Breast cancer is the second most frequently diagnosed and most common cancer among women. Although it is rather rare among young women, it is the most common malignancy and one of the leading causes of cancer-related deaths for this age group . The meaning of a breast cancer diagnosis for a young woman is likely different and more devastating than it would be for an older woman. Recent studies suggest that this population tends to exhibit more aggressive forms of breast cancer , with potentially unique and complex biological features [2,3]. Fortunately, the number of women who survive breast cancer has increased over the years due to early diagnosis and more effective treatments [9,10].
However, the price of successful therapy may be long-term treatment-related side effects and the risk of a compromised quality of life [11,12,13]. The vast majority of young breast cancer patients are premenopausal at diagnosis; these women, who are usually found to have hormonal receptor-positive breast cancer, receive hormonal therapy. This type of therapy, continues for at least five to ten years. One of its consequences is induced ovarian failure, which leads to clinical manifestations of estrogen deficiency and a rapid change in menopausal status [14,15,16].
Early menopause due to cancer treatment may manifest in symptoms including hot flashes, night sweats, vaginal dryness, weight gain and tiredness [13,17,18]. These symptoms, in contrast to symptoms that are part of the natural occurrence of menopause, are considered to be particularly severe and unexpected for patients who are, age-wise, pre-menopausal. Thus, menopausal status change plays a crucial role for these young breast cancer survivors, a group which has been found to be at greater risk for poorer quality of life compared with an age-matched general population [19,20], as well as compared with postmenopausal patients [21,22].
One of the affected qualities of life domains is sexuality. Sexuality is considered to be a multi-dimensional construct consisting of several different dimensions, such as sexual desire [23,24,25,26], interest in sex [9,24,26], sexual pleasure [15,27], sexual satisfaction [24, 26,28], the ability to relax and enjoy sex [25,28], pain and discomfort during sexual intercourse [9,15, 27,29], sexual disorders  and frequency of sexual activity [15, 24, 26,27].
Findings indicate that nearly all women diagnosed with breast cancer experience some degree of sexual dysfunction [26, 28]. However, studies have shown that younger women report a greater degree of decreased quality of life and, specifically, more sexual dysfunction than do older patients [29, 30]. One explanation to account for this finding may be younger patients’ early menopause . The transition to menopause frequently affects women's sexual functioning . For younger women, early menopause leads to a rapid change in status and to the abrupt appearance of menopausal symptoms. Thus, for them, the sexual dysfunction, which likely originated from the premature menopause, is often severe and traumatic [14,33]. In their study, Champion et al. (2014) found that in comparison to young healthy women, young breast cancer survivors who underwent premature menopause often reported more sexual dysfunction such as lack of interest in sex, sexual difficulties during intercourse, decreased desire, and poorer ability to relax during sexual activity. In a study that assessed the association between menopause-related symptoms and quality of life among young pre-menopausal breast cancer patients, it was found that patients who had worse menopausal symptoms after cancer therapy reported poorer quality of life in all aspects, among them sexual functioning . Two studies   found that compared to the general population, premenopausal women with breast cancer reported on lower frequency of sexual activity, less pleasure and more discomfort during sexual activity. A factor associated with these outcomes in both studies was the experience of a menopausal transition as part of the adjuvant therapy.
It is clear that the occurrence of menopausal symptoms among young breast cancer survivors results in considerable sexual impairment. Several studies provide important explanations for this phenomenon. Hormonal therapy, which often triggers premature ovarian failure, leads to diminished levels of estrogen and testosterone, affecting aspects of sexual functioning [25,35]. The marked depletion of hormones is associated with weakened libido and arousal along with changes in the vulvovaginal area, and increased tissue fragility . Kedde et al. (2013) found that hormonal treatment caused long-term occurrences of genital arousal disorder or lack of lubrication, decreased libido, dyspareunia, or anorgasmia. These disorders, as they result in pain during intercourse, lead to significant disruptions of sexual functioning . It has also been argued that one of the key factors in the decline of sexual activity is the lack of sexual desire. Vaginal dryness and dyspareunia lead to less satisfaction during sex, and therefore cause women to have less desire for and interest in sex [13,33].
Most studies in this area have focused on the negative dimensions of sexuality, such as pain, discomfort, and difficulty during sex. By contrast, very few studies have focused on pleasure during sex. Our study, suggests that besides the assessment of the discomfort, the evaluation of pleasure as well. We assumed that the symptoms experienced by young breast cancer survivors due to their premature entry into menopause would have a significant impact on their sexual activity. We tried to determine whether the decrease sexual activity resulted from lower levels of pleasure and greater discomfort during sexual activity.
Based on the above-reviewed literature, we hypothesized that there would be differences between young breast cancer survivors and young healthy women in sexual activity frequency, such that young breast cancer survivors would report less frequent sexual activity. We also hypothesized that there would be differences between the groups in both the pleasure and the discomfort experienced during sexual activity. Finally, we hypothesized that the differences between the groups in sexual activity frequency would be attributed to pleasure and discomfort, both of which would be attributed to menopausal symptoms.