Sexual Dysfunction After Cancer: Why Aren’t We Talking About It?

The incidence of sexual dysfunction in cancer survivors can be high and long lasting, but early discussion, evaluation, and treatment of sexual problems can improve sexual outcomes, reduce emotional distress, and facilitate recovery in survivors. The problem is, patients and their providers are not talking about sex, according to 2 experts who implored attendees at the 2018 Oncology Nursing Society Congress to start talking about it.

The mind is often considered the most important human sex organ. But when patients feel too embarrassed to broach the subject of sexual dysfunction with their providers, this significant aspect of human existence remains ignored, resulting in a profound and negative impact on survivors’ quality of life and that of their intimate partners. To compound the problem, studies have shown that most providers are not bringing it up with their patients.

Sexual dysfunction is defined as changes that adversely influence sexual function, leading to psychological distress or stress within relationships. In survivors, sexual difficulties can occur from various causes, including the cancer itself, psychological distress associated with a cancer diagnosis, treatment side effects, complications of therapy, or altered relationships during and after treatment.

D. Kathryn Tierney, RN, PhD, Oncology Clinical Nurse Specialist, Stanford Health Care, noted that the World Health Organization views sexuality as “a central aspect of being human throughout life,” but sexuality is not just about sex, Dr Tierney said.

Sexual Dysfunction in Women

Assessing and intervening in sexual dysfunction requires the consideration of physiologic, psychological, and social dimensions of sexuality.

Sexual dysfunction in women is often related to lack of arousal or pain during intercourse. Physiologic causes can include ovarian failure, hormonal changes, fatigue and decreased physical stamina, or vaginal alterations caused by premature menopause, graft-versus-host disease, or radiation therapy.

“Premature menopause is not just associated with physiologic changes, but also the loss of youth and reproductive capabilities. It’s closely tied with our image of ourselves as women,” Dr Tierney said.

Depression and anxiety correlate with reduced interest in sexual activity, low self-confidence, few satisfying sexual relationships, and altered body image.

“One of the big barriers to addressing sexuality in cancer patients is, we simply don’t want to talk about it,” she said. Many healthcare providers feel that they have not had sufficient training to have these discussions. The providers feel they may embarrass the patient or themselves, or they worry that nothing can be done. Patients fear being dismissed, making their provider uncomfortable, or being told that there are no treatment options.

However, discussions about sexual dysfunction should take place before initiating cancer therapy. The discussions should be part of the informed consent process, particularly if there are any concerns about infertility, early menopause, or sexual changes, Dr Tierney advised.

“If you can start by saying, ‘You’re likely to experience less interest in sexual activity for the next several months following treatment,’ you’ve introduced the topic in a nonthreatening way,” she said. “Be proactive in providing this information to patients and their partners, because they’re not going to ask.”

By doing this, the provider has identified him or herself as a resource, validated that sexuality is a legitimate area of concern, and helped to facilitate adaptation by setting realistic expectations for potential changes.

Treatment Options for Women

Treatment options are available, Dr Tierney said, and effective treatments will combine education, support, and symptom management. Therapy should be tailored to the individual patient to relieve the specific symptoms; however, she recommends that lifestyle modifications—such as exercise, relaxation training, and learning to identify hot-flash triggers—be attempted for approximately 3 months before considering hormone replacement therapy used for postmenopausal women or other pharmacologic interventions.

In assessing female sexual arousal disorder, remember psychological factors such as anxiety, depression, fatigue (in both partners), body image, and relationship issues. Psychological distress can be treated with antidepressants, but avoid selective serotonin reuptake inhibitors, which decrease desire and intensity of orgasm, Dr Tierney advised. Provide education and counseling for couples, and discuss good communication strategies, relaxation training, and cognitive retraining.

No androgen therapies for sexual dysfunction in women have been approved by the FDA, but a testosterone patch in addition to estrogen therapy can increase sexual fulfillment. Testosterone cream applied to the clitoris can improve vaginal atrophy and lubrication, dehydroepiandrosterone vaginal gel can improve sexual function, and arousal oil (ie, Zestra) may help women to reach orgasm.

For pain during intercourse, consider topical or systemic estrogen, vaginal lubricants, vaginal dilators to restretch vaginal tissues, pelvic floor exercises, prolonged foreplay, and nonpenetrative sexual activity. Flibanserin (Addyi) is an FDA-approved, nonhormonal therapy for premenopausal women with low sexual desire, but it has been associated with adverse effects.

Address fertility preservation in all people of reproductive age before the use of any cytotoxic therapy, and refer those patients to a reproductive specialist, Dr Tierney advised.

She also urges providers to consider options such as sensate focus therapy, which is centered on partners touching and pleasuring nonsexual and sexual areas of each other’s bodies. The end goal may not be intercourse but rather partners reacquainting themselves with one another.

Sexual Dysfunction in Men

Jeffrey Albaugh, PhD, APRN, CUCNS, Director, William D. & Pamela Hutul Ross Sexual Health Clinic, NorthShore University HealthSystem, Glenview, IL, suggested that healthcare professionals are often unprepared to deal with sexual dysfunction, and most are unlikely to discuss it with patients. He cited a study showing that more than 90% of healthcare professionals considered conversations about sex important, but 94% admitted they would not ask their patients about it.1 Nurses are also unlikely to bring it up, and more than 50% of internists working with cancer survivors said they never or rarely address sexual dysfunction.2

“So no one is talking about sex, but trust me, your patients are suffering. And often, they’re suffering in silence,” said Dr Albaugh. But patients are not asking about it either. Another study showed that among men who were using the healthcare system, only a minority sought treatment for their erectile dysfunction, mostly because of embarrassment or miseducation. Even in urology offices, patients are unlikely to bring up erectile dysfunction.

A 2010 LiveSTRONG survey of more than 3000 patients with cancer showed that fertility was a concern to approximately 60% of respondents, but 70% said that they did not receive information about options for preserving fertility.3

“We sometimes assume older patients aren’t concerned about fertility,” Dr Albaugh said. “But don’t assume anything, and always ask about fertility; assist and direct patients to resources for sperm preservation.”

The majority of men with prostate cancer report that their quality of life is severely or moderately affected by erectile dysfunction. A study of more than 1000 men who underwent radical prostatectomy revealed that 2 years posttreatment, approximately 80% still had erectile dysfunction.4 At 5 years, 7 in 10 men still had erectile dysfunction.4

“You can be cured of prostate cancer but still plagued by sexual dysfunction,” explained Dr Albaugh.

Normalize conversations about sexual health, he stressed. Many patients with cancer have sexual or intimacy issues and are waiting to hear from their providers that it is okay to ask questions, and that there are resources and information that can help.

Intimacy is about communication and connectedness on all levels, Dr Albaugh said. But men and women can achieve pleasure and connectedness without intercourse. Communication with partners is key; talking about sex does not always come easily, but practice helps.

Treatment Options for Men

According to Dr Albaugh, treatment for sexual dysfunction should be motivated by patients after discussing risk, benefits, and cost.

Oral agents for erectile dysfunction, such as sildenafil citrate (Viagra) and tadalafil (Cialis), are equally effective, he said. They work in approximately 60% to 70% of men, but in those who have had radiation or surgery in the pelvic area, failure rates can be as high as 90%. However, when the nerves recover (at an average of 2 years posttreatment), these oral agents can be effective again.

“These medications are simple, discreet, and most popular by a landslide,” Dr Albaugh said.

Efficacy rates of 80% to 90% have been reported with FDA-approved, noninvasive vacuum pumps, but using them effectively requires practice. Urethral suppositories, such as alprostadil (Muse), are easy to use, but come with a high price tag (approximately $100 per tablet) and only work in approximately 50% of patients who use them. Intracavernous injections, delivered via a small diabetic needle, are effective but can cause pain, scarring, and other side effects. When conservative treatments are not effective, penile implant surgery is a viable option, albeit invasive and irreversible.

Dr Albaugh stressed the importance of ruling out and treating other underlying nonhormonal causes of erectile dysfunction, and making psychological referrals when necessary.

“We’re hardwired for connectedness; it’s not just about sex. That’s why many people are devastated when they feel disconnected from their partner,” he said.

For some patients, sex may not be an important part of their lives anymore, and that is okay too, he added. But get them talking about it. Stop, listen to their goals, and be present with them.

Dr Albaugh’s book, Reclaiming Sex & Intimacy After Prostate Cancer, can be downloaded for free at www.drjeffalbaugh.com.


References

  1. Haboubi NH, Lincoln N. Views of health professionals on discussing sexual issues with patients. Disabil Rehabil. 2003;25:291-296.
  2. Park ER, Bober SL, Campbell EG, et al. General internist communication about sexual function with cancer survivors. J Gen Intern Med. 2009;24(suppl 2):407-411.
  3. Beckjord EB, Reynolds KA, van Londen GJ, et al. Population-level trends in post-treatment cancer survivors’ concerns and associated receipt of care: results from the 2006 and 2010 LiveSTRONG surveys. J Psychosoc Oncol. 2014;32:125-151.
  4. Penson DF, McLerran D, Feng Z, et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol. 2008;179(5 suppl):S40-S44.

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