Cancer, Sexual Health & Intimacy
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, erotic expression, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behavior, practices, roles and relationships. It is clear that these issues go far beyond medical concerns. Sexual concerns are common among patients in the process of diagnosing, treating, and recovering from cancer.
The purpose of this document is to understand successful promotion of sexual health in patients diagnosed with cancer. As patients move away from the acute phase of illness, healthy sexual functioning is an important step toward re-establishing their sense of well-being. Several physiologic and psychological factors specific to oncology patients (eg, advanced disease, radical surgery, pelvic irradiation, symptoms related to menopause, pre-morbid sexual dysfunction, and negative self-concept) can promote sexual morbidity. These issues may place cancer survivors at increased risk for the development of sexual problems.
Approximately 50% of women who survive breast or gynecologic malignancy report severe, long-term sexual problems. Several studies have shown that sexual dysfunction is highly prevalent in the population of cancer patients and sexual morbidity occurs in up to 90% of women with cancer (1). Most of the studies have reported the range 30% to 100%. Breast cancer survivors note that sexual problems are bothersome and disheartening exceptions to the restoration of their high level of functioning. For patients who have survived other types of cancer (eg, Hodgkin's lymphoma, leukemia), at least 25% are left with sexual complaints. Most commonly, these patients report hypoactive desire disorder, and/or dyspareunia. Women at greatest risk for sexual problems include those with cancer of the vulva or vagina and those who have had a pelvic exenteration.
Physicians and nurses need to be informed about the potential sexual outcomes for patients with gynecologic cancer. Patients make few inquires, despite their concerns, healthcare providers need to initiate discussion of sexuality topics. When question do arise, an informed and understanding response encourages future disclosure of questions and concerns. Body image concerns impose psychological barrier to intimacy and sexual desire, and the resulting partner conflicts and relationship miscommunications can be severe, debilitating, and painful. Misconceptions among patients and their partners, such as the fear of being "radioactive", are also encountered.
Technologic advances have changed our perceptions concerning malignancy. It is now often viewed as chronic illness. The medical community continues to improve therapeutic modalities by focusing on techniques that not only improve cancer survival rates, but decrease long-term side effects and suffering as well. New surgical techniques and adjunctive therapies reflect the growing emphasis on quality of life. Even for the older woman or the woman who is not currently sexually active, such information is desirable. The most important determiner factor of the frequency of sexual activity for a woman is the presence of a healthy and interested sexual partner, not age per se. A pre-treatment sexual history is best obtained by questioning the patient directly. A brief sexual history should be obtained from all patients before treatment (2). Obtaining a sexual assessment can achieve three goals:
- It identifies sexuality as an area of importance to the patient with gynecologic cancer.
- It provides the healthy baseline data necessary to evaluate any future changes in sexual functioning.
- It provides an informed context for future discussions about sexuality with the medical team.
Questionnaires can be used to assess such topics as sexual behavior or sexual arousal. The following areas can be briefly surveyed during a discussion with a patient: marital status and availability of current sexual partner(s); frequency of sexual activity; presence of female sexual dysfunction (e.g., lack of desire, orgasmic difficulties) and presence of sexual dysfunction in the partner (e.g., premature ejaculation, erectile difficulties). Survivorship initiatives are now a critical focus for many cancer institutions and governmental organizations. These programs formulate comprehensive treatment plans for cancer survivors and promote research in this area. Post-treatment resources and sexual health programs are integral parts of these survivorship initiatives.
Sexual dysfunction is a common consequence of cancer therapy that may persist after treatment is completed. Patients make few inquires, despite their concerns, healthcare providers need to initiate discussion of sexuality topics. When questions do arise, an informed and understanding response encourages future disclosure of questions and concerns. Departments caring for patients with gynecologic cancer need to determine how they will provide psychosexual help. For the individual patient, preventive rather than rehabilitative efforts are desirable. Women at greatest risk for problems include those with cancer of the vulva or vagina and those who have had a pelvic exenteration. In contrast to preventive services, rehabilitative services may be considered for women at less risk. The assessment of the cancer patient includes a detailed history, physical examination, psychological evaluation, and when appropriate laboratory and radiologic studies. Sexual status, orientation, and history are also assessed (3). Patients are encouraged to see both the gynecologist and psychologist for initial and follow-up evaluation and follow-up surveillance. Once the comprehensive assessment is completed, a therapeutic management plan is formulated.
A number of issues should be considered before any type of therapy instituted:
- Systemic Illness: evaluation and treatment of chronic illnesses such as uncontrolled hypertension, hypercholesterolemia, diabetes (mellitus), and/or underlying thyroid dysfunction may do much to eliminate factors contributing to sexual dysfunction. Treatment of chronic illnesses can also improve general well-being, which may enhance sexuality.
- Medications: antidepressants and antihypertensive medications can alter sexual desire, arousal, and orgasm. Physicians should check pharmacologic guides to identify potential offending agents. Occasionally, medication regimens can be modified by altering dosing and/or time intervals or specific drug classes to decrease sexual side effects.
- Pain Management: complaints of pain can influence a woman's sexual response and limit her interest in sexual activity. Removing pain as an obstacle to sexual functioning can actually have additional analgesic benefits, as many patients report relief of pain, improved mood, and an increased sense of relaxation after resuming sexual activity.
Specific medical interventions may enhance sexual functioning for selected patients. Concerns regarding hormonal manipulation are common in breast and gynecologic cancer patients. Patients with estrogen-sensitive tumors rarely use hormone replacement therapy (HRT), probably because of a perceived increase in cancer risk associated with HRT and/or the side effect profiles. Local use of non-medicated, non-hormonal vaginal moisturizers such as Replens or vitamin E suppositories can provide significant relief for the symptoms of vaginal atrophy. It is recommended that these agents be used two or three times weekly. In addition, patients are instructed to wear a light protective pad when using vitamin E suppositories, which may stain undergarments. The use of water-based vaginal lubricants (Astroglide, KY Jelly) with intercourse is also encouraged. Despite these efforts, certain sexual activities may remain impossible. For example, surgical modification of the introitus for a patient with cancer of the vulva may not be successful, so the woman and her partner need to reorient themselves to a sexual lifestyle that does not include vaginal intercourse.
Patients and oncologists are now using topical estrogen more often to treat vaginal atrophy. The use of 17-beta estradiol tablet (Vagifem) that is minimally absorbed into the systemic circulation is helpful in many patients. Estrogens administered vaginally are well absorbed, and the required effective topical dosages are minimal. Patient feedback indicates that these vaginal tablets are easy to use, less messy than cream preparations, and technically simpler to insert than estrogen rings (4). Patients should be educated about their genital anatomy and how cancer therapy and surgical procedures can affect their sexual functioning. The debunking of many long-standing sexual myths and the instructional guidance of trained professionals is an important part of this educational process.
Sexual devices for patients who have undergone pelvic surgery and/or radiation therapy, vaginal shortening, narrowing, and scar tissue can often impede penetration, causing dyspareunia. This may lead patients to avoid many types of sexual activity. Vaginal dilators with water- or hormone-based lubricants can help to lengthen and widen the vagina and stretch the scar tissue that contributes to the discomfort associated with vaginal intercourse. In addition, devices such as the EROS clitoral stimulator can be prescribed for patients who have had cervical, rectal or vaginal cancer. Preliminary data shows promise that this device may be helpful in combating arousal difficulties after cervical cancer therapy (5).
Alternative and Complementary Medicine:
Many non-medical pharmacologic therapies have potentially detrimental side effects, and have no scientific data supporting their ability to alleviate sexual dysfunction. Although patients try agents such as chocolate, ginseng, oysters, and black cohosh to enhance sexuality; randomized controlled clinical trials are needed to ensure safety and efficacy and to demonstrate a low side-effect profile. Referral for an evaluation by a sub-specialist may be appropriate for certain clinical conditions. Consultants may include oncologists, social service providers, nutritionists, exercise therapists, and psychiatrists.
Certified sexual therapists are trained to deal with cancer patients and their body-image issues and changes in intimacy, sexuality, self-esteem, and mood. Marital, individual, couples and group therapy by a trained therapist to deal with cancer-related sexual issues are helpful. Behavior techniques offer a useful place to begin. This should be conducted by a professional who is trained broadly in sexual therapy and familiar with the specific difficulties of the patient with gynecologic cancer.
- Desire Problems -- it commonly occurs in the early months of recovery and may be a part of normal, prolonged recuperative process. Determining what conditions for sexual activity are more or less appealing and encouraging sexual activity under the most desirable circumstances may be needed. Increasing the frequency and variety of intimate activities (not only sexual behaviors) that the woman might find pleasurable is helpful to both the patient and her partner.
- Enhancing Arousal -- many desire phase interventions have been used to enhance arousal, including the use of individual and couple body-touching exercises. These can reinforce relaxing and enjoyable sexual activity to a woman or a couple. This is important because many patients come to sexual therapy after many frustrating, discouraging, or unsatisfactory sexual encounters. These activities are not strenuous, which is helpful to the woman who is not fully recovered or who tires easily. Touching of an area affected by treatment should be eliminated or introduced gradually. Such a strategy can be less anxiety provoking for a woman and her partner. Also both partners can learn what sensitivity, if any, remains in affected areas.
- Reducing Negative Sexual Reactions -- women may react negatively to their changed bodies after radial surgery, such as vulvectomy or pelvic exenteration. Extreme responses may include disgust or anxiety when looking at the site, and fear of being seen by others. Many healthy women with sexual difficulties or anxieties have similar feelings. For such women, anxiety-reducing techniques, particularly systematic desensitization, or individual sensate focus exercises have proved effective (6). Although such activities may not change a woman's negative body feelings to positive, the feelings may become neutral, or at least non-disruptive to her sexual activities and overall mood.
- Orgasmic Dysfunction -- the difficulty is typically acute, with disruption occurring immediately after treatment. Before beginning a treatment program for orgasmic difficulties, it is important that other reasons for orgasmic difficulties be assessed, including insufficient arousal or dyspareunia. The most successful treatment programs for healthy, non-orgasmic women include a series of individual sexuality and masturbation exercises. The early steps of such programs involve body touching, identification of genital anatomy, actual body and genital self-examination to identify pleasurable sensations, and focused genital stimulation. Even though pelvic or genital anatomy after cancer treatment is changed, it is possible that orgasm can still be experienced through other means, because women can experience orgasm with genital stimulation or without specific organs such as the clitoris, once believed critical to the response.
- Resolution Disruption -- sources of difficulty may include residual pain if there has been dyspareunia or continued arousal from lack of orgasm. The most straightforward remedy to such problems is enhanced functioning during earlier phases of the sexual response cycle so that the resolution period is satisfactory. However, for those women with permanent sexual changes, efforts should be made to counteract feelings of discouragement, "letdown", or continued tension that might predominate a woman's view of her sexual functioning during resolution phase.
Departments caring for patients with gynecologic cancer need to determine how they will provide psychosexual help. For the individual patient, preventive rather than rehabilitative efforts are desirable. This should include the routine provision of sexual information to patients, particularly those at high risk for sexual problems. In contrast to preventive services, rehabilitative services may be considered for women at less risk. With such a system, women would usually be seen only after sexual problems had developed. Although they might be more difficult to treat them, the positive benefit of having a readily available treatment program would be important to the patients. Patients returning for follow-up need to be informed of the availability of such a resource.
Educating patients about sexual myths and the potential impact of cancer treatment on sexual function and providing instructional guidance and support are all integral parts of treatment. Research has shown that compliance with therapeutic modalities and preventive measures is more likely if education and close follow-up are undertaken prior to the initiation of cancer treatment. Individual treatment plans created and implemented by the professional sexual health care team to educate patients and their partners so they can enjoy fulfilling, pleasurable sexual activity during and after cancer therapy. Quality-of-life concerns in cancer survivorship are paramount for both clinicians and patients. It helps women to take a more active role in her sexuality, gives her an improved body concept, and allows her to discover new modes of experiencing sexual pleasure. The woman should be oriented to focus on the positive aspects of her sexual life, such as the continued ability to engage in sexual activity, the experience of physical closeness and intimacy with her partner, and the sharing of alternative sexual activities with her partner.
- Anderson BL. Surviving cancer: the importance of sexual self-concept. Med Pediatr Oncol. 1999;33(1)15-23.
- American Cancer Society. Sexuality for Women and Their Partners. Available at: caner.org/docroot/ MIT/MIT _7_1x_SexualityforWomenandTheirPartners.asp?. Accessed January 10, 2006.
- Metz M, Epstein N. Assessing the role of relationship conflict in sexual dysfunction. J Sex Marital Ther. 2002;28(2):139-164.
- Fourcroy J. Female sexual dysfunction: potential for pharmacotherapy. Drugs. 2003;63(14):1445-1457.
- Schroder M, Mell LK, Waggoner S, et al. A clinical trial of EROS therapy for treatment of sexual dysfunction in irradiated cervical cancer patients. International Society for the Study of Women's Sexual Health; October 16-19, 2003; Amsterdam, The Netherlands.
- Bernhard LA. Sexuality and sexual healthcare for women. Clin Obstet Gynecol. 2002;45(4):1089-1098.
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