Side effects are a given with most cancer treatments, and can range from fatigue and nausea to issues with intimacy and sexuality.

Patients diagnosed with cancer face many challenges, throughout treatment and beyond. Side effects are a given with most treatments, and can range from fatigue and nausea to issues with intimacy and sexuality.

Although some people may not be comfortable discussing sexual side effects with their doctor, either because of a sense of modesty or embarrassment, or because they consider these reactions to be much less important than other physical symptoms, many patients experience a change in this area, and it can be rather distressing to both patient and partner.

A cancer diagnosis is an emotional experience

It is not surprising that when faced with a cancer diagnosis and the challenges of treatment, sexual desire and feelings of intimacy may lessen. Physical changes can also affect one’s feelings of attractiveness. “Body image concerns can result in sexual side effects, commonly in breast cancers or cancers of the head and neck, says Janet A. Bloch ANP, MSN, director of the Linda B. and Robert B. Wiggins Wellness Center at the Huntsman Cancer Institute in Utah.

Emotional issues can also arise from any cancer diagnosis, says Bloch. “The diagnosis itself may result in depression or anxiety, and this and/or medications to treat these conditions may cause side effects that affect libido or sexual function.”

She also says that a diagnosis of cancer can make people re-examine their lives and relationships, and that “not uncommonly, relationships that were tenuous before the diagnosis, may dissolve after it.”

Sexual side effects of treatment

Generally, in the case of men, Bloch said the treatment of prostate cancer, either surgically or with radiation, is the most common physical cause of erectile dysfunction.

For women, she points out that gynecologic cancer treatment, such as pelvic surgery or radiation, can cause problems such as painful intercourse (dyspareunia) from vaginal scarring, and consequent stenosis, or shortening and/or narrowing of the vaginal canal. Also, aromatase inhibitors, which are oral estrogen-blocking medicines that are commonly used to treat breast cancer, can cause vaginal dryness and painful intercourse. Women treated with chemotherapy, which may precipitate premature menopause, may also develop vaginal dryness or atrophy (thinning of the vaginal lining) that can result in painful intercourse.

A common symptom during treatment for men is erectile dysfunction, or the inability to get an erection adequate for intercourse. This symptom is common after prostate cancer surgery (radical prostatectomy) or radiation. In the case of women, common challenges include decreased libido and painful intercourse.

Bloch has outlined several treatments and how they can affect intimacy, self-image, and physical function for men and women.

Chemotherapy

Bloch says chemotherapy can affect libido for both men and women because it can cause side effects such as fatigue, nausea, mouth sores, and diarrhea, which just make people feel unwell and thus uninterested.

Premenopausal women who undergo chemotherapy may experience premature menopause, causing them to develop vaginal dryness or atrophy, which can result in painful intercourse. For some women, menopause is associated with a decrease in libido, perhaps because of the decreased circulation of estrogen and testosterone.

Bloch also said research suggests that some chemotherapy drugs, such as Taxol, Oncovin, that cause neuropathy, or nerve problems, may also affect one’s ability to achieve orgasm.

Radiation therapy

Radiation therapy can cause different physical and sexual side effects, depending on the organ being treated, that can reduce one’s interest in sexual activity.

• Prostate: Radiation therapy for treating prostate cancer can cause erectile dysfunction.
• Gynecologic: Pelvic radiation for treating gynecologic cancers, such as uterine cancer, can cause vaginal stenosis (shortening and/or narrowing of the vaginal canal) or scarring, leading to painful intercourse.
• Head and neck region: Radiation therapy for treating head and neck cancers can cause xerostomia (dry mouth) and pain, affecting libido.
• Gastrointestinal tract: Any radiation therapy affecting the gastrointestinal tract can cause pain and stenosis (shortening) in structures such as the esophagus, and/or diarrhea, such as when given for treating colorectal cancers, and thus indirectly affect one’s libido.

Surgery

Surgery can also affect one’s desire to engage in sexual activity, depending on the site of the cancer. Although surgeons try to avoid damaging as many nerves as possible while performing surgery to remove a tumor, sometimes this is not possible. Severed nerves can contribute to sexual side effects, such as erectile dysfunction.

• Prostate cancer: Radical prostatectomy, or removal of the entire prostate and some surrounding tissues, can result in erectile dysfunction, or impotence, which may or may not improve spontaneously over the 1 ½ years after surgery. Men who undergo nerve-sparing procedures are thought to be less likely to have their function affected, but often even these individuals have problems with erectile dysfunction. Prostatectomy can also result in urinary incontinence, which may prevent men from wanting to be intimate with a partner.
• Gynecologic cancers: Surgery for treating gynecologic cancers can cause painful intercourse from scarring and shortening of the vaginal canal.
• Ovarian cancer: Women who have undergone an oophorectomy to remove the ovaries can experience a decrease in their libido because of the resulting decline in circulating estrogen and testosterone levels.
• Breast cancer: Mastectomy can cause women to have an altered body image and sense of sexuality.
• Head and neck cancers: Surgery to treat cancers in the head and neck can cause body image concerns, resulting in decreased libido.

Hormone therapy

• Metastatic prostate cancer may be treated with medicines that block androgens, resulting in decreased libido.
• Breast cancer can be treated with aromatase inhibitors, which may cause vaginal dryness from the resulting decrease in circulating estrogen levels, causing women to experience painful intercourse.
• Hormone therapy can cause issues specific to gender.

For men:

Although sexual side effects can occur from treatment of any cancer, men with cancer in the pelvic area (bladder, colon, rectal, prostate, testicular) are more likely to experience these issues. Older men are also more prone to these side effects because aging itself is often associated with sexual dysfunction, and cancer treatment may accelerate these. In many men, these side effects are temporary, but depending on the size and location of the tumor, some men will not be eligible for nerve-sparing surgery, and these effects will be permanent.

Bloch advises men who undergo prostatectomy to consult with a specialist in erectile dysfunction as soon as possible after the surgery. “There is evidence that earlier intervention can help function return earlier, and may actually result in function returning that otherwise would not,” Bloch says, adding that this includes participation in a “penile rehab” program of PDE5 inhibitors (drugs such as Viagra, Levitra, Cialis) at low dose on a regular basis, plus intracavernosal injection (Trimix or Bimix) or intraurethral pellet (MUSE), which men can be taught to self-administer, and/or use of a vacuum pump. Penile prostheses are also an option if these other measures fail.

Dr. John Mulhall, director of the male sexual and reproductive medicine program and a board-certified urologist and microsurgeon who specializes in sexual and reproductive medicine and surgeryat Memorial Sloan-Kettering Cancer Center in New York, says that patients should be prepared to discuss this issue when they meet with their treating physician, and that side effects during cancer treatment are often patient-specific.

He also says that patients should act as their own advocates and not be afraid to discuss a treatment plan with their doctor. “They should be armed with research and information, and be prepared with a list of questions to ask their doctor,” he said. He said that treatment options may vary based on a patient’s age and lifestyle and their desires for optimum sexual function. “For some men, age is a factor; a man in his 40s may want more out of sexual intimacy than a man in his 70s,” says Mulhall. “A frank discussion about expectations, and what the quality of sexual of function should be during and after surgery and follow-up treatment is very important.”

For women:

Marta Ann Crispens, MD, FACOG, assistant professor of gynecologic oncology at Vanderbilt University Medical Center in Nashville, says hormone receptor–positive breast cancers can cause difficulties with sexual function because of loss of vaginal lubrication associated with anti-estrogen treatment. She also says that patients undergoing treatment for gynecologic cancers, such as ovarian, endometrial, or cervical cancer, may have similar problems with lubrication from premature menopause caused by removal of the ovaries. Dr. Crispens also adds that changes in body image may interfere with libido.

Dr. Crispens also reports that cancers treated with pelvic radiotherapy, such as cervical, endometrial, vaginal, vulvar, anal, and rectal cancers, are another common cause of sexual dysfunction because of loss of lubrication and scarring/narrowing or shortening of the vagina. “Patients with cancers of many types experience changes in body image, loss of energy, their partner’s response to the diagnosis, and changes in their relationship with their partner,” she said.

Women battling breast cancer especially often struggle with their sexuality during and after breast cancer treatment. “Physically, they may be suffering from fatigue or nausea due to treatment.” says Elissa Thorner Bantug, MHS, program coordinator, Breast Cancer Survivorship Program with The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Maryland. “Body image issues resulting from scars, hair loss, and the removal of a woman’s breast may interfere with sexual relations.” From an emotional and physiologic standpoint, she says patients may be suffering from depression, frustration sadness or anger, and may experience decreased libido. “Vaginal dryness and difficulty reaching climax are common complaints,” Bantug adds.

Communication and connection with your partner is key

Bantug offers tips to improve your communication with your partner in order to maintain or rekindle your sexual relationship. She cautions, however, that if your problems continue, these concerns should be addressed with your doctor.

• Talk honestly with your partner about how you are feeling emotionally and what difficulties you may be experiencing physically
• Encourage your partner to share his or her concerns, worries, and needs as well.
• Realize that not all intimacy must include sexual intercourse. There are many ways to be intimate with your partner such as kissing, touching, cuddling or hugging.
• To avoid fatigue, try napping or pick a time of the day for sex when you have the most energy.
• If you feel uncomfortable with your body because of surgery or scars, try wearing clothing or lingerie that makes you feel more comfortable, or keep the room dimly lit.
• Break up your routine by having sex in a place other than your bedroom, change the lighting, modify positions, use candles, play soft music, or experiment with intimacy aids.
• For vaginal dryness, lubricants and moisturizers can be very effective. Try KY Jelly, Astroglide, Replens, or silicone-based lubricants. NOTE: The use of estrogen-containing lubricants should be discussed with your doctor to determine safety.

In summary, Dr. Crispens says that loss of sexual interest is a complex problem, and that having and being a supportive, understanding partner is crucial. For some, couples counseling or sex therapy may be necessary. “Open communication between a patient and her partner is crucial,” Dr. Crispens says, adding that support groups can also be helpful. Patients can contact their local chapter of the American Cancer Society or the local medical center to find a referral to cancer support groups in their area.