Washington, DC—The incidence of sexual dysfunction among cancer survivors remains high, but early discussion, evaluation, and treatment to address this health issue can improve sexual outcomes, reduce emotional distress, and facilitate recovery.
The problem is that patients and their providers are not talking about sex, according to D. Kathryn Tierney, PhD, RN, Clinical Assistant Professor, School of Medicine, Primary Care and Population Health, Stanford University, CA, and Jeffrey Albaugh, PhD, APRN, CUCNS, Director, William D. and Pamela Hutul Ross Clinic for Sexual Health, NorthShore University HealthSystem, Glenbrook Hospital, Glenview, IL, who encouraged attendees at the Oncology Nursing Society (ONS) 2018 Congress to engage in more open discussions about this subject.
The mind is often considered the most important sex organ in humans. However, when patients feel too embarrassed to broach the subject of sexual dysfunction with their providers, this significant aspect of human existence is ignored, resulting in a profound and negative impact on cancer survivors’ quality of life, as well as that of their intimate partners. To compound the problem, studies have shown that most providers are not discussing the topic with their patients.
Sexual dysfunction is caused by changes that adversely influence sexual function, leading to psychological distress or stress within relationships. In cancer survivors, altered sexuality may occur because of the disease itself, psychological distress associated with diagnosis and treatment, side effects or complications associated with therapy, or altered relationships during and after treatment. The World Health Organization views sexuality as “a central aspect of being human throughout life.” But sexuality is not just about sex, Dr Tierney noted. All individuals have a lifelong need for intimacy and emotional connectedness, and assessing and intervening in sexual dysfunction requires the consideration of physiologic, psychological, and social dimensions of sexuality.
Sexual Dysfunction in Women
Sexual dysfunction in women is usually related to either a lack of arousal or pain with penetration. Physiologic causes may include ovarian failure, hormonal changes, fatigue, and decreased physical stamina, or vaginal alterations that can be attributed to factors such as 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 is closely tied with our image of ourselves as women,” Dr Tierney noted.
Psychological causes of sexual dysfunction may include depression and anxiety, which correlate with less interest in sexual activity, decreased self-confidence, less satisfying sexual relationships, and altered body image.
“One of the big barriers to addressing sexuality in cancer patients is, we simply do not want to talk about it,” she said. Many providers feel they have not had sufficient training to have these discussions. They feel they may embarrass the patient or themselves, or they worry nothing can be done. Patients fear being dismissed, making their provider uncomfortable, or being told there are no treatment options.
However, discussions about sexual dysfunction should take place before the initiation of therapy. They 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 are likely to experience less interest in sexual activity for the next several months following treatment,’ you have introduced the topic in a nonthreatening way. Be proactive in providing this information to patients and their partners, because they are not going to ask,” she explained. 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 changes that may occur.
According to Dr Tierney, treatment options are available, and effective treatments will combine education, support, and symptom management.
Therapy should be individualized and tailored to relieve symptoms, but she recommends that lifestyle modifications (eg, exercise, relaxation training, learning to identify hot-flash triggers) be attempted for approximately 3 months before considering menopause hormone therapy or other pharmacologic interventions.
When assessing female sexual interest/arousal disorder, remain cognizant of psychological factors such as anxiety, depression, fatigue (in both partners), body image, and relationship factors. Psychological distress can be treated with antidepressants, but avoid selective serotonin reuptake inhibitors, because they are known to decrease sexual desire and the intensity of orgasm, she advised. Provide education and counseling for couples, and discuss good communication strategies, relaxation training, and cognitive retraining.
There are currently no FDA-approved androgen therapies for treating female sexual dysfunction, but a testosterone patch in addition to estrogen therapy may increase sexual fulfillment in women. Testosterone cream applied to the clitoris can improve vaginal atrophy and lubrication, dehydroepiandrosterone vaginal gel can improve sexual function, and female arousal gel, such as Zestra, may help women to reach orgasm.
For pain during penetration, 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 low sexual interest in premenopausal women, but it has been associated with adverse effects.
Address fertility preservation in all children and adults of reproductive age before any cytotoxic therapy, and refer those patients to a reproductive specialist, Dr Tierney added.
She also urged providers to consider sensate focus therapy, which is centered on partners touching and pleasuring both nonsexual and sexual areas of each other’s bodies. The end goal may not be intercourse, but rather on partners reacquainting themselves with one another. Dr Albaugh recommends this practice for men with sexual dysfunction after cancer as well.
Sexual Dysfunction in Men
Healthcare professionals often feel unprepared to deal with sexual dysfunction, and most are unlikely to discuss it with patients, Dr Albaugh reiterated. One study revealed that >90% of clinicians considered conversations about sex to be important, but 94% admitted they would not ask their patients about it. Nurses are also unlikely to bring up the topic, and more than half of internists working with cancer survivors said they never or rarely address sexual dysfunction.
“So, no one is talking about sex, but trust me, your patients are suffering. And often they are suffering in silence,” Dr Albaugh said.
Patients are not talking about sex either. Another study found that, among a population of men who were already using the healthcare system, only a minority sought treatment for their erectile dysfunction (ED), primarily because of embarrassment or miseducation. Even in urology offices, patients were unlikely to bring up ED.
A 2010 Livestrong survey of >3000 patients with cancer found that fertility was a concern to approximately 60% of respondents, but 70% said they did not receive information about options for preserving fertility.
“We sometimes assume older patients are not concerned about fertility. But do not assume anything, and always ask about fertility; assist and direct patients to resources for sperm preservation,” he noted.
The majority of men with prostate cancer report that their quality of life is either severely or moderately affected by ED. A study of >1000 men who underwent radical prostatectomy revealed that 2 years after treatment, almost 80% still experienced ED, and 5 years after treatment, 7 of 10 still had it.
“You can be cured of prostate cancer, but still plagued by sexual dysfunction,” Dr Albaugh said.
Normalize conversations about sexual health, he stressed. Many patients with cancer have sexual or intimacy issues, and they are waiting to hear from their providers that it is okay to ask questions and there are resources and information that can help.
Intimacy is about communication and connectedness on all levels, he said. But men and women can achieve pleasure and connectedness without intercourse or penetration. Communication with partners is key; talking about sex does not always come easily, but practice helps.
According to Dr Albaugh, treatment for sexual dysfunction should be motivated by patients after discussing the risks, benefits, and costs.
Oral agents, such as sildenafil citrate (Viagra) and tadalafil (Cialis), are all equally effective at treating ED. They work in approximately 60% to 70% of patients, 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 (an average of 2 years after treatment), oral agents can be effective again.
“These medications are simple, discreet, and most popular by a landslide,” he stated.
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, are easy to use, but they come with a high price tag (approximately $100 per tablet) and only work in approximately 50% of patients. Intracavernosal injections delivered via a small diabetic needle are effective, but they 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.
He also stressed the importance of ruling out and treating other underlying, nonhormonal causes of ED, and making psychological referrals when necessary.
“We are hard wired for connectedness; it’s not just about sex. That is why many people are devastated when they feel disconnected from their partner,” he stated. For some patients, sex may not be an important part of their lives anymore, and that is okay too, but get them talking about it. Stop, listen to their goals, and assist them when possible.
Dr Albaugh wrote a book for cancer survivors dealing with sexual dysfunction after prostate cancer. The entire work can be downloaded free of charge at www.drjeffalbaugh.com.