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Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Chapter Overview
Sexual dysfunction in men and women after treatment for cancer is one of the most common problems of survivorship, yet most survivors experiencing sexual dysfunction do not receive medical help. Left untreated, sexual dysfunction does not resolve, but instead persists over many years. Not all survivors are distressed about sexual dysfunction. Factors associated with distress include young age, being in a relationship, and having enjoyed sexuality before the cancer diagnosis. The most common problem for which men seek help is erectile dysfunction, although loss of desire for sex, difficulty reaching orgasm, and pain during sexual activity also occur after a number of treatments. Pelvic surgery and radiation are common causes of erectile dysfunction, but hypogonadism also sometimes occurs in survivors of intensive chemotherapy. In women, chemotherapy-induced ovarian failure is a major risk factor for vaginal dryness, dyspareunia, and consequent loss of interest in sex. Pelvic radiation therapy, surgery that changes vaginal or vulvar anatomy, or vaginal complications of graft-versus-host disease are also problematic. Oncology clinics should provide basic education, counseling, and referrals. The optimal treatment for sexual dysfunction is multidisciplinary, with a medical specialist and a mental health professional working together to assess the problem and create a treatment plan.
How Many Cancer Survivors Have Sexual Problems?
A recent report by the Centers for Disease Control and Prevention noted that 69% of the estimated 14 million cancer survivors currently living in the United States have had prostate, breast, gynecologic, urinary tract, or colorectal malignancies (Rowland et al. 2011). A number of studies have suggested that at least half of survivors of these pelvic cancers end up with long-term sexual dysfunction that does not resolve without medical or psychological treatment (Sadovsky et al. 2010). Furthermore, these sexual problems tend to be severe, affecting desire, ability to become aroused, and ability to reach orgasm. Pain with sex is a major problem, particularly for women. A recent survey by the Livestrong Foundation of more than 2,300 cancer survivors who were younger than 55 years at diagnosis confirmed that 46% experienced sexual problems in the first few years after their treatment, and less than a quarter of this group sought professional help (Rechis and Boerner 2010). Survivors ranked sexual problems third among their concerns about physical health, behind energy and concentration.
At MD Anderson, a survey was used to estimate how many outpatients wanted help for sexual problems (Huyghe et al. 2009b). Respondents included 129 men and 124 women who either received the questionnaire in the mail or picked it up during a clinic visit. Although this survey had only a 29% return rate, the results were quite similar to those in reports from the literature. Most respondents had breast or prostate cancer. Eighty percent of men reported that they had been sexually active at diagnosis, but only 60% were active when completing the questionnaire. Among women, 73% were sexually active at diagnosis compared with 59% when completing the questionnaire. About half of men attributed a new problem with erectile function to their cancer treatment, and 30% said it was hard to reach an orgasm or their sensation of pleasure was weak. Forty-six percent of women developed a problem with vaginal dryness after cancer or treatment, and 45% experienced a loss of desire for sex. Given the conventional wisdom that negative changes to “body image” are a major factor in sexual problems in cancer survivors, it was interesting that only 18% of men and 16% of women believed that a partner would not find them attractive. Physiologic changes in ability to enjoy sex were much more common.
Respondents were also asked how likely they would be to make an appointment in the next year in a clinic that treated cancer-related sexual problems. Twenty-four percent of men and 21% of women said they would definitely make an appointment. In a phone survey of almost 1,500 Americans aged 40–80 years (not selected for health status), a very similar percentage of men and women reported seeking help for their sexual problem (Laumann et al. 2009).
Obviously, not all men and women with cancer are distressed about having a sexual problem. Risk factors for distress in both men and women include young age, having a sexual partner, and being in a relatively new relationship. For men, having a much younger partner often prompts them to seek help (Schover et al. 2002).
Types of Cancer-Related Sexual Problems
Despite the very large variety of cancer sites and treatments, most sexual problems among male and female cancer survivors fall into a few categories (Sadovsky et al. 2010). Typical complaints for women are loss of desire for sex and vaginal dryness that causes pain with sexual touching or intercourse. If a woman is not in the mood for sex and experiences pain with caressing, she is of course also unlikely to experience strong sexual pleasure or to reach an orgasm, but these tend to be secondary issues (Carter et al. 2011).
For men, difficulty getting or maintaining firm erections is the most common problem leading them to seek help. Some men lose interest in sex despite having normal erections, but more often, repeated erectile dysfunction leads to emotional distress and avoidance of sexual activity. Most men can still experience the sensation of orgasm, even without a firm erection, but many men stop sexual stimulation if an erection does not result, and thus no longer have orgasms either. Cancer treatment may also interfere with ejaculation of semen and with the subjective quality of orgasm, although either one may be impaired while the other remains intact. Most men who have dry orgasms report that the sensation is still satisfying and intense, but at least a third complain that their pleasure is weaker, and a few report that orgasms are more prolonged and pleasurable than normal (Barnas et al. 2004).
Although pain during sex is less common in male than in female cancer survivors, about 10% of male cancer survivors also notice pain after radical pelvic surgery, either upon getting an erection or at the moment of orgasm. Such problems are particularly common after surgery or radiation therapy for prostate cancer, although these symptoms tend to improve over time (Barnas et al. 2004; Huyghe et al. 2009a). Pain with erection is sometimes associated with inflammation and eventual fibrosis and plaque formation in the tunica albuginea, leading to penile curvature (Peyronie disease). Penile curvature has recently been noted to be more common than usual after radical prostatectomy (Tal et al. 2010).
How Cancer Treatment Interferes with Sexual Function
Physiologically, normal sexual function in men and women requires intact pathways in the brain and spinal cord, normally functioning autonomic nerves in the pelvis, and reasonably healthy cardiovascular systems in the genital area, as well as normal levels of the hormones involved in sexual desire and arousability. Cancer treatment may damage one or more of these systems.
Central Nervous System Malignancies
Little is known about the direct effects of tumors in the central nervous system on sexual function. The limited survival time for many patients with brain tumors is one barrier. Researchers have not attempted to correlate brain tumor location with specific sexual problems. Areas of the brain and neurotransmitters involved in sexual desire and arousal have only recently been identified (Pfaus 2009). However, changes in personality or motivation can also cause indirect damage to a couple’s sex life. The caretaking partner may lose interest in sex if the person with a brain tumor develops dementia or is chronically angry and depressed. Patients with brain tumors often have decreased sexual desire, but hypersexuality also occasionally occurs. Tumors affecting the spine, either as a primary site (e.g., Ewing sarcoma) or as a metastatic site (as in leptomeningeal disease), can interrupt erotic sensation and orgasm or disrupt the reflexive increase in genital blood flow during sexual arousal.
Hematopoietic Cancer
For men and women treated for hematopoietic cancer, the stronger the intensity of the chemotherapy regimen, the more likely that sexual function will be damaged (Yi and Syrjala 2009). For women, alkylating chemotherapy drugs and combination chemotherapy administered at high doses (e.g., in preparation for stem cell or bone marrow transplantation) can cause permanent, premature ovarian failure. Menopausal symptoms are usually more severe after these abrupt hormonal changes than after natural menopause. Cancer survivors with ovarian failure often have severe hot flashes that disturb their sleep, adding to chronic fatigue and problems with concentration.
However, vaginal atrophy is most destructive to sexual function in women (Carter et al. 2011). Normally during female sexual arousal, the vagina deepens considerably and the upper vagina “balloons,” rising from the pelvic floor. As blood flow increases dramatically in the clitoris, vulvar tissues, and vaginal walls, a slippery transudate appears as droplets of fluid on the vaginal mucosa, preparing the vagina for sexual intercourse. With estrogen deprivation, the vaginal mucosa and vulvar skin become thin and easily irritated or torn. Genital blood flow is decreased, so that these changes take place more slowly and are attenuated. The woman experiences vaginal dryness and tightness. Attempts at penetration often cause burning pain, with spotting of blood caused by small mucosal tears. The vaginal pH increases, leaving women vulnerable to repeated bacterial or yeast infections. Postcoital urinary tract infections also may become chronic.
If women end up with permanent ovarian failure, systemic hormonal replacement therapy can reverse vaginal atrophy as well as protect bone density and reduce hot flashes. However, the genital symptoms are better controlled with vaginal estrogen, whether in the form of a cream, suppository, or vaginal ring (Suckling et al. 2006). Low-dose rings and suppositories can treat vaginal atrophy without elevating serum estrogen above the usual postmenopausal levels.
Women who develop graft-versus-host disease (GVHD) after an allogeneic hematopoietic transplantation are at risk of developing vaginal symptoms (Stratton et al. 2007). The granulocyte colony-stimulating factors used in stem cell rescue appear to elevate genital GVHD rates even more than bone marrow transplantation, affecting at least 25% of women with systemic GVHD. Women should be warned to watch for early signs of genital GVHD, which include pain and redness on the vulva, similar to symptoms of vulvar vestibulitis. If untreated, genital GVHD can lead to vaginal adhesions and stenosis, making intercourse very painful or even impossible. Most centers treat women with a combination of medication for the systemic GVHD and topical ointments for the genital area that combine estrogen with a strong corticosteroid or other immunosuppressant medication. Adhesions can often be gently stretched and eventually eliminated by frequent use of vaginal dilators.
Intensive chemotherapy is not as destructive to male sexual function but can sometimes damage the Leydig cells in the testicles, leading to a hypogonadal state (Yi and Syrjala 2009). If a man experiences decreased desire for sex, often accompanied by difficulties with erection, hot flashes at night, and severe fatigue, it is important to check serum testosterone levels. Testosterone replacement restores sexual function for most men. Injections often produce high initial hormone tests but cannot maintain normal levels even when given every 2 weeks. Patches or gels can provide a more stable level of testosterone.
It is unclear whether genital GVHD in men contributes to the high rates of male sexual problems that occur after hematopoietic transplantation, but chronic skin irritation on the glans of the penis can make sexual stimulation painful in some survivors. Topical creams similar to those used in women (but without the estrogen) may be used to treat these problems in men.
Breast Cancer
Chemotherapy is the treatment most likely to cause sexual dysfunction in women treated for breast cancer (Schover 2008a). Early research was focused on the psychological impact of breast loss, but now that most women can choose either breast reconstruction or conservation, the type of localized treatment with surgery and radiation is not correlated with sexual outcomes. Women treated with tamoxifen or raloxifene notice few changes in sexual desire or vaginal dryness. Some problems attributed to tamoxifen in women diagnosed with breast cancer before menopause actually are related to ovarian failure caused by the chemotherapy preceding treatment with tamoxifen. A number of young women experience temporary ovarian failure during and after adjuvant chemotherapy for breast cancer. It is unclear whether their levels of sexual function return to normal if their menstrual cycles return.
With the advent of aromatase inhibitors as the treatment of choice for postmenopausal women with hormone-sensitive breast cancer, rates of sexual problems have increased greatly (Baumgart et al. 2011). Aromatase inhibitors prevent estrogen from being produced in peripheral tissue, further reducing the estrogen available in the genital area, even in women who already had mild vaginal atrophy. Vaginal dryness and pain with sex are problems for as many as two-thirds of women treated with aromatase inhibitors. However, even a low-dose vaginal estrogen therapy may elevate serum estrogen levels enough to interfere with the beneficial effects of aromatase inhibitors in some women, making breast oncologists very reluctant to prescribe hormonal therapies.
Pelvic Radiation Therapy
In both men and women, radiation to the pelvic area causes high rates of sexual dysfunction. The timing of these changes is important in designing follow-up research, which often does not assess patients for a long enough period to detect the damage. At the end of treatment, acute genital pain can be a problem. Sexual function may then seem to normalize, only to get worse again beginning several months after the end of radiation therapy (Sadovsky et al. 2010). Sexual function may worsen for at least 3–5 years after completion of treatment. Inflammation in the target zones leads to a gradual process of fibrosis that can reduce blood flow in the genital area.
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