
Cancer and Sexual Health
Sexuality is a complex characteristic that involves the physical, psychological, interpersonal, and behavioral aspects of a person. Recognizing that "normal" sexual functioning covers a wide range of behavior is important. Ultimately, sexuality is defined by each patient and his/her partner according to sex, age, personal attitudes, and religious and cultural values.
Many types of cancer and cancer therapies can cause sexual dysfunction. Research shows that approximately 50% of women who have been treated for breast and gynecologic cancers experience long-term sexual dysfunction. Nearly 70% of men who have been treated for prostate cancer experience long-term sexual dysfunction.
An individual's sexual response can be affected in many ways. The causes of sexual dysfunction are often both physical and psychological. The most common sexual problems for people who have cancer are loss of desire for sexual activity in both men and women, problems achieving and maintaining an erection in men, and pain with intercourse in women. Men may also experience inability to ejaculate, ejaculation going backward into the bladder, or the inability to reach orgasm. Women may experience a change in genital sensations due to pain, loss of sensation and numbness, or decreased ability to reach orgasm. Most often, both men and women are still able to reach orgasm, however, it may be delayed due to medications and/or anxiety.
Unlike many other physical side effects of cancer treatment, sexual problems may not resolve within the first year or two of disease-free survival and can interfere with the return to a normal life. Patients recovering from cancer should discuss their concerns about sexual problems with a health care professional.
Factors Affecting Sexual Function in People With Cancer
Both physical and psychological factors contribute to the development of sexual
dysfunction. Physical factors include loss of function due to the effects of
cancer therapies, fatigue, and pain. Surgery, chemotherapy, and radiation
therapy may have a direct physical impact on sexual function. Other factors that
may contribute to sexual dysfunction include pain medications, depression,
feelings of guilt from misbeliefs about the origin of the cancer, changes in
body image after surgery, and stresses due to personal relationships. Getting
older is often associated with a decrease in sexual desire and performance,
however, sex may be important to the older person's quality of life and the loss
of sexual function can be distressing.
Surgery-Related Factors
Surgery can directly affect sexual function. Factors that help predict a
patient's sexual function after surgery include age, sexual and bladder function
before surgery, tumor location and size, and how much tissue was removed during
surgery. Surgeries that affect sexual function include breast cancer, colorectal
cancer, prostate cancer, and other pelvic tumors.
Breast Cancer
Sexual function after breast cancer surgery has been the subject of much
research. Surgery to save or reconstruct the breast appears to have little
effect on sexual function compared with surgery to remove the whole breast.
Women who have surgery to save the breast are more likely to continue to enjoy
breast caressing, but there is no difference in areas such as how often women
have sex, the ease of reaching orgasm, or overall sexual satisfaction.
Colorectal Cancer
Sexual and bladder dysfunctions are common complications of surgery for rectal
cancer. The main cause of problems with erection, ejaculation, and orgasm is
injury to nerves in the pelvic cavity. Nerves can be damaged when their blood
supply is disrupted or when the nerves are cut.
Prostate Cancer
Newer nerve-sparing techniques for radical prostatectomy are being debated as a
more successful approach for preserving erectile function than radiation therapy
for prostate cancer. Long-term follow-up is needed to compare the effects of
surgery with the effects of radiation therapy. Recovery of erectile function
usually occurs within a year after having a radical prostatectomy. The effects
of radiation therapy on erectile function develop very slowly and gradually
for two or three years after treatment. The cause of loss of erectile function
differs between surgery and radiation therapy. Radical prostatectomy damages
nerves that make blood vessels open wider to allow more blood into the penis.
Eventually the tissue does not get enough oxygen, cells die, and scar tissue
forms that interferes with erectile function. Radiation therapy appears to
damage the arteries that bring blood to the penis.
Other Pelvic Tumors
Men who have surgery to remove the bladder, colon, and/or rectum may have improved
recovery of erectile function if nerve-sparing surgical techniques are used. The
sexual side effects of radiation therapy for pelvic tumors are similar to those
after prostate cancer treatment.
Women who have surgery to remove the uterus, ovaries, bladder, or other organs in the abdomen or pelvis may experience pain and loss of sexual function depending on the amount of tissue/organ removed. With counseling and other medical treatments, these patients may regain normal sensation in the vagina and genital areas and be able to have pain-free intercourse and reach orgasm.
Chemotherapy-Related Factors
Chemotherapy is associated with a loss of desire and decreased frequency of
intercourse for both men and women. The common side effects of chemotherapy such
as nausea, vomiting, diarrhea, constipation, mucositis, weight loss or gain, and
loss of hair can affect an individual's sexual self-image and make him or her
feel unattractive.
For women, chemotherapy may cause vaginal dryness, pain with intercourse, and decreased ability to reach orgasm. In older women, chemotherapy may increase the risk of ovarian cancer. Chemotherapy may also cause a sudden loss of estrogen production from the ovaries. The loss of estrogen can cause shrinking, thinning, and loss of elasticity of the vagina, vaginal dryness, hot flashes, urinary tract infections, mood swings, fatigue, and irritability. Young women who have breast cancer and have had surgeries such as removal of one or both ovaries, may experience symptoms related to loss of estrogen. These women experience high rates of sexual problems since there is a concern that estrogen replacement therapy, which may decrease these symptoms, could cause the breast cancer to return. For women with other types of cancer, however, estrogen replacement therapy can usually resolve many sexual problems. Also, women who have graft-versus-host disease (a reaction of donated bone marrow or peripheral stem cells against a person's tissue) following bone marrow transplantation may develop scar tissue and narrowing of the vagina that can interfere with intercourse.
For men, sexual problems such as loss of desire and erectile dysfunction are more common after a bone marrow transplant because of graft-versus-host disease or nerve damage. Occasionally chemotherapy may interfere with testosterone production in the testicles. Testosterone replacement may be necessary to regain sexual function.
Radiation Therapy-Related Factors
Like chemotherapy, radiation therapy can cause side effects such as fatigue,
nausea and vomiting, diarrhea, and other symptoms that can decrease feelings of
sexuality. In women, radiation therapy to the pelvis can cause changes in the
lining of the vagina. These changes eventually cause a narrowing of the vagina
and formation of scar tissue that results in pain with intercourse, infertility
and other long term sexual problems. Women should discuss concerns about these
side effects with their doctor and ask about the use of a vaginal dilator.
For men, radiation therapy can cause problems with getting and keeping an erection. The exact cause of sexual problems after radiation therapy is unknown. Possible causes are nerve injury, a blockage of blood supply to the penis, or decreased levels of testosterone. Sexual changes occur very slowly over a period of six months to one year after radiation therapy. Men who had problems with erectile dysfunction before getting cancer have a greater risk of developing sexual problems after cancer diagnosis and treatment. Other risk factors that can contribute to a greater risk of sexual problems in men are cigarette smoking, history of heart disease, high blood pressure, and diabetes.
Hormone Therapy-Related Factors
Hormone therapy for prostate cancer can decrease normal hormone levels and cause
a decrease in sexual desire, erectile dysfunction, and problems reaching orgasm.
Younger men do not always experience the same degree of sexual dysfunction. Some
treatment centers are experimenting with delayed or intermittent hormone therapy
to prevent sexual problems. It is not yet known if these modified treatments
affect the long-term survival of younger men.
The effects of tamoxifen on the sexuality and mood of women who have breast cancer are not clearly understood.
Psychological Factors
Patients recovering from cancer often have anxiety or guilt that previous sexual
activities may have caused their cancer. Some patients believe that sexual
activity may cause the cancer to return or pass the cancer to their partner.
Discussing their feelings and concerns with a health care professional is
important for patients. Misbeliefs can be corrected and patients can be
reassured that cancer is not passed on through sexual contact.
Loss of sexual desire and a decrease in sexual pleasure are common symptoms of depression. Depression is more common in patients with cancer than in the general healthy population. It is important that patients discuss their feelings with their doctor. Getting treatment for depression may be helpful in relieving sexual problems.
Cancer treatments may cause physical changes that affect how an individual sees his or her physical appearance. This view can make a man or woman feel sexually unattractive. It is important that patients discuss these feelings and concerns with a health care professional. Patients can learn how to deal effectively with these problems.
The stress of being diagnosed with cancer and undergoing treatment for cancer can make existing problems in relationships even worse. The sexual relationship can also be affected. Patients who do not have a committed relationship may stop dating because they fear being rejected by a potential new partner who learns about their history of cancer. One of the most important factors in adjusting after cancer treatment is the patient's feeling about his or her sexuality before being diagnosed with cancer. If patients had positive feelings about sexuality, they may be more likely to resume sexual activity after treatment for cancer.
Assessment of Sexual Function in People with Cancer
Sexual function is an important factor that adds to quality of life. Patients
should discuss their problems and concerns about sexual function with their
doctor. Some doctors may not have the appropriate training to discuss sexual
problems. Patients should ask for other information resources or for a referral
to a health care professional who is comfortable with discussing sexuality
issues.
General Factors Affecting Sexual Functioning
When a possible sexual problem is identified, the health care professional will
do a detailed interview either with the patient alone or with the patient and
his or her partner. The patient may be asked any of the following questions
about his or her current and past sexual functioning:
- How often do you feel a spontaneous desire to have sex?
- Do you enjoy sex?
- Do you become sexually aroused (for men, are you able to get and keep an erection, or for women, does your vagina expand and become lubricated)?
- Are you able to reach orgasm during sex? What types of stimulation can trigger an orgasm (for example, self-touch, use of a vibrator, shower massage, partner caressing, oral stimulation, or intercourse)?
- Do you have any pain during sex? Where do you feel the pain? What does the pain feel like? What kinds of sexual activity trigger the pain? Does this cause pain every time? How long does the pain last?
- When did your sexual problems begin? Was it around the same time that you were diagnosed with cancer or received treatment for cancer?
- Are you taking any medications? Did you start taking any new medications or did the doctor change the dose of any medications around the time that these sexual problems began?
- What was your sexual functioning like before you were diagnosed with cancer? Did you have any sexual problems before you were diagnosed with cancer?
Psychosocial Aspects of Sexuality
Patients may also be asked about the significance of sexuality and relationships
whether or not they have a partner. Patients who have a partner may be asked
about the length and stability of the relationship before being diagnosed with
cancer. They may also be asked about their partner's response to the diagnosis
of cancer and if they have any concerns about how their partner may be affected
by their treatment. It is important that patients and their partners discuss
their sexual problems and concerns and fears about their relationship with a
health care professional with whom they feel comfortable.
Medical Aspects of Sexuality
Patients may be asked about current and past medical history since many medical
illnesses can affect sexual function. Lifestyle risk factors such as smoking and
high alcohol intake can also affect sexual function as well as prescribed and
over-the-counter medications. Patients may be asked to fill out questionnaires
to help identify sexual problems and may undergo a variety of physical
examinations, blood tests, ultrasound studies, measurement of nighttime
erections, and hormone tests.
Treatment of Sexual Problems in People with Cancer
Many patients are fearful or anxious about their first sexual experience after
cancer treatment. Fear and anxiety can cause patients to avoid intimacy, touch,
and sexual activity. The partner may also feel fearful or anxious about
initiating any activity that might be thought of as pressuring to be intimate or
that might cause physical discomfort. Patients and their partners should discuss
concerns with their doctor or other qualified health professional. Honest
communication of feelings, concerns, and preferences is important.
In general, a wide variety of treatment modalities are available for patients with sexual dysfunction after cancer. Patients can learn to adapt to changes in sexual function through reading books, pamphlets, and Internet resources or listening to and watching videos and CD-ROMs. Health professionals who specialize in sexual dysfunction can provide patients with these resources as well as information on national organizations that may provide support. Some patients may need medical intervention such as hormone replacement, medications, or surgery. Patients who have more serious problems may need sexual counseling on an individual basis, with his or her partner, or in a group. Further testing and research is needed to compare the effectiveness of various treatment programs that combine medical and psychological approaches for people who have had cancer.
Fertility Issues
Radiation therapy and chemotherapy treatments may cause temporary or permanent
infertility. These side effects are related to a number of factors including the
patient's sex, age at time of treatment, the specific type and dose of radiation
therapy and/or chemotherapy, the use of single therapy or many therapies, and
length of time since treatment.
Chemotherapy
For patients receiving chemotherapy, age is an important factor and recovery
improves the longer the patient is off chemotherapy. Chemotherapy drugs that
have been shown to affect fertility include: busulfan, melphalan,
cyclophosphamide, cisplatin, chlorambucil, mustine, carmustine, lomustine,
cytarabine, and procarbazine.
Radiation
For men and women receiving radiation therapy to the abdomen or pelvis, the
amount of radiation directly to the testes or ovaries is an important factor.
Fertility may be preserved by the use of modern radiation therapy techniques and
the use of lead shields to protect the testes. Women may undergo surgery to
protect the ovaries by moving them out of the field of radiation.
Procreative Alternatives
Patients who are concerned about the effects of cancer treatment on their
ability to have children should discuss this with their doctor before treatment.
The doctor can recommend a counselor or fertility specialist who can discuss
available options and help patients and their partners through the
decision-making process.
IMAGES PROVIDED BY:
- MedicineNet
REFERENCES:
Medically reviewed by John A. Daller, MD; American Board of Surgery with subspecialty certification in surgical critical care August 17, 2017
The above information has been provided with the kind permission of the National Cancer Institute (www.cancer.gov).
Principles and Practice of Sex Therapy. 4th Edition. "Sexuality & Illness."