivors, the questionnaire does not adequately represent women who were not sexually inactive within the past four weeks. In the survey, 15 of the 19 items include a \u0026ldquo;no sexual activity\u0026rdquo; or \u0026ldquo;did not attempt intercourse\u0026rdquo; response, which is assigned a score of zero [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, these questions do not distinguish whether the absence of sexual activity was due to the lowest level of sexual functioning or a lack of a sexual partner, preference to not engage in penetrative sex, or other factors unrelated to changes secondary to cancer treatment, which may impact the analysis of FSFI response data [24, 25]. The current study included all participants who returned a FSFI survey, regardless of whether the participant was currently sexually active or not. To circumvent this issue, median scores were compared instead of means in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and analyses specific to each domain including Desire and Satisfaction were included. Our ongoing work considers the number of \u0026ldquo;0\u0026rdquo; responses when analyzing total FSFI responses and employs other methods to assess sexual dysfunction that include sexually inactive women, such as the Female Sexual Distress Scale [26]. Future studies should seek to understand why women with cancer choose to not engage in sexual activity and consider this reasoning during comparative analyses.\u003c/p\u003e\u003cp\u003eAny practitioner who treats patients with cancer, including but not limited to breast cancer, should be aware of the potential for sexual dysfunction during and after treatment. In order to optimize screening and referral strategies, brief sexual symptom questionnaires can be employed in this clinical setting [27]. Best practices for discussing and treating these concerns for providers who may not be comfortable discussing these sensitive topics are described in a recent publication directed towards breast surgical oncologists who encounter symptomatic breast cancer patients on endocrine suppression [28]. Patients themselves should also be gently encouraged to have open discussions about their symptoms in order to bring them to the attention of their oncologic team. Failing to recognize and treat these quality-of-life concerns may impact treatment compliance and therefore oncologic outcome.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eConflicts of Interest and Funding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDr. Rojas has received speaker honoraria from Pacira Pharmaceuticals (2023) for a presentation highlighting perioperative multimodal analgesia strategies and has served in an advisory role for Merck and Novartis (2024). Dr. Rojas receives funding from the NCI Early-Stage Surgeon Scientist Program (ESSP) NIH/NCI P30 CCSG Supplement Grant (AWD-005240 | GR023102), 2023-2026.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics Approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eApproval for the current study was granted by University of Miami Institutional Review Board. The research was conducted in accordance with the ethical standards set forth by the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to Participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study. Only de-identified patient data is included in the present study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availability\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are stored in the University of Miami RedCap database and are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Erin Kobiella, Sanjana Satish, Fay Pon, Lia Jeung, Chloe Shields, Melissa Curran, Tizeta Wolde, Jessica Moore, Samantha Greenseid, Tulay Koru-Sengul, Wei Zhao, Frank Penedo, and Kristin Rojas. The manuscript was drafted by Erin Kobiella, Sanjana Satish, Kristin Rojas and the final manuscript was completed by Erin Kobiella and Kristin Rojas. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the patients of the Menopause, Urogenital, and Sexual Intimacy Clinic (MUSIC\u003csup\u003eTM\u003c/sup\u003e) Sexual Health After Cancer Program of the Sylvester Comprehensive Cancer Center at University of Miami Miller School of Medicine. We also want to thank the Sylvester Comprehensive Cancer Survivorship Research Program and the generous donors whose support has led to the implementation, success, and ongoing expansion of the MUSIC\u003csup\u003eTM\u003c/sup\u003e program.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Cancer Society. Cancer Treatment \u0026amp; Survivorship Facts \u0026amp; Figs. 2022 2024. Atlanta: American Cancer Society; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVegunta, S., Kuhle, C. L., Vencill, J. A., Lucas, P. H., \u0026amp; Mussallem, D. M. (2022). 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Surveillance and Care of the Gynecologic Cancer Survivor. \u003cem\u003eJournal of Women's Health\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(11), 899\u0026ndash;906. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/jwh.2014.5127\u003c/span\u003e\u003cspan address=\"10.1089/jwh.2014.5127\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMelissant, H. C., Jansen, F., Schutte, L. E. R., Lissenberg-Witte, B. I., Buter, J., Leemans, C. R., Sprangers, M. A., Vergeer, M. R., Laan, E. T. M., \u0026amp; Verdonck de Leeuw, I. M. (2018). The course of sexual interest and enjoyment in head and neck cancer patients treated with primary (chemo)radiotherapy. \u003cem\u003eOral Oncology\u003c/em\u003e, \u003cem\u003e83\u003c/em\u003e, 120\u0026ndash;126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.oraloncology.2018.06.016\u003c/span\u003e\u003cspan address=\"10.1016/j.oraloncology.2018.06.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaser, R. E., Li, Y., \u0026amp; Carter, J. (2012). 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The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. \u003cem\u003eJournal of Sex \u0026amp; Marital Therapy\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(1), 1\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/00926230590475206\u003c/span\u003e\u003cspan address=\"10.1080/00926230590475206\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGerstenberger, E. P., Rosen, R. C., Brewer, J. V., Meston, C. M., Brotto, L. A.,\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWiegel, M., \u0026amp; Sand, M. (2010). Sexual desire and the female sexual function\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"cancer, sexual dysfunction, genitourinary syndrome of menopause, menopause, survivorship","lastPublishedDoi":"10.21203/rs.3.rs-7143576/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7143576/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePURPOSE\u003c/h2\u003e\u003cp\u003eTo correlate genitourinary exam (GU) findings to patient-reported sexual dysfunction in female cancer survivors.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study included female cancer patients seen at a South Florida sexual health after cancer program. GU anatomy disruptions and patient-reported sexual dysfunction were evaluated by Adapted Vulvovaginal Exam Score (AVES) and Female Sexual Function Index (FSFI), respectively. Multivariate analyses compared, FSFI scores between patients with AVES\u0026thinsp;\u0026gt;\u0026thinsp;3 vs. 0\u0026ndash;3, (AVES\u0026thinsp;\u0026gt;\u0026thinsp;3 corresponds to more abnormal GU exam). Adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) were calculated.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e\u003cp\u003eAVES was calculated for 162 female patients treated between 2020\u0026ndash;2022. Median age was 46; 57% were Hispanic, and 79% had breast cancer. Common symptoms included vaginal dryness (55%) and dyspareunia (45%). Of 108 women with FSFI scores, 97% met criteria for female sexual dysfunction (FSD). 23% were found to have vaginal stenosis, and 42% had a narrowed vaginal introitus. Those with AVES\u0026thinsp;\u0026gt;\u0026thinsp;3 had significantly lower FSFI lubrication, orgasm, satisfaction, and pain domain scores. Any endocrine therapy use was associated with worse AVES scores (aOR 0.20, 95% CI 0.05\u0026ndash;0.80, p\u0026thinsp;=\u0026thinsp;0.024), an association strongest with aromatase inhibitor (AIs) use. Low satisfaction scores\u0026thinsp;\u0026lt;\u0026thinsp;3.6 were nearly three times more likely to have abnormal GU exams (aOR\u0026thinsp;=\u0026thinsp;2.81; 95% CI: 1.03\u0026ndash;7.65; p\u0026thinsp;=\u0026thinsp;0.044).\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e\u003cp\u003eFSD in female cancer survivors is associated with previously unreported GU exam disruptions that can limit or prevent sexual activity through pain and worsened sexual satisfaction. Ongoing work evaluates targeted interventions to improve symptoms and quality of life for this growing survivor population.\u003c/p\u003e","manuscriptTitle":"More Than Just “Vaginal Dryness”: Sexual Dysfunction Correlates with Genitourinary Anatomy Disruptions in Female Cancer Survivors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 18:37:02","doi":"10.21203/rs.3.rs-7143576/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T14:30:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T13:59:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140080191702566321449257363019628511216","date":"2025-09-08T13:24:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T16:54:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233811336471444317442099635897379783231","date":"2025-08-26T16:29:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-26T14:55:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-26T14:18:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-28T02:42:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-07-16T22:46:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c357a4f3-0fdd-449d-921a-e556b96ec528","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:03:06+00:00","versionOfRecord":{"articleIdentity":"rs-7143576","link":"https://doi.org/10.1007/s00520-025-10046-2","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-11-13 15:56:57","publishedOnDateReadable":"November 13th, 2025"},"versionCreatedAt":"2025-09-04 18:37:02","video":"","vorDoi":"10.1007/s00520-025-10046-2","vorDoiUrl":"https://doi.org/10.1007/s00520-025-10046-2","workflowStages":[]},"version":"v1","identity":"rs-7143576","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7143576","identity":"rs-7143576","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}