In the present study, we found a high prevalence of SD in female cancer survivors who underwent fertility preservation in the past, especially general SD (60.4%). This percentage is nearly twice as high as in a healthy population: 37.7% suffer from severe and 32.1% from moderate SD. However, the risk for psychological distress (anxiety and depression) was not significantly increased in cancer survivors. Most patients have not completed their family planning at time of follow-up and showed signs of a diminished ovarian reserve with low AMH levels and reduced AFC.

Our findings with regard to SD are in line with other studies. In a review including 20 different cancer types, mean FSFI value ranged from 16.25 to 19.58 in middle-aged patients with colorectal, gynecological, and breast cancer, respectively. SD prevalence was higher than 60% in all cancer types, with the highest value for gynecological cancer (78.44%, 95% CI 68.36–88.52%) [24]. When aged-matched cancer survivors were analyzed (mean age at follow-up, 29 years) with a longer follow-up period (mean 20.9 (± 7.8 years), SD was present in 57% [3]. Dysfunction was most common for sexual interest (36%), orgasm-ability (32%), and vulvar discomfort (19%). In our study, dysfunction was most common in orgasm, arousal, desire, and satisfaction. Of note, SD was assessed by another tool—the PROMIS Sexual Function and Satisfaction—but with similar domains.

Studies focusing on breast cancer patients found a prevalence of SD of 75% in 64 patients assessed by the FSFI and applying the cut-off value of 26.55 [20]. In addition, an association between sexual function and age, hormone therapy, and women’s mental health was detected. Hormone therapies (e.g., tamoxifen and aromatase inhibitors) can lead to vaginal dryness and thus changes in neurobiological function such as desire or arousal affecting also orgasm. In our study, 30% of women were under ongoing hormone therapy at the time of follow-up. Although age did not seem to influence the prevalence of SD in our study, data from previous studies imply that sexual satisfaction, lubrication, sexual arousal, and frequency of sexual intercourse decrease physiologically with increasing age [25, 26]. Moreover, in women with breast cancer, sensation in the affected breast may be altered, possible painful scars, and a constant reminder of the disease triggered by touching the breast could affect sexuality. After breast surgery, self-esteem might be lower, and feelings of shame or not feeling as attractive as before may occur and have an impact on sexuality. Additionally, although more than half (69%) of our patients had a regular menstrual cycle, 26% reported amenorrhea, which has a significant impact on sexual function by causing vaginal dryness [25]. Possible influencing factors include duration and type of gonadotoxic treatment as well as age at treatment and age at time of follow-up. In breast cancer patients, chemo- and radiotherapy duration is usually 6–8 months, not including adjuvant therapies such as tamoxifen and aromatase inhibitors. In hematological cancer patients, treatment duration lasts between 8 and 10 months. Patients were at a young mean age at time of treatment (28.3 years) and time of follow-up (33.4 years) with an adequate follow-up time in which return of menstrual cycle is possible. In this young cohort, a prevalence of amenorrhea of 26% is high as side effects/consequences of an estrogen deficiency including risk of osteopenia, osteoporosis, cognitive impairment, and coronary artery disease need to be prevented.

The prevalence of anxiety and depression in cancer patients in the literature ranges from 7 to 88% and from 3 to 65.5%, respectively [20]. In our study, risk for anxiety and depression was 11.3% and 5.7%, respectively. Possible risk factors as detected in the review by Ostovar et al. include cancer type (breast and lung cancer), cancer stage (advanced), gender (female), age (older-aged), and type of therapy (chemotherapy). Of note, 16 different screening tools were used in the included studies [20]. Especially patients with advanced breast cancer seem to suffer from anxiety and depression [27]. Focusing on the cohort of female cancer survivors with metastatic breast cancer < 40 years, Park et al. found mean scores of 4.4 ± 3.7 and 7.9 ± 5.0 in the HADS depression and HADS anxiety scale, respectively [28]. In both subscales, especially in the anxiety subscale, these results are higher than in our cohort which might be linked to the metastatic situation. In patients with hematologic cancer, the other major part of our cohort, anxiety, and depression is less frequently investigated in long-term survivors. In early survivorship, anxiety seems not to be influenced by unmet psychological needs during chemotherapy [29]. In a Swedish study, 20 out of 54 participants (37%) showed a higher score in the anxiety subscale than the control group (HADS questionnaire) [30]. On the other hand, the depression scale revealed only 8% participants with depressive symptoms. Interestingly, since anxiety and depression are not increased in our cohort and all patients are sexually active, the likelihood of a sole psychological explanation is limited and might be explained by increased resilience after the survival of cancer and the lack of disease recurrence.

According to the literature, AMH might reflect remaining ovarian reserve after cancer treatment [31, 32]. Women with low AMH levels (< 0.7 ng/ml) and thereafter diminished ovarian reserve seem to have a lower chance to achieve a pregnancy [33]. In our study, median AMH levels were 1.07 ng/ml, and 53% of the participants younger than 40 years showed values below 1.0 ng/ml at time of follow-up. However, no association between lower AMH values and increased risk for anxiety, depression, or SD was found.

When focusing on infertile women, Tanha et al. found impaired sexual function in infertile women (25.7 ± 4.6 years) compared to fertile women (32 ± 1.1 years) by applying the FSFI [34]. Also, in our study, 11/15 patients with current desire to get pregnant suffer from SD, compared to only 5/13 who already completed their family planning.

Although our results reflect recently published date, there are some limitations. First, the low participation rate may have led to a selection bias. Patients who are willing to participate in a study might be in better psychological and sexual functioning state with less prevalence for depression and anxiety. Due to the small sample size, we were not able to control for confounding factors, such as medication or ongoing psychotherapy. Second, the relatively long study interval ended up in the loss of more than 50 patients. Third is the heterogeneity of our cohort with regard to cancer type, chemotherapy regime, and chosen fertility preservation method. Fourth is the single time point of the questionnaire. In addition, other questionnaires, such as the Short-Form-36 (SF-36) or the Sense of Coherence-13 (SOC-13) might provide a more comprehensive picture of patients’ mental health [30].

As SD is present in young female cancer survivors, sexual function needs to be addressed at the time of fertility preservation counseling and during follow-up visits. Possible approaches especially in adolescent and young cancer survivors are displayed in the review by Peleg Nesher et al. [35]: after evaluation of SD in four steps as provided by Bartlik et al. [36], patients can be offered couple/sex therapy, sexual medicine or further referral to a specialist (gynecologist/endocrinologist/urologist). Depending on current family planning, both contraception and hormone therapy as well as non-hormonal treatment options can be offered to improve vaginal dryness and other treatment-related discomfort.