CANCER AND SEXUAL HEALTH, FERTILITY & INTIMACY
Are Sexual Side Effects Common? Yes.
"Sexual dysfunction is a common consequence of cancer treatment, affecting at least half of men and women treated for pelvic malignancies over a quarter of people with other types of cancer. Problems are usually linked to damage to nerves, blood vessels, and hormones that underlie normal sexual function. Sexual dysfunction also may be associated with depression, anxiety, relationship conflict, and loss of self-esteem." (source)
"Sexuality is an integral part of quality of life that can be radically altered by the adverse effects of cancer therapies. Following treatment, sexual dysfunction can arise from physical and psychological changes in body image and self-concept, altered sense of attractiveness, physical discomfort, and emotional distress, diminishing overall quality of life. Estimates of overall prevalence rates of sexual difficulties associated with cancer and its treatment range from 40% to 100%." (source)
"The incidence of sexual dysfunctions ranged between 30% and 80% in women with cancer. Women with cancer had a 2.7- and 3.5-fold higher risk of developing sexual dysfunctions, mainly alterations in desire, arousal, and orgasm, than women without cancer." (source)
"A survey of patients in a radiation oncology clinic showed that 87% of patients reported that cancer treatment impacted sexual function or desire, but only 27.9% reported ever formally being asked about sexual health." (source)
"When compared with men, women with cancer are significantly less likely to be asked about sexual health by their medical teams (53% vs. 22%, respectively). This is consistent with a previously reported study that estimated 80% of patients with prostate cancer received information about sexual dysfunction after cancer treatment compared with 33% of patients with breast cancer. These data continue to highlight the lack of attention paid to sexuality after cancer." (source)
"Decreased sexual sensation and sexual responsiveness affects over 60% of women diagnosed with cancer, while erectile dysfunction affect up to 75% of men with cancer." (source)
"Despite the high frequency of sexual toxicity, however, few survivors were warned about this potential side effect, and even fewer were formally asked about their sexual health after treatment. What’s more, results showed that women who survive cancer may be significantly less likely than men to have their sexual side effects addressed by their provider. Based on these findings, authors of the study recommended that oncology practices integrate questionnaires that assess sexual health into survivorship care for all patients." (source)
"Changes in sexual functioning – one of the most ubiquitous life-altering, adverse effects of prostate cancer treatment – impact gay and heterosexual men very differently. Yet too few health care providers ask about their patients’ sexual practices or know the answers when asked about the effect of prostate cancer on gay men’s sexuality or where we can receive culturally competent support on issues of sex, intimacy and our relationships." (source)
"Many of the issues that affect sexual function are much longer lasting than other cancer treatment side effects and often are not seen until years after treatment, as patients might not feel up to exploring their sexuality for some time and may not even realize any issues have arisen. But the distress related to these changes is real and measurable and can persist for years." (source)
"Noteworthy, this burden can affect the male subject even when he is not the patient but the caregiver. Indeed, since cancer involves all the family members, male partners of oncological patients may experience emotional distress leading to sexual issues. In this context, the male partner could experience feelings of unattractiveness, fear to start sexual activity and loss of libido, up to the occurrence of ED." (source)
Cancer types with higher rates of treatment-related sexual side effects:
- Breast cancer
- Prostate cancer
- Gynecological cancers
- Colorectal cancers
- Bladder cancer
- Head & Neck cancer
- Lung cancer (notably in women)
Cancer's Impact on Sexual Health & Sexual Function
Potential Sexual Side Effects Associated with Cancer Treatments
- loss of sexual desire/decreased libido
- fatigue/decrease in sexual stamina
- infertility, loss of menses, damage to eggs/ovaries/sperm
- vaginal stenosis (narrowing/tightening/shortening of the vaginal canal)
- vaginal dryness
- vaginal spasm
- erectile dysfunction/difficulty getting and keeping an erection
- reduction in penile length
- poor self-image/body-image, reduced confidence and self-esteem
- medically-induced early-onset menopause/cessation of avarian function
- difficulty or inability to reach orgasm
- inability to ejaculate
- loss of sensation
- vaginal atrophy
- insomnia/sleep disturbances
- hot flashes
- difficult or painful intercourse (dyspareunia)
- reduced testosterone production
- reduced estrogen production
- performance anxiety
- urinary or fecal incontinence
- weight gain or weight loss
- physical disfigurement and/or scarring as the result of surgeries
- "When people are distracted by their appearance, they cannot focus on their sexual pleasure, and this negatively affects their sexual function." (source)
- "Pelvic surgeries (e.g., prostatectomy, colorectal surgery) and/or pelvic radiation therapy in men can damage the pelvic nerves and alter blood supply to the area, leading to loss of libido, erectile dysfunction, ejaculation changes, and painful intercourse." (source)
- "Estrogen levels drop naturally during chemotherapy. It is well known that a lack of estrogen results in atrophy of the urogenital system and dyspareunia, lowering sexual desire and arousal." (source)
- "Antiandrogen hormonal therapy to treat prostate cancer reduces production of testosterone and leads to decreased libido, erectile dysfunction, and difficulty achieving orgasm." (source)
- "Hematopoietic stem cell transplantation commonly leads to chronic sexual dysfunction, persistent vaginal dryness, erectile dysfunction, and low libido." (source)
- "Chronic graft-versus-host disease can affect genital mucus membranes, resulting in vaginal dryness, pain, stenosis, and scarring." (source)
- "Estrogen-depleting hormonal therapies for breast cancer, such as tamoxifen and aromatase inhibitors, lead to changes in the genital epithelium (e.g., vulva, vagina), causing vaginal dryness, atrophy, and pain with intercourse (dyspareunia) and with routine clinical pelvic examinations, and decreases libido." (source)
- "Chemotherapy agents can damage the ovaries by destroying ovarian follicles or the blood supply to the ovary, resulting in vaginal changes and temporary or permanent cessation of menses and infertility." (source)
- "Gynecologic surgeries, colorectal surgery, and pelvic radiation therapy can result in vaginal stenosis (narrowing and shortening of the vagina), vaginal atrophy, pelvic nerve damage, and changes in blood supply to the area, causing pain and discomfort during sex." (source)
- "Mental health disorders may also interfere with sexual function and impair the lives of women under cancer treatment. After treatment, women reported doubts about the disease, fear of recurrence, lack of information about treatments and follow-up, changes in lifestyle, recurrence of symptoms, and concerns about disease prevention in first-degree relatives; these doubts therefore generated psychological distress." (source)
- "Surgical treatments like mastectomy or orchiectomy or the placement of a temporary or permanent stoma can adversely affect a healthy body image and therefore lead to changes in sexual self-esteem. This might have a long-lasting effect on cancer patients sexuality in consequence of anatomical defects incurred, whereas sexual dysfunctions caused by chemotherapy and radiotherapy mostly disappear after terminating treatment." (source)
- "In the case of hormonal treatment, a significant number of cancer patients become menopausal during active cancer treatment, and postmenopausal symptoms often remain stable after active cancer therapy. Also hormonal treatment (e.g., androgen deprivation therapy) can lead to erectile dysfunction in men with long-lasting effects even after termination of the therapy." (source)
What Can Be Done to to Relieve, Reduce, or Reverse Side Effects?
Though sexual side effects are not discussed as often or as openly as they should be considering their prevalence, there are many resources for relief and help. You do not need to hide or "put up with" side effects that negatively effect your sex life, relationships, or self-esteem.
Below are some considerations for sexual side effect improvement:
- "Early use of vaginal moisturizers and lubricants is recommended to prevent progression to chronic vaginal atrophy and loss of tissue elasticity, and to provide vaginal lubrication." (source)
- "Early and regular use of vaginal dilators may help to prevent vaginal atrophy and subsequent pain during pelvic examinations and sexual activity." (source)
- Vacuum erection devices (VEDs) "ASCO recommends that vacuum erection devices (VEDs), medicated urethral systems for erection, or intracavernosal injections be used as adjunct therapies in patients who lack responsiveness to PDE5i (ED medications). Furthermore, VEDs should be used daily to prevent loss of penile length. Preservation of penile length or faster restoration of erectile function may result from use of these therapies sooner after cancer treatment, although this remains to be definitively determined." (source)
- "Inflatable penile prosthesis (IPP) should be considered when patients lack responsiveness to less invasive therapies such as PDE5i, VEDs, and intracorporal injections. These devices allow patients with ED to resume penetrative sexual intercourse without interfering with urination, ejaculation, sensation, or orgasm." (source)
- Vaginal dilators for vaginal stretching and muscle relaxation
- Dildos, vibrators, or other penetrative sex toys for vaginal stretching
- Individual or couple psychosocial/psychosexual counseling
- Vaginal laser therapy (not yet FDA-approved)
- "Nonhormonal vaginal moisturizers which come in various formulations—from hyaluronic acid to paraben-free to polycarbophilic—and do not require a prescription. The key to effectiveness is consistent application, and we suggest use on a regular basis at least three times per week." (source) (Replens Long-Lasting Vaginal Moisturizer, for example)
- Hormone replacement therapies
- Erectile dysfunction prescription medications
- "Interventions such as education, technology-based educational interventions, psychosexual counseling, sensate focus, cognitive behavioral therapy, hypnosis, mindfulness, and exercise have shown benefit." (source)
- Referral to reproductive endocrinology to discuss fertility preservation prior to treatment (sperm, egg, embryo banking)
- Referral to urology
- Referral to gynecology
- Referral to a certified sex therapist
- Referral to pelvic pain specialist
- Referral to pelvic floor therapist
- Referral to sexual medicine specialist
- Referral to a grief counselor
- Open communication with sexual partner(s)
- Extended foreplay
- Sensual touch
- Kegel exercises
- Changes in sexual position, time of day, location
- Filbanserin is approved by FDA to treat low sexual desire in pre-menopausal women
- Cognitive behavioral therapy
- Bremelanotide is an injectable medication used to treat low sexual desire in pre-menopausal women
- Lidocaine to reduce pain/discomfort
- Ospemifene is a daily oral tablet used to relieve vaginal dryness (not a libido booster)
- Antidepressants, anticonvulsants, anticholinergics, progestins for treatment of hot flashes
- Mindfulness therapy
- Prescription phosphodiesterase enzyme inhibitors (sildenafil, vardenafil, tadalafil, avanafil) for erectile dysfunction
- Alprostadil (penile injection or intraurethral tablet) for erectile dysfunction
- Physical therapy
- Masturbation to increase sexual confidence and decrease performance anxiety
- Relaxation techniques
- Massage
- "Couples should focus on strengthening their relationship and physical affection for each other through means other than sexual intercourse. It may be necessary for couples to expand their sexual repertoire by engaging in non-penetrative sexual activities such as manual stimulation, deep kissing, or oral sex. The use of alternative sexual methods can allow the couple to maintain intimacy, even if challenges with ED and loss of libido persist." (source)
Talk to your doctor about which of these possible solutions are right for you.
How Can Oncologists and Other Healthcare Providers Help?
Let's Talk About Sex, Maybe?
It's clear, when reviewing scientific literature, that both patient awareness and education of potential sexual side effects and the necessary follow-up and referral to appropriate specialists is not being delivered as it should. There is plenty of room for improvement in caring for people with cancer who are faced with or experiencing impactful sexual side effects due to treatment. Health care provider's embarrassment, shame, or discomfort surrounding conversations about sexual health needs to take a backseat to the needs and the care of patients. Patients want to be aware of possible sexual dysfunction resulting from their treatments, and they want education, discussion, validation, and support. Let's give it to them.
If you provide care to oncology patients, please consider incorporating the following practices to better serve the sexual health and psychosexual needs of your patients:
- "Cancer care professionals should ask about sexual health concerns around the time of diagnosis and throughout follow-up. Incorporating sexual health as a routine review of systems or standardized assessment is a way to bring forward these concerns." (source)
- "Sexuality concerns are not solely for the primary oncology provider to address. Given the many domains in which sexuality can be affected by cancer and treatment, a multidisciplinary team including urologists, urogynecologists, gynecologists, pelvic floor physical therapists, mental health providers, and sex therapists, among others, can best meet the needs of women who have concerns." (source)
- "The narrative in cancer care has to change for cancer centers globally to provide holistic care, including sexual well-being discussions, not only at diagnosis but throughout a patient’s cancer journey. Working toward destigmatizing cancer and conversations about sexuality are the first steps in LMICs. The knowledge of oncology medical professionals about sexuality and fertility guidelines and treatments, as well as affordable access to these treatments, must be improved. Providing accurate and culturally appropriate information to patients and their families about cancer and its impact on sexuality may help to dispel myths." (source)
- "Our findings emphasize the notion that sexuality should be viewed as a health issue that has an impact on quality of life and other factors detrimental or beneficial to the overall health and well-being of cancer patients. Accordingly, it seems that management of psychological and mental well-being in cancer patients is crucial when it comes to treatment and recovery process. As our data might show, it is therefore wrong to assume that cancer patients have no concerns about their sexual health. The occurrence of sexual problems in cancer patients indicates the importance of those being able to talk about their concerns, as previous studies show that often those concerns and the conversations about them are considered as a taboo in cancer care." (source)
- "Professional psychosocial/psychosexual counseling should be offered to all patients with cancer, with the goal being to improve sexual response, body image, intimacy and relationship issues, and overall sexual functioning and satisfaction. Most insurances, including Medicare, cover sexual health assessment and treatment under mental health services. Having a strong referral network of mental health professionals and sexual therapists will improve the quality of care and provide a team-based approach. The American Association of Sexuality Educators, Counselors, and Therapists (AASECT) is an excellent resource for connecting healthcare providers with professional sexual therapists across the United States." (source)
- "Psychoeducative interventions, where cancer patients get access to high-quality information about the short and long-term effects of cancer and its treatment are helpful. In addition, careful consideration of treatment options, particularly in the context of surgical procedures that may be associated with impaired sexual physiology, is essential. Healthcare professionals should guide and prepare their patients to have sufficient information about treatments and possible side effects, including sexual health disruptions that may persist even into survivorship." (source)
- "Information about sexual history and trauma should always be collected. If a person has been raped, sexually assaulted, or received unwanted touch in the past, it is possible that a provider might unknowingly retraumatize that patient. Asking permission to touch (“Is it OK if I undo your gown?”), and asking questions about a patient’s sexual history are crucial to avoiding retraumatization, particularly among patients with pelvic, rectal, or breast cancers." (source)
- "Healthcare practitioners should initiate conversations with patients regarding the potential for sexual dysfunction at the time of cancer diagnosis and throughout treatment and follow up. Physical symptoms of sexual dysfunction should be treated, whenever possible, and all cancer survivors presenting with psychological distress related to sexual dysfunction should be offered professional counseling." (source)
- "The degree of psychological distress among cancer survivors experiencing sexual dysfunction should be closely monitored as there may be an increased risk of depression, anxiety, and even suicidal ideation in this population." (source)
- "The Ex-PLISSIT model is an invaluable tool for assessing sexual health. The letters of the name refer to the 4 different levels of intervention that a provider can apply: permission, limited information, specific suggestions, and intensive therapy. According to Dr. Sage Bolte, PhD, LCSW, Chief Philanthropy Officer and President, Inova Health Foundation, the vast majority of patients will not require the intensive therapy step. Using the model, first obtain permission to initiate sexual discussion and legitimize sexual concerns. This doesn’t mean overtly asking for permission to initiate the conversation, she noted, but using relationship-neutral language, inform the patient/partner that discussion of sexuality is part of routine assessment. Be aware of cultural and religious issues, and inquire about their previous sexual trauma/history. Ask how their illness has affected their sexual self and relationships. If the patient expresses some concern (eg, sex is painful), normalize the conversation and offer limited information in the form of a specific, quick tip: “Are you using vaginal moisturizers or lubricants?” Directing the patient to resources can also help. Specific suggestions take a bit more time and might require a follow-up appointment or referral to another provider. Provide prescriptions (or sample products) as needed/available, and include the partner in these discussions, as this facilitates communication between the couple and normalizes potential problems." (source)
- "For sexual- and gender-minoritized women, sexuality concerns must be a part of their cancer care, which starts with acknowledging their identity. Institutions must allow the collection of sexual orientation and gender identity data and work toward becoming a friendly environment for all people they serve, including this population. Beyond data collection, oncology care providers can work toward a more inclusive environment in several tangible ways. First, their education materials and posters in waiting rooms and examination rooms can include images of SGM individuals and couples to provide a more inclusive waiting room experience. Second, they can educate their staff and personnel about communication strategies that may encourage SGM patient disclosures, including using appropriate language such as “partner.” Third, they should routinely provide the opportunity for all patients to disclose their sexual orientation and gender identity, whether by self-administered form or direct inquiry as part of the doctor-patient visit. Last, they can adopt the use of personal pronouns and inquire about their patients’ own preferred pronouns to show respect for the individual." (source)
- "ASCO’s Expert Panel acknowledged that additional education concerning changes in erection capacity and alternative ways to maintain intimacy may be required for gay and bisexual men." (source)
- "The 27 prostate cancer survivors in the Albaugh et al. study recommended that information be provided before, during, and after cancer treatment. These men commented that patients may lack sufficient understanding or may not be mentally prepared to process all of the information upon first learning of their cancer diagnosis. This study observed that patient experiences are improved when patients feel that the physician devotes the time to provide information and answer questions. Reports of poor patient experiences are commonly associated with the belief that the physician was overly optimistic about sexual function outcomes. Additionally, some men in the study felt they were not adequately informed about the effects of treatment on their sexual function and thus felt unprepared to cope following treatment. Several of these participants stated that they regretted having their procedure done. These findings demonstrate the importance of setting clear expectations starting at the time of cancer diagnosis and continuing to discuss sexual function throughout the treatment and recovery process. " (source)
Oncosexual Health & Oncofertility
Coming Soon!
There's much more in store for this page. Stay tuned! In the meantime, please take advantage of the resource collection below to learn more about sexual health, intimacy, and fertility as it relates to cancer and cancer treatment. If you haven't yet visited the Newly Diagnosed page for a thorough overview of the early cancer experience, please check it out.
