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Life After Cancer A Roadmap for Cancer Survivors

Changes in Sexuality and Sexual Problems
Adapted from Everyone's Guide for Cancer Supportive Care and Everyone's Guide to Cancer Therapy

Christine M. Derzko, MD, David G. Bullard, PhD, and Ernest H. Rosenbaum, MD

Becoming Sexually Active Again
Sexuality and Cancer

Becoming Sexually Active Again
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Cancer affects all aspects of your life. So it's not surprising that it can affect your sexual feelings and the ways you express those feelings. You and your spouse or partner remain sexual beings and may have much the same needs and desires as you had before the illness struck.

Sexuality can be expressed in many ways - in how we dress and how we move and speak, as well as by kissing, touching, masturbation and intercourse. Changes in body image, tolerance for activity and anxieties about survival, family or finances can strain the expression of sexuality and can create concerns about sexual desirability. But if you were comfortable with and enjoyed your sexuality before your illness, the chances are excellent that you will be able to keep or regain a good sexual self-image despite any changes brought about by cancer.

Many people, and in particular those dealing with an illness, find that being sexually active is not important to them to maintain a loving, intimate relationship. This can be a healthy, normal choice for any individual or couple. However, the loss of interest may be transient for others, and they may be quite distressed either by their loss of libido (sexual interest) or by their inability to respond or perform sexually as they had in the past. If sexual intimacy has been a joy and comfort to you, you may want to resume or continue being sexually active even after your cancer has been diagnosed and has been treated or is being treated.

This may require some adaptation of your normal sexual patterns, and it might be a challenge to change them. Support groups can give understanding and encouragement, and open, comfortable communication with your partner is essential. Make a point of sharing your concerns with your partner: he or she wants and needs to help sort out the problems. You may also need specific information and guidance from your doctor. But don't make the mistake of trying to be a good patient by not complaining and simply suffering in silence. Sexuality is a legitimate area of concern. Don't be shy: take the initiative and ask your doctor any questions you have about your sexuality. Seek referral to a sexual counselor if needed. You can overcome many problems, reduce tensions and get much more sexual satisfaction.

Treatment for some cancers may have little effect on sexuality beyond the effects of fatigue, pain, weakness or other temporary side effects. However, there are two distinct questions and concerns which may arise. First, in the younger patient, will the treatment of my cancer affect or impair my ability to have a family in the future, and if so, what can I do about it? Second, will the treatment directly affect my ability to function sexually? It is important to recognize that lengthy treatments and impaired fertility may cause marital stress unless both partners are encouraged and willing to communicate their feelings.

Sexuality and Cancer
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The treatment of several kinds of cancer may directly affect sexual function. For more information, please refer to Everyone's Guide to Cancer Survivorship, available in bookstores October/November 2007.

Drugs That Affect Sexual Desire and Activity
Most cancers occur in people over 50, many of whom may have already experienced some decrease in sexual activity. The diagnosis of cancer itself may result in a significant reduction in sexual desire, as can such diseases as diabetes, alcoholism and/or psychological problems. Furthermore, it is important to know that a great many drugs can lower sexual desire and activity and therefore can lead to sexual dysfunction. Ask your doctor.

Problems Women Experience
Painful Intercourse You may find that intercourse is painful not only after treatment for a genital cancer but also if pelvic or total body radiation has been part of your therapy. There are four common reasons why this problem may arise:
Infections of the bladder or vagina (this may be a recurring problem)
Lack of lubrication
Vaginal shortening
Anxiety with resulting spasm of the vaginal muscles
Have a gynecological examination to find the cause.

Lack of lubrication The vagina may feel dry in the presence of a yeast infection. If this cause is excluded, commonly there are two reasons:
(a) inadequate estrogen effect
(b) lack of adequate sexual arousal.

Estrogen is produced normally during reproductive life by the ovaries. Surgical removal of the ovaries permanently deprives the body of this natural source of female hormones. Chemotherapy and radiation therapy may temporarily or permanently stop the production of estrogen. This removal of estrogen may be an important and necessary part of the treatment of the primary cancer (e.g., breast cancer and uterine [endometrial] cancer but not cervical cancer).

Estrogen hormonal therapy (HT) may be in the form of either systemic medication such as pills, patches, gels, injections or implants; or local vaginal applications of creams, an estrogen-containing vaginal ring, vaginal tablets or suppositories containing estrogen.

It may take many months for hormone treatment, local and/or systemic, to return the vagina to normal and improve lubrication. If the cause is not enough lubrication, use of saliva, a natural lubricant, or products such as baby oil or water-soluble lubricants can reduce friction. Artificial lubricants such as K-Y® jelly, Astroglide, Jergens® and other creams may make intercourse possible where the lack of circulating estrogens has caused dryness. Replens (a non-hormonal vaginal gel that is available without prescription in both the United States and Canada) is a vaginal moisturizer which is applied three times a week and may improve lubrication for sexual arousal and intercourse.

Fear and anxiety may prevent the normal flow of vaginal fluids in response to sexual stimulation. Correction of this situation requires a number of combined treatments: application of a lubricating cream or gel plus relaxation, and, most importantly, communication with your partner. Taking a little more time to enjoy foreplay may promote relaxation, enhance sexual response and increase vaginal lubrication.

Time, patience, sharing your feelings with your partner and support group members, and seeking help from your doctor and possibly a sex counselor are your best guarantees of improving the quality of your sexual and intimate experiences.

Problems Men Experience
Physical and Emotional Causes of Erectile Dysfunction (ED)
If you can get an erection by masturbating or you wake up with an erection, it is most likely that anxiety or trying too hard is the cause of dysfunction, and it's not a physical problem. If you are not sure of the cause, ask your doctor to refer you to a urologist or sex therapist for evaluation and treatment.

Taking the Pressure Off
The more options you have for sexual expression, the less pressure there is on having erections. This in turn makes it more likely that they will happen. Many couples report that they have learned to have very pleasurable sexual experiences without erections or intercourse. Many kinds of sexual expression and stimulation do not require an erect penis. It may be reassuring to know that to have an orgasm many women need or prefer direct stimulation by hand or mouth on or around the clitoris. This is stimulation that even an erect penis in a vagina can't provide. Patience, communication, and time are critical factors in developing pleasurable sexual experiences.

If erections don't come back and intercourse is important to you and your partner, ask your doctor to refer you to a sex therapist for counseling.

A number of new medications for erection problems have come on the market in the last few years. Taken before a sexual encounter, these medications increase blood flow to the penis, resulting in erections. The first of these, sildenafil (Viagra), became available in late 1997, followed by vardenafil (Levitra) and tadalafil (Cialis). They differ in onset of action, duration of action, and interaction with food. Sildenafil and vardenafil should be taken on an empty stomach for optimal effect and have an onset of action of thirty to sixty minutes and duration of action of about four hours. On the other hand, tadalafil can be taken without regard to meals and has an onset of action of about forty-five minutes and duration of action of twenty-four to thirty-six hours. Side effects include headaches, visual disturbances, and flushing. Though considered generally safe for most men (including those using most blood pressure medications), sildenafil, vardenafil, and tadalafil should not be used by men taking nitrates.

If even with the help of these medications you are still not getting erections, the counselor may refer you to a urologist. Together with you and your counselor, the urologist can explore options such as use of a vacuum pump, injection therapy, or a penile implant.

Hormone Androgen Deprivation Therapy (ADT) for Prostate Cancer Prostate cancer is the most common form of male cancer, and the most common treatment is ADT by either surgical orchiectomy (removal of the testicles) or medical orchiectomy with gonadotropin-releasing hormone. In addition to the possible side effects of osteoporosis and metabolic syndrome, it can cause sexual dysfunction, hot flashes, and gynecomastia (enlarged breasts).

Developing Helpful Attitudes and Practices Whenever you are ready to become sexually active again, there are a few things you should keep in mind.
You are loved for who you are, not just for your appearance.
We are all sexual beings. Whether sexually active or not, sexuality is part of who we are
Survival overshadows sexuality. If you've lost your good health, it is normal and natural for stress, depression, worry and fatigue to lower your interest in sex. Sexual interest and feelings will probably come back when the immediate crisis has passed.
Share your feelings. This sharing may feel awkward at first. Learning how and when to talk about sexual issues may not come easily. You may feel shy or nervous about exploring new and different ways of finding sexual pleasure. It is a good move is to make the first move.

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First appeared December 28, 2007; updated August 2, 2008