Let's Talk About Sex, Fertility, and Intimacy After Cancer

In the United States, 38.5% of men and women will receive a cancer diagnosis at some point.¹ Many of these patients will suffer in silence with sexual and fertility problems because of the stigma associated with them. Patients wait for their trusted healthcare professionals to bring up the subject, which often doesn’t happen. A study by Park et al found that 62% of internists working with patients with cancer never or rarely address sexual issues.² Patients need to know that it is OK to ask about and address sexual health issues.

Findings from several studies show that sexual issues are common among many patients. For instance, in a Livestrong Foundation study, investigators determined that sexual dysfunction was among the top 3 physical concerns reported by 43% of the men and women with cancer.³

Adverse Effects Experienced by Patients

Cancer treatment can affect sex and intimacy in terms of functional changes, physical disfigurement, and/or alterations in relationship dynamics with partners. Sexual dysfunction can involve loss of sexual desire, lack of arousal, and/or orgasm problems in both genders. For women, it could also involve pain with sex, lack of lubrication and vaginal dryness, atrophy, and/or stenosis. Specific issues for men include erectile dysfunction (ED), ejaculatory dysfunction, and/or hypogonadism (low testosterone accompanied by symptoms).

Treatments involving surgery, chemotherapy, and radiation can affect reproductive organs, leading to sexual dysfunction or infertility. Chemotherapy, specifically, can alter hormones such as estrogen and testosterone, leading to a multitude of sexual problems, including decreased desire, dryness, pain with penetration, or ED.

Although fertility may not be a concern for all patients, assumptions should be put aside and fertility information should be addressed and offered to anyone who might be interested in childbearing. In a study of 3129 patients with cancer, fertility was a concern for about 60%, of whom 70% said they did not receive information about options for preserving fertility.³ Cancers, such as prostate, colon, testicular, ovarian, uterine, and cervical, often occur in the pelvic area, which contains the reproductive organs—ovaries, uterus, fallopian tubes, testicles, and prostate. Surgical excision of or radiation therapy to these organs can lead to infertility.

RESOURCES FOR PATIENTS WITH SEXUAL CONCERNS

American Cancer Society

The American Cancer Society resource discusses sexual feelings and attitudes during cancer, as well as fertility. Within this page, additional online resources are listed for specific needs of men and women.

bit.ly/cancerandsexlife

MiddlesexMD

Targeted to women with breast cancer, MiddlesexMD provides sexual health information and products that can help women of any age

middlesexmd.com

National Cancer Institute

The National Cancer Institute gives an overview of treatments and the sexual health issues they may cause, as well as ways to manage them.

For men: bit.ly/sexualhealth-men

For women: bit.ly/sexualhealth-women

Northshore University HealthSystem

A series of free videos tackles

topics ranging from arousal disorder

to penile implants.

bit.ly/sexualhealth-videos

Reclaiming Sex and Intimacy After Prostate Cancer

The free online book is a guide for men and their partners following a cancer diagnosis. It is written by Jeffrey Albaugh, PhD, APRN, CUCNS.

drjeffalbaugh.com

Addressing Sexual Concerns

As patients perceive sexual dysfunction as a problem—a bother—they often feel embarrassment and shame that negatively affect quality of life.^4-6 However, healthcare professionals can help prevent that by taking immediate actions following a patient’s cancer diagnosis. For instance, patients should receive pamphlets and other educational materials about sexual health and fertility issues—they all will need this information. Most important, let patients know that sexual issues are not uncommon, and resources are available to help them understand and address the problems. Simply normalizing the situation opens the door for further discussion or information seeking.

Treatment of fertility and sexual problems is directed and driven by the patient’s goals and desires. Because sexual dysfunction is multifactorial, assessment and treatment can be time intensive and complex. Referral to an appropriate trained expert, such as through the Sexual Medicine Society of North America or the American Society of Sexual Educators, Counselors and Therapists, is significant, but the most critical step is to let patients know that they are not alone and there are treatment options.

For many women with cancer, vaginal dryness occurs. Treatment may include local intravaginal estrogen therapy, nonhormonal moisturizers used regularly, hyaluronic acid, ospemifene, and/or lubricants to reduce friction during sex.⁷ Penetrative pain also can be related to pelvic floor muscle hypertonicity or stenosis. This can be treated with pelvic floor physical therapy, vaginal dilators, and intravaginal muscle relaxants.

ED is an adverse effect seen in men following cancer treatment but can be treated with phosphodiesterase type 5 inhibitors—eg, sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)—a vacuum constriction device, intraurethral suppository, intracavernosal injections, or a penile implant.^8,9 Premature ejaculation can be treated with cognitive behavioral therapies (eg, stop/start, positioning, and squeeze technique), layered condoms to decrease sensation, desensitizing sprays or gels, and/or off-label use of antidepressants.¹⁰ Hypogonadism in men involves a low testosterone blood level combined with symptoms such as decreased sex drive, energy, or mood; fatty weight gain; and decreased ability to concentrate. The syndrome is typically treated with testosterone (eg, transdermal or buccal patch, injection, pellets, or nasal spray). Because testosterone is a steroid, proceeding with such therapy after cancer diagnosis and treatment may be controversial and even contraindicated—specifically in the case of prostate cancer, because steroids may increase or contribute to cancer growth. Experts in replacement therapy should handle this with care and caution, collaborating with the oncology team.

Diminished ability to climax affects both men and women. Identifying and resolving the underlying cause, such as use of antidepressants and/or pain medications, can improve the ability to orgasm. In some cases, consulting a sex therapist and/or adding vibration to stimulation may help a patient orgasm.

Sexual issues often involve a psychogenic component, which can negatively affect intimacy and sexual encounters. Concerns about ED or pain during penetration, for example, can affect self-confidence, self-esteem, and quality of life. It may be beneficial for men and women to address body image issues, function loss, or relationship problems through sex or relationship therapy.

In terms of fertility, it is critical that patients are offered the option of retrieving and preserving gametes prior to cancer treatment that may permanently compromise their ability to produce their own sperm or oocytes (eggs). Some treatments, such as chemotherapy and radiation, may temporarily halt sperm or egg production. Removal of the sex organs, which produce gametes, may permanently impair a patient’s ability to bear children. Although cancers of the reproductive system would more likely lead to infertility issues, chemotherapy for other types of cancers may also affect the hormonal system and possibly lead to infertility. All these factors must be considered.

One option is cryopreservation of sperm or oocytes, which requires planning on the patient’s part. Men who have reached puberty can donate sperm (ideally, several samples, not just 1) prior to cancer treatment. Assistive methods for ejaculation can also be engaged when needed for sperm extraction. If sperm donation is not an option or a male has not reached puberty, testicular gonadal tissue can be cryopreserved. Women can preserve oocytes or embryos, which requires 10 days of ovarian stimulation with gonadotropins, followed by transvaginal needle aspiration of mature oocytes while under sedation. The challenging thing about preserving embryos is that women must choose a sperm donor to fertilize the egg before cryopreservation. Ovarian tissue also can be cryopreserved. Assistive reproductive methods can also be helpful, including insemination and in vitro fertilization; other, more advanced implantation options continue to become available.

Empowering Patients

Sexuality is a vital part of the human experience. Therefore, identifying and helping patients address fertility and sexual issues is an essential part of cancer care. Oncology nurses can be on the front line of providing information about sexual dysfunction, which should be available to patients before, during, and after treatment. Empowering patients with information about fertility and sexual dysfunction treatment options allows men and women to make their own informed decisions about treatment. As cancer survival rates increase and patients live longer, addressing long-term adverse effects such as sexual dysfunction becomes increasingly paramount. That can be as simple as providing a list of some of the excellent resources available or letting the patient know that sexual issues are common after cancer.

References

1. Howlader N, Noone AM, Krapcho M, et al, eds. SEER cancer statistics review (CSR) 1975-2014. Surveillance, Epidemiology, and End Results Program website. seer.cancer.gov/csr/1975_2014/. Published April 2017. Updated June 28, 2017. December 23, 2017.

2. Park ER, Bober SL, Campbell EG, Recklitis CJ, Kutner JS, Diller L. General internist communication about sexual function with cancer survivors. J Gen Intern Med. 2009;24(suppl 2):S407-411. doi: 10.1007/s11606-009-1026-5.

3. Rechis R, Reynolds KA, Beckjord EB, Nutt S. “I learned to live with it” is not good enough: challenges reported by post-treatment cancer survivors in the LIVESTRONG surveys. LIVESTRONG website. d1un1nybq8gi3x.cloudfront.net/sites/default/files/what-we-do/reports/LSSurvivorSurveyReport_final_0.pdf. Published May 2011. December 28, 2017.

4. Penson DF, Feng Z, Kuniyuki, et al. General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Results from the prostate cancer outcomes study. J Clin Oncol. 2003;21(6):1147-1154. doi: 10.1200/JCO.2003.07.139.

5. Carter J, Stabile C, Gunn A, Sonoda Y. The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues. J Sex Med. 2013;10(suppl 1):24-34. doi: 10.1111/jsm.12002.

6. Ye S, Yang J, Cao D, Lang J, Shen K. A systematic review of quality of life and sexual function of patients with cervical cancer after treatment. Int J Gynecol Cancer. 2014;24(7):1146-1157. doi: 10.1097/IGC.0000000000000207.

7. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902. doi: 10.1097/GME.0b013e3182a122c2.

8. Albaugh JA, Marchese KE, Lewis JH. Understanding Erectile Dysfunction: Patient Evaluation and Treatment Options. 2nd ed. Pitman, NJ: Society of Urologic Nurses & Associates; 2015.

9. Porst H, Burnett A, Brock G, et al. SOP Conservative (medical and mechanical) treatment of erectile dysfunction. J Sex Med. 2013;10(1):130-171. doi: 10.1111/jsm.12023.

10. McMahon CG, Jannini E, Waldinger M, Rowland D. Standard operating procedures in the disorders of orgasm and ejaculation. J Sex Med. 2013;10(1):204-229. doi: 10.1111/j.1743-6109.2012.02824.x.