Alyssa Dweck1, 2 and Michael Krychman3, 4
(1)
Mount Kisco Medical Group, Northern Westchester Hospital, Mt. Kisco, NY, USA
(2)
Mt. Sinai School of Medicine, New York, NY, USA
(3)
Southern California Center for Sexual Health and Survivorship Medicine, Newport Beach, CA, USA
(4)
University of California Irvine, Irvine, CA, USA
Michael Krychman
Email: mkrychman@aol.com
Keywords
CancerGynecologic cancerSexualitySexual healthFemale sexual dysfunction (FSD)Survivorship
27.1 Introduction
The American Cancer Society cites almost 800,000 new cancer diagnoses in 2012 with 5-year survival rates on the rise [1]. Survivorship and quality of life issues, including sexual function, are gaining more popular attention. It should come as no surprise that sexual dysfunction affects the majority of women treated for cancer, with some reports suggesting that nearly all women with breast cancer have treatment-related sexual complaints [2]. Female sexual dysfunction (FSD) includes a broad range of psychological, physical, and interpersonal issues. Common complaints include loss of libido, difficulty with arousal, dyspareunia, and anorgasmia. Despite these reports, sexual function is often a neglected part of the survivor experience. Practitioners cite time constraints and lack of training in sexual health as barriers to treatment. This chapter will discuss not only the broad issues regarding female sexuality faced universally by cancer patient/survivors, but also elucidate on nuances specific to specific cancers.
27.2 Patient History
When addressing sexual problems in the cancer patient, it is critical to consider what predates the cancer diagnosis. Is chronic disease or mental illness an issue? Are current medications and doses impacting the sexual response cycle? Is the patient happily partnered or not? Are other life stressors present that may be contributing to sexual complaints? Are age-related changes in sexuality an issue? What was the sexual repertoire prior to diagnosis? This demographic and historical background is essential and should be elicited through a focused sexual history with inquiry about the least intrusive topics first, followed by the more intimate ones. Open-ended questions are most effective to retrieve important history. Patients want their healthcare professional to initiate discussions of sexuality at diagnosis, prior to, during, and after treatment. Women want to know whether and when sex is permissible during and after treatment and appreciate detailed and candid advice regarding sexual intimacy. However, women may find it embarrassing, awkward, inappropriate, or taboo to bring up the subject of sexuality themselves, especially in light of a life-threatening illness. Some may feel guilt contemplating sex in that they should just be “happy to be alive.” Patients may be overwhelmed with medical information and fail to ask.
An important educational resource for both healthcare professionals and patients is the American Cancer Society pamphlet (2013): Sexuality for the Woman with Cancer (http://www.cancer.org/acs/groups/cid/documents/webcontent/002912-pdf.pdf).
27.3 Common Complaints Affecting Sexuality in Cancer Patients and Survivors
27.3.1 Fatigue
Fatigue is ubiquitous in cancer patients and can present at the time of diagnosis, after medical or surgical therapy, or persist after treatment. Cancer-related fatigue is often a complex phenomenon since it can be due to separate medical issues, treatment related, or due to the cancer itself. A productive counseling point can be to encourage patients to time sexual relations around their most energetic time of day. Patients should be given permission to consider sex a priority in the morning, for example, when energy levels may be highest and fatigue at its lowest. Resuming exercise, which increases energy and improves mood, is another important clinical suggestion. The clinician must also address other causes of fatigue including cancer-related anemia, hypothyroidism, depression, poor nutrition, and poor sleep habits.
27.3.2 Fertility
Many women will be diagnosed with cancer in their reproductive years, including up to 25 % of women with breast cancer [3]. Patients interested in fertility preservation should undergo pretreatment counseling regarding options such as embryo or oocyte cryopreservation, egg donation, gestational surrogacy, and adoption. It is crucial to have this conversation and engage a reproductive endocrinologist in a timely fashion. By the same token, contraception may be needed or need to be altered in light of new cancer diagnosis. Hormonal contraception is contraindicated for those with breast or uterine cancers or other hormonally sensitive tumors. The nonhormonal IUD, barrier methods, and permanent sterilization may be the only viable options in these cases. Some women may become amenorrheic and seemingly menopausal without the need for contraception, particularly in their 40s during chemotherapy, only to see the return of menses months after chemotherapy cessation. Contraception should be reconsidered in these patients if menses resume and menopause is not definitive. Some women who experience a permanent and irreversible loss of fertility may experience mood changes, including depression and anxiety. Since many view reproduction as the primary goal of sexuality, the loss of fertility may impact a woman’s perception of sexuality and she may report sexual disinterest.
27.3.3 Pain
Pain is an often a universal symptom for the cancer patient/survivor. Surgical site pain, chronic bone and muscle pain, and pain or heightened sensitivity due to radiation injury are common. As a result, analgesia may be necessary before sexual intercourse. Premedication with narcotics, acetaminophen, or nonsteroidal anti-inflammatory medication appropriately administered before sex may be beneficial. Topical anesthetics such as xylocaine jelly applied to painful areas may also be helpful. Open communication between partners is essential. Sexual repertoires may need to be altered since what may have previously been stimulating may now be uncomfortable. For example breast skin that was once sensual when touched may be painful after radiation. Abdominal scars might be sensitive or numb. In contrast, scars may be sensual and erotic for some. Finally, some patients experience phantom pain or chronic pain, which may impair sexual function. A pain management consultation may be valuable in these cases.
27.3.4 Menopausal Symptoms
Vasomotor symptoms, sleeplessness, and genitourinary syndrome of menopause (GSM) (which was previously called vulvovaginal atrophy) are common, particularly for those with estrogen-sensitive cancers – especially in those women who are taking aromatase inhibitors or selective estrogen receptor modulators. Conservative treatment options include dressing in layers with moisture-wicking fabrics, dietary manipulation to avoid caffeine, alcohol, and spicy or large meals. Cooling sheets and pillows, fans, lowered thermostat settings, and over-the-counter or prescription sleeping aids may also help, although definitive data from randomized clinical trials may be lacking. Mindfulness exercises, meditation, yoga, and regular exercise are also considered beneficial. Antidepressants, in particular selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and dopamine agonists, are commonly used. Anxiolytics, clonidine, and gabapentin are also medical options for vasomotor symptoms in those patients who cannot or will not take estrogen therapy. Low-dose paroxetine was recently FDA approved as the first nonhormonal medication with efficacy for reducing frequency and severity of moderate to severe vasomotor symptoms due to menopause. This novel medication may be appropriate for some cancer patients with vasomotor symptomatology. Nutraceuticals, vitamins, and herbal supplements remain controversial in the cancer patient and should be considered with extreme caution. In fact, the American College of Obstetricians and Gynecologists (ACOG) claims soy, over-the-counter phytoestrogens, dong quai, and ginseng are ineffective for vasomotor symptoms [4].
27.3.5 Dyspareunia and VVA
Dyspareunia and GSM can directly result from chemical or surgical castration. Estrogen depletion diminishes blood flow and natural lubrication to the genito-pelvic organs. Subsequent abstinence due to avoidance may worsen the situation. For those without estrogen-dependent cancers, this conundrum can be treated effectively with minimally absorbed local vaginal estrogen in the form of a local cream, ring, or tablet. In addition, there is a recently approved oral medication, ospemifene, a selective estrogen receptor modulator for the treatment of moderate to severe dyspareunia, a symptom of GSM due to menopause; safety of use in cancer patients is based on individual malignancies. Although in some oncological populations the use of local intravaginal estrogen products has gained popularity, long-term safety trials on the use of minimally absorptive local estrogens in cancer patients, especially those with hormonally sensitive tumors, are lacking [5]. All patients can benefit from nonhormonal vaginal moisturizers used regularly and long term. Replens™, for example, used regularly 2–3 times weekly, is over the counter, may restore vaginal pH, is generally well tolerated, and typically provides relief. Compounded hyaluronic acid used vaginally twice weekly or vitamin E capsules are effective moisturizers as well. Water-based, silicone-based, or oil-based lubricants are encouraged during sexual relations. Common products include KY Jelly™, Astroglide™, Wet Platinum™, Good Clean Love, and coconut oil. Paraben, glycerin, fragrance, bactericide, and spermicidal and dye-free options are gaining popularity, and these additives should be avoided in the menopausal cancer survivor. Vulvar soothing creams like Neogyn™ are effective for vulvar pain.
27.3.6 Psychological and Relationship Issues
Emotional consequences due to or in spite of physical changes from cancer treatments include feeling unattractive, changes in sexual self-esteem, lacking femininity, and direct impact on partner or relationship. Sexual well-being is central to psychological well-being and quality of life. Sexual intimacy assists in the cancer recovery process [6]. The transition from lover and marital partner to caretaker or housemate can disrupt the relationship creating excessive tension and impact effective communication. Concerns about infidelity due to discrepancy in sexual interest cannot be ignored and sexually transmitted infection screening may be appropriate. Negative consequences experienced by partners of breast cancer patient/survivors include fear of causing pain during sex, lack of interest in sex, difficulties in communication, and change in roles. These concerns do not differ according to age, relationship status, sexual orientation, or current stage of cancer treatment [6].
In those studied seeking new relationships, “not feeling desirable” and “fear of rejection” were most commonly reported and more so by women seeking new heterosexual relationships compared with those seeking same sex ones [6]. Perhaps this discrepancy speaks to the importance of penetrative vaginal intercourse in heterosexual couples. Exploration of noncoital sexual practices should be emphasized when counseling these patients.
Some feel a true sense of loss when vaginal intercourse, the “ideal expression of marital intimacy,” is lost. Others report lack of intercourse not distressing with satisfaction from oral sex, self-stimulation, or alternative sexual expression. This is clearly dependent on the importance placed on intercourse prior to cancer diagnosis. Some are so grateful to have “survived” cancer and alive intercourse is secondary. Other survivors feel the lack of intercourse is age and not cancer related and that intercourse is not needed to maintain a harmonious marital relationship and that intimacy is more emotional/mental than physical. For some couples, a platonic nonsexual or celibate relationship becomes acceptable and less complicated than dealing with a reconfigured body and a partner [7].
In regard to couples’ fate after cancer diagnosis, some report communication problems or increased conflict and attribute this relationship breakdown to cancer [6]. Other couples living with cancer are no more likely to separate than those in the general community [8]. In some instances, cancer may have a positive relationship effect by creating greater intimacy [9].
Rarely, women with cancer report an increased sexual pleasure or desire and that sex is a way of feeling alive during treatment. These cases are in the minority but suggest that detrimental sexual effects cannot be assumed for all women [9].
27.4 Medical Sex Therapy
Sexual function after cancer diagnosis and treatment may not return to baseline and realistic expectations should be discussed. Sexual medicine focuses on a “new normal.” First, it is imperative to manage underlying chronic medical conditions. Address medications particularly antidepressants and antihypertensives which have direct effects on arousal, libido, and orgasm. Nutrition and exercise optimization are crucial. Stress reduction and fatigue management are paramount. Specific sexual assignments may be given including bibliotherapy or erotic/instructional book reading or video exploration, self-stimulation exercises, and relaxation techniques. Mindfulness training and sensate focus exercises including non-genital touching, solo or mutual masturbation, and if and when ready genital and coital activity can follow. Partners need to agree not to proceed to intercourse unless both are adequately prepared.
Vaginal moisturizers and lubricants remain the mainstay treatments for moderate to severe dyspareunia due to GSM. Books such as The Joy of Sex by Dr. Alex Comfort [10] illustrate alternate sexual positioning and additions to the sexual repertoire in cases where intercourse is not possible. Alternate sexual pleasuring techniques can be introduced, including manual, digital, or oral stimulation. Formal graduated dilator programs in combination with moisturizers and lubricants are essential for those with pelvic floor hypertonus, vaginal stenosis, narrowing, and scarring; and subsequent dyspareunia. Specialty trained pelvic floor physical therapists employ manipulative techniques and intravaginal diazepam or trigger point injections to treat hypertonic pelvic muscles to alleviate sexual pain. Vibrators/self-stimulators give additional stimulation to the clitoris and vagina and provide novelty to the sexual experience. Another handheld sexual device, the Eros Clitoral Stimulator®, provides suction to increase clitoral vasocongestion and stimulation which has been shown to be effective in small clinical trials in certain subpopulations including those who have cervical cancer [11].
Hypoactive Sexual Desire Disorder (HSDD)
The antidepressant bupropion has been used off-label to treat lowered sexual desire complaints, and one study suggests a positive effect on arousal and orgasm in women [12]. Testosterone therapy has often been used off-label for HSDD in women and is not FDA approved. In fact, a randomized crossover trial in 150 women with cancer showed no differences in sexual function using testosterone cream over placebo during a 4-week treatment period [13]. The efficacy and safety of androgen therapy in cancer patients are unknown. Phosphodiesterase inhibitors used to treat erectile dysfunction in men have not proven efficacious in trials with women and remain unstudied in the cancer population [14]. Zestra®, an over-the-counter arousal botanical oil used topically prior to sex, has shown increased arousal and sexual satisfaction in women [15]. A small case series presentation suggests a positive sexual response to Zestra in breast cancer patients [16]. Flibanserin , a 5-HT1A agonist and 5-HT2A antagonist, and bremelanotide, a melanocortin agonist, are two medications that are in clinical development. They show excellent promise for the treatment of female sexual dysfunction and may be considered for use in the oncological patients given the fact that they are nonhormonal.
27.5 Specific Cancer Considerations
27.5.1 Breast Cancer
Breast cancer survivors make up a large proportion of cancer survivors in the US; in fact the American Cancer Society estimates a staggering 232,670 new diagnoses in 2014 [17]. Disfiguring surgery is not uncommon and tends to be more significant in younger women [18]. Breast cancer survivors may hide their bodies from their partners with lingerie, dim lights, or blatant avoidant behavior. Scars and skin fibrosis of the breast and axilla can limit range of motion. Lymphedema may present. During intimacy, position changes and liberal use of pillows for comfort may be helpful. Radiation can lead to skin changes including rash, burning, decreased sensation, skin thickening, and discoloration. Of particular concern is numbness or discomfort in the previously erogenous breast and chest. Chemotherapy may cause nausea, vomiting, diarrhea, and alopecia on the head, eyelashes and eyebrows, and genitals. Weight gain is common, particularly in those receiving chemotherapy and endocrine therapies. All of these medical issues have a negative effect on sexual self-esteem and feelings of attractiveness. Tamoxifen can cause hot flashes, vaginal discharge and itching, dysfunctional uterine bleeding, and uterine cancer. Severe atrophic changes in the genitals, bone loss, and fracture risk exist for those on aromatase inhibitors. Immediate premature menopause may occur and existing menopausal symptoms may worsen due to chemotherapy or endocrine treatment.
The psychological ramifications of breast cancer are significant. Research shows that the strongest predictor of sexual problems after breast cancer is lower perceived sexual attractiveness [18]. In addition women who have a poor body image after breast cancer have lower rates of sexual satisfaction and are more dissatisfied with their sexual relationship than those with a positive body image [19]. While the physical pain associated with mastectomy diminishes with time, the emotional pain may persist and women grieve the loss of their breast(s) and feel mastectomy is associated with being “half a woman” [20]. In fact, the quality of a woman’s relationship is a stronger predictor of sexual satisfaction, sexual functioning, and sexual desire after breast cancer than the physical or chemical damage to the body after treatment [21–23].
27.5.2 Endometrial Cancer
The American Cancer Society estimates about 52,630 new cases of uterine cancer for 2014 [17]. Surgical staging remains the standard of care and includes total hysterectomy, removal of ovaries and tubes, and possible lymph node dissection. Laparoscopy is both safe and feasible and associated with quality of life advantage over laparotomy [24]. Endometrial cancer is often diagnosed at an early stage and the overall prognosis is excellent. Postoperative external beam radiation to the pelvis and/or intracavitary vaginal brachytherapy may be used for later-stage disease. In general, sexual function and fear of sex declined after surgery for uterine cancer but recovered to preoperative levels by 6 months [25]. Laparoscopy patients indicated physical appearance as more important and had higher scores of satisfaction with stomach appearance, overall appearance, and in feeling like a women although improvement over time was noted in both groups [25]. In other words, minimally invasive surgery did not differ from laparotomy regarding resumption of or improvements in sexual function postoperatively, but laparoscopic patients were more satisfied with their overall feminine appearance [25]. One study suggested that while uterine cancer patients treated with either surgery alone or surgery and intravaginal brachytherapy reported symptoms of dry, short, and tight vaginas, there was no significant difference in sexual functioning, sexual worry, or sexual enjoyment between the two [26]. It should be noted that since endometrial cancer is usually a diagnosis in older ages, baseline sexual function might be lower due to a variety of factors including relationship duration, age, and hormone status.
27.5.3 Cervical Cancer
Cervical cancer is usually diagnosed in reproductive-aged women so fertility or potential lack thereof may be an issue. A majority of patients are sexually active at the time of diagnosis in part due to younger age. Treatment of early-stage cervical cancer consists of cervical conization, radical trachelectomy, or radical hysterectomy with pelvic lymphadenectomy. As such, shortening of the vagina and disruption in neurovascular supply can result in dyspareunia, arousal, orgasm, and sexual positioning difficulties. Changes in position during intercourse to avoid deeper thrusting are advised. Alternatives to missionary position, such as female superior, side by side, or rear entry, are helpful. The Come Close® device , available in the United Kingdom, may be placed around the base of the penis to prevent deep thrusting and collision dyspareunia. Decreased libido and diminished vaginal lubrication seem to be the only side effects that persisted in a two-year study period [27]. If adjuvant radiotherapy is needed, treatments can cause bloody and foul smelling vaginal discharge, vaginal stenosis, polyuria, and bleeding. Lymphedema in the lower extremities can occur and can be managed with compression stockings, physical therapy, and lymph massage locally.
In one study, the ability to achieve orgasm was unimpaired in cervical cancer survivors; however, dyspareunia was more common than in healthy controls [28]. This was more frequently reported and lasted longer in patients treated with radiotherapy compared to surgery [28]. Lack of lubrication was more frequent in cervical cancer survivors than in healthy controls. In general, in the cervical cancer population, impaired sexual function seems to be accompanied by pain during vaginal intercourse, and decreased desire and arousal are, at least in part, a result of pain [28]. As such, if treatment focuses on avoidance of pain, arousal and desire will improve. The vast majority of cervical cancer is caused by human papilloma virus (HPV) infection. Since this is sexually transmitted, it may be associated with complex psychological ramifications.
Unique to cervical cancer is the media impact achieved with advertisements related to HPV. Women question their own or their partners’ past relations or feel embarrassed discussing their cancers because of the potential blame on sexual conduct [29].
27.5.4 Colorectal Cancer
The American Cancer Society estimates 66,000 new colorectal cancer diagnoses for 2014 [17]. An overwhelming patient concern in the treatment colorectal cancer is the potential ostomy. Women are frightened and concerned for potential odor, gas, soiling, and fecal or fatal accidents. Patients should be educated to carefully orchestrate ostomy management techniques when engaging in sexual activity. The various techniques employed to manage a stoma and appliance before, during, and after sex are numerous and creative. Women may apply a new bag so it is empty during relations. Cover the pouch with towels and fixate its position with tube tops or nightgowns to keep the pouch stable, insure accident prevention, and keep the pouch hidden [30]. Others may place special tablets within the ostomy bag to mask potential odors, while others may opt for sexy coverings for their ostomy appliance.
27.5.5 Anal Carcinoma
Anal cancer is distinct from colorectal cancer. Risk factors include smoking, history of multiple sexual partners and anal intercourse, impaired immunity including HIV, HPV infection, and age over 50. Anal carcinoma is treated with surgical resection with or without chemoradiation, and in some cases permanent colostomy is needed. Issues with ostomy care and rituals regarding sexuality are discussed above. Acute effects of treatment include skin reaction including desquamation, pain, nausea, vomiting, diarrhea, and hair loss. Later effects include vaginal stenosis, changes in rectal or anal function, flatus and fecal incontinence, pain, and acceleration of menopausal symptoms. Psychosocial effects include depression, embarrassment, and, specific to anal cancer, anxiety over the relationship of anal carcinoma to sexual practices, HIV or HPV infection, and the possibility of needing a colostomy. The skin is a sensual organ so prevention of skin changes and early treatment for radiation induced skin damage are essential. Extreme sensitivity to touch can occur due to radiation. Guidance may be needed to avoid “touch” that is experienced as discomfort [31].
27.5.6 Ovarian Cancer
Ovarian cancer is unique since early detection is limited. Typical treatment is surgical debulking with adjuvant chemotherapy depending on stage. Total hysterectomy with removal of ovaries and tubes has profound emotional and psychological impact at the core of femininity and fertility. First-line chemotherapy usually involves a platinum or taxane compounds known to cause fatigue, nausea, vomiting, weight change, changes in cognition, alopecia, peripheral neuropathy, and symptoms of menopause. In addition, preexisting sexually transmitted diseases often flare as a result of induced immune suppression. Oral antiviral therapy for genital or oral herpes and antifungal treatment for yeast vaginitis may be required. Long-term sexual consequences of taxane and platinum chemotherapy regimens may include clitoral neuropathy, affecting sensation and pain tolerance. Since the majority of women diagnosed with ovarian cancer are older than 60, sexual activity may already have declined due to age, hormonal decline, and partner and relationship status. In fact, predictive of greater levels of sexual activity after ovarian cancer were satisfaction with the appearance of one’s body, being younger than age 56, not being actively treated, and being married [32].
27.5.7 Vulvar Cancer
Vulvar cancer accounts for only 3–5 % of gynecologic malignancies [33]. Uniquely, many of these patients may have avoided sex prior to diagnosis due to symptoms of their cancer including vulvar pain, itching, burning, soreness, bleeding, ulcers, or the existence of multifocal lesions. Surgical treatments including wide local excision, simple or radical vulvectomy with lymphadenectomy, and adjuvant radiation therapy have further negative sexual consequences. Depending on the location of the vulvar lesion, in order to obtain adequate surgical margins, clitorodectomy may be necessary, causing obvious sexual dysfunction. Inability to have intercourse due to vaginal stenosis can occur and even aggressive vaginal rehabilitation with dilators and physical therapy may be warranted. Women feel “lop-sided” after hemivulvectomy; complain of loss of sexual sensation, due to fibrosis and lymphedema; and have concern about loss of control over bodily functions. In addition, since so much publicity surrounds the more common breast or colon cancers, lack of public awareness may contribute to the vulvar cancer patient’s sense of aloneness [34]. Lastly, as the majority of vulvar carcinomas occur secondary to vulvar dermatoses such as lichen sclerosus, preexisting scarring and sexual dysfunction from these conditions may contribute to sexual dysfunction and need to be addressed.
27.6 Conclusion
As more women survive cancer due to medical and treatment advances, the need for optimal strategies that address quality of life facets including sexual function are critical. While cancer and its treatments directly contribute to sexual dysfunction, many confounding medical issues also influence post-cancer sexual functioning. Medications, partner status, depression and anxiety, personal self-esteem, premorbid sexual status, and cultural and religious influences are paramount etiological factors which must be addressed in tandem with the physiological and psychological ramification of cancer and its treatments. As such, addressing sexual dysfunction in the cancer patient requires education, open communication, lifestyle modifications, therapy, and support from a multidisciplinary team of healthcare professionals. Specialized cancer centers with survivorship programs are ideally suited to provide comprehensive care since they offer a multifaceted approach to sexual health and involve gynecology, internal medicine, sex therapy, social work, pharmacology, psychology, nutrition support, physical therapy, and spiritual healing.
27.7 Patient and Provider Resources
· The American Cancer Society (ACS): http://www.cancer.org/
· North American Menopause Society (NAMS): http://www.menopause.org/
· International Society for the Study of Women’s Sexual Health (ISSWSH): http://www.isswsh.org
· International Society for Sexual Medicine (ISSM): www.issm.info
· European Society for Sexual Medicine (ESSM): www.essm.net
· American Congress of Obstetricians and Gynecologists (ACOG): http://www.acog.org/
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