Cancer treatments carry a host of side effects that can affect patients’ ability to have and enjoy sex. The sexual dysfunction arising from these side effects, which include functional changes, physical disfigurement, and altered relationship dynamics, can often be addressed, but uncovering sexual dysfunction can prove challenging.
The exact prevalence of sexual dysfunction among cancer survivors is hard to pin down—patient populations and definitions of sexual dysfunction vary from study to study—but it is widespread. A 2010 survey by the Livestrong Foundation revealed that nearly two-thirds of the more than 3,100 cancer survivors who responded had at least some impairment of sexual function following treatment.
“Sexual dysfunction is a huge quality-of-life issue in cancer patients,” said Andrea Milbourne, M.D., a professor in the Department of Gynecologic Oncology and Reproductive Medicine at The University of Texas MD Anderson Cancer Center. “We’ve had patients who have said their partners leave them because they can’t have sex.”
Moreover, according to the Livestrong survey, 30% of the patients who reported sexual dysfunction also reported that they did not receive care for it.
Driving the high rate of sexual dysfunction among cancer survivors is the fact that some of the most prevalent cancers—particularly cancers of the pelvic region—are linked with treatments that cause sexual dysfunction. Surgery for certain cancers may require the full or partial removal of sex organs. Both surgery and radiation can damage or destroy nerves, vasculature, and other structures that are essential to sexual function and pleasure. Cytotoxic chemotherapy and hormone therapy can cause hormonal changes—temporary or permanent menopause in some women, for example, or low testosterone levels in men—that make it difficult or impossible to have or enjoy sex.
“Most people who undergo cancer treatment can be expected to return to their normal selves, but it depends on the type of cancer, and it depends on the treatment,” said Andrea Bradford, Ph.D., an assistant professor in the Department of Gynecologic Oncology and Reproductive Medicine. “Somebody with an early melanoma on his arm who might get surgery or radiation would not be considered high-risk for sexual dysfunction, but the picture is really different for a person with advanced prostate cancer.”
Other cancer treatment–related conditions, such as fatigue, can also contribute to sexual dysfunction in cancer survivors. In addition, the incidence of sexual dysfunction in the general population is relatively high, which can make it difficult to determine whether the source of the dysfunction is indeed related to the cancer treatment.
Common sexual issues in men following treatment for pelvic cancers—mainly prostate, bladder, and colorectal cancers—include erectile dysfunction, anejaculation, painful ejaculation, and urine leakage during intercourse. The most frequent of these is erectile dysfunction, which can occur as a result of low testosterone levels, damage to the nerves that control erections, or damage to the blood vessels supplying the penis. For patients who were otherwise healthy and did not have erectile dysfunction before treatment and for whom the nerves were saved, a number of treatment options can be used to restore erectile function.
“The patient may respond well to phosphodiesterase type 5 inhibitors such as sildenafil (Viagra), tadalafil (Cialis), avanafil (Stendra), or vardenafil (Levitra). If the medication does not work or if the patient would like his sexual function to return earlier, we do something called penile rehabilitation, where we start the patient on a vacuum erection device and penile injection therapy early,” said Run Wang, M.D., a professor in the Department of Urology. “If none of those options work, we can always do a penile implantation, and the satisfaction rate for that is very high.”
Men whose prostate and seminal vesicles are removed or damaged as a result of surgery or radiation therapy may experience anejaculation—the inability to ejaculate with or without orgasm. Although this may take some getting used to, Dr. Wang said, “These patients need to understand that this is the consequence of the surgery and that it is a normal phenomenon.”
An α-adrenergic antagonist (α-blocker) can be prescribed to relieve the pain some men experience during ejaculation. Medication or surgery can be used to prevent urine leakage during sex.
The majority of male cancer patients who have sexual dysfunction after treatment are prostate cancer patients. However, Dr. Wang said, “We commonly see patients with all types of cancers who also have erectile dysfunction.”
Common physical issues among women who have received treatment for ovarian, cervical, or other pelvic cancers include vaginal dryness, stenosis, and foreshortening (particularly in women who have received treatment for cervical cancer), all of which can contribute to pain during intercourse.
“About half of the women I see have some degree of pain with sexual activity,” Dr. Bradford said. “A lot of these women keep their partners at arm’s length because they don’t want to become too intimate for fear that their partner is going to expect them to do something that causes them pain. Their solution to that is often to avoid any kind of intimacy altogether.”
Topical moisturizers can be used to relieve vaginal dryness, and water- or silicone-based lubricants can be used before and during sex. Low-dose vaginal estrogen replacement with a cream, ring, or tablet can also be used to moisturize the vagina and relieve vaginal atrophy. Vaginal dilators may be used to help lengthen and widen the vagina in patients with vaginal scarring, stenosis, or foreshortening resulting from surgery or radiation therapy.
Diminished or loss of interest in sex is also common following cancer treatment.“What I hear from a lot of my female patients is that they just have no interest in sex after treatment, that if their partners didn’t ask for it, they could go years without it,” Dr. Milbourne said. “Unfortunately, we don’t have a lot that we can offer medically to help women with their lack of libido.”
In some women, the early menopause that results from the removal or damage of both ovaries can cause or exacerbate sexual dysfunction.
The scars of surgery and other cancer treatments are often more than just skin deep. Disfigurement or other physical changes can give rise to anxiety, depression, or changes in self-esteem that can inhibit a person’s ability to enter a sexual relationship.“
Sexual desire has so many different facets to it,” Dr. Milbourne said. “Patients who have lost hair, who’ve lost or gained a lot of weight, who have a colostomy—you name it—may think, ‘How can my partner still find me attractive when even I don’t find myself attractive?’ It’s really hard to separate the physical from the mental.”
Dr. Milbourne recalled one patient whose clitoris had to be removed because of vulvar cancer involvement. Afraid of what a partner would think, the patient decided to cease seeking out romantic relationships altogether. Dr. Milbourne said, “That may not have anything to do with what we formally think about as physical sexual function, but because of how she perceives herself, she’s not willing to engage in any relationship, sexual or otherwise.”
A “new normal” for sex
The term “the new normal” is often used to summarize the depth and breadth of lifestyle changes that many cancer survivors must embrace after their treatments end. Some patients find adjusting to this life easier than others do, particularly when it comes to sex.
“After their treatment, some patients don’t necessarily feel back to normal, but their family, their friends, their loved ones—even their own partners—may apply pressure to get back to normal, and that can include sexual activity,” Dr. Bradford said. “Many women tell me that they don’t feel like the person they were before treatment, but their partners say, ‘You’re fine, you’re cured, you’re healthy—why aren’t you more interested in sex?’”
Although several factors can hinder patients’ attaining a fulfilling sex life after cancer, the major risk factor for ongoing sexual problems is having an inflexible definition of sex or sexual performance.
“Many cancer survivors are inhibited by the fact that the sex they have after treatment may not necessarily be identical to the sex they had enjoyed before, or they may be so distraught by the idea of not being able to perform as they once had that they just avoid it altogether,” Dr. Bradford said. To address this issue, Dr. Bradford suggests that patients find some kind of intimacy with their partners that they enjoy and let go of some of their preconditions or expectations about sex that may not be serving them well any longer.
“A patient might say, ‘I can’t keep an erection throughout intercourse, so I’m not going to even try,’” Dr. Bradford said. “But the patient’s partner might say that she enjoys the closeness of sexual intimacy and that she would rather have that in some form than live like roommates for the rest of their lives.”
An elusive conversation
Telling patients that their treatments may cause sexual dysfunction is part of appropriate informed consent. Nevertheless, this information—and any related concerns patients might have—may get shoved aside when a cancer diagnosis looms large.
“When they’re first diagnosed, many patients are purely focused on the cancer,” Dr. Wang said. “They’re scared, and they can’t even begin to think about the possible sexual side effects down the road.”
Other patients “may want to ask about it but don’t because they feel that it’s frivolous to be asking about sex when they should be concerned about their lives,” Dr. Milbourne said. “And a lot of people think, ‘We’ll deal with this afterwards—if it happens.’”
When sexual dysfunction does occur after treatment, many patients are reluctant to talk about their sexual health, even if it is affecting their quality of life. And doctors themselves may find it difficult to talk about sexual issues. Cultural beliefs, feelings of embarrassment, the formal nature of the physician-patient relationship, and other factors can prevent an important conversation from happening. In some cases, patients may feel that it is not their place to broach the subject.
Given patients’ reluctance to talk about sexual dysfunction, Drs. Bradford, Milbourne, and Wang said, physicians must take the initiative to start the conversation with their patients.
“As physicians, we should be frank, we should be complete, and we should be proactive to bring the topic up,” Dr. Wang said.
According to Dr. Bradford, the topic of sexual function should be brought up early after the cancer diagnosis if the treatment carries a high risk of causing sexual problems. Although patients may not want to take action when they’re newly diagnosed or getting treatment, they should be made to feel comfortable about talking about sexual dysfunction later on.
To help put patients at ease, Dr. Bradford said, any discussion about sexual dysfunction should begin with a statement that normalizes it. When physicians tell their patients that sexual dysfunction is very common or that they ask all their patients about sexual dysfunction, it helps patients feel like they’re not being singled out and helps lower the barrier for patients to disclose their concerns.
Talking to patients about sexual dysfunction is one thing, but effectively addressing patients’ concerns or treating their sexual dysfunction is another.
“Most oncologists don’t have enough training or time to address these issues in depth or effectively prepare the patient for these issues,” Dr. Milbourne said. “If we can’t treat patients for their sexual dysfunction, we should refer them to a specialist who can.”
Numerous resources are available to men and women experiencing sexual dysfunction after cancer treatment. For example, sexual health counselors and therapists with expertise in treating cancer survivors can be located through the American Association of Sexuality Educators, Therapists, and Counselors or the Society for Sex Therapy and Research.
Additional resources for men can be found at www.sexhealthmatters.org, the Web site of the Sexual Medicine Society of North America. Dr. Wang, the president-elect of the society, also serves as the director of MD Anderson’s Sexual Medicine Program in the Department of Urology, whose services include comprehensive penile rehabilitation and counseling. Although current MD Anderson patients are primarily seen in the clinic, its services are also available to outside patients.
For women, help is also available through the Women’s Integrated Sexual Health (WISH) Program in the Gynecologic Oncology Center at MD Anderson. The program’s services, which include sexuality education and counseling, medical evaluation of sexual dysfunction, and short-term psychotherapy for coping with sexual dysfunction, are available to MD Anderson patients and patients in the community alike.
Dr. Bradford, who established and runs the WISH Program along with her colleagues in the Gynecologic Oncology Center, noted that involving the patient’s partner to some extent in the patient’s care is usually very helpful. She said, “I often encourage patients to come in with their partners, because sexual issues belong to the couple; they are not the fault of the cancer survivor.”
For more information, contact Dr. Andrea Bradford at 713-745-4466, Dr. Andrea Milbourne at 713-745-6986, or Dr. Run Wang at 713-745-7575.
The Livestrong Foundation survey referred to in this article is available at www.livestrong.org/what-we-do/our-approach/reports-findings/survivor-survey-report.
To locate a sexual health counselor or therapist with expertise in treating cancer survivors, contact the American Association of Sexuality Educators, Counselors, and Therapists at 202-449-1099 or visit www.aasect.org/referral-directory or contact the Society for Sex Therapy and Research at 847-647-8832 or visit www.sstarnet.org/therapist-directory.php.
MD Anderson patients can obtain a referral to the Sexual Medicine Program or the WISH Program from their physicians. Patients in the community can self-refer to the Sexual Medicine Program by calling 713-745-7020 or the WISH Program by calling 713-792-8340.
For a more comprehensive discussion of sexual dysfunction in cancer patients, see Schover LR. Sexuality. In: Foxhall LE and Rodriguez MA, eds. Advances in Cancer Survivorship Management. New York, NY: Springer, 2015:401–412.
OncoLog, June 2015, Volume 60, Issue 6