Let's talk about sex...after cancer

Changes in sexual intimacy following the diagnosis and treatment for cancer are distressing and can have a significant impact on the quality of life for cancer survivors. Research shows that as many as 90% of patients report problems with sexual intimacy and 52% report problems with body image (Averyt & Nishimoto, 2014; Bober & Varela, 2012; Roth, Carter, & Nelson, 2010).  Because sex is often a difficult topic for patients and even some physicians to talk about, this is too often an overlooked and unaddressed problem for cancer survivors and their partners.

It is important to understand how cancer treatment can impact sexual functioning. Here are some examples of how different cancer treatments can change sex for survivors (adapted from Roth, Carter, & Nelson, 2010):

-   chemotherapy and radiation can lead to fatigue as well as potential skin changes
-   chemotherapy can also cause nausea, vomiting, diarrhea, and hair loss, which can impact desire and feelings of attractiveness
-   medications used to treat the side effects of cancer treatment, such as those for nausea, pain, depression and anxiety, can also impact desire, ability to achieve orgasm and ejaculation in men
-   psychological factors such as anxiety, depression and difficulty coping can also impact sexual intimacy
-   surgical interventions, such a removal of the breast, can impact body image as well as physical sensitivities due to nerve damage
-   surgical removal of reproductive organs and genitalia including the ovaries, uterus, cervix, vulva or vagina can lead to nerve damage and scar tissue that can make sexual activity painful or uncomfortable
-   radiation of a woman's pelvis can result in inflammation, narrowing and/or loss of flexibility of the vaginal opening causing pain during intercourse
-   hormonal deprivation due to surgery or medication can induce menopause, often causing vaginal dryness, decreased sexual satisfaction and loss of interest in sex
-   placement of a temporary or permanent ostomy for urine or stool to treat bladder, colon or rectal cancer may require management during sexual activity and can also lead to changes in body image
-   removal of the prostate or bladder and/or radiation to the pelvis can lead to erectile dysfunction and incontinence
-   removal of lymph nodes in the abdomen (retro-peritoneal nodes) can cause retrograde ejaculation (semen that ejaculates into the bladder) causing discomfort and feelings of awkwardness
-   radiation to the pelvis can also lead to diarrhea or rectal bleeding

There are a number of reasons that patients find it difficult to address these challenges. For some, there is a fear of being rejected by their partners. This fear can lead to feelings of isolation and insecurity. Some partners and patients may want to protect the other partner from having to discuss the changes the patient has experienced and instead keep their thoughts to themselves leading to a loss of communication and connection (Roth, Carter, & Nelson, 2010). However, it is important to know that there is help available.

The following sections explain how to address specific issues related to changes that have taken place during treatment. Although these interventions often focus on the survivor, it is important to note that including a supportive partner can make a very big difference in the success of these interventions for many patients.

Body Image

Some of the first challenges that may need to be addressed are those related to body image. For some, engaging in programs that offer women beauty techniques to use during treatment, such as Look Good, Feel Better, can help boost confidence. For others, it can be important to engage in psychotherapy to help process the losses that have come with treatment and to address changes in self image that have resulted from diagnosis and treatment. Support groups or one-on-one discussions with other cancer survivors can also help with addressing feelings of loss and can provide practical tips for overcoming common struggles with bodily changes, such as the use of an ostomy bag, as a result of treatment.

Changes in Vaginal Health

For women who have experienced changes in vaginal health due to treatment, using water-based vaginal lubricants, nonhormonal vaginal moisturizers and pelvic floor exercises are an important first step in restoring vaginal health. If vaginal dryness continues to be a challenge then vaginal estrogen may be an option, which should be discussed with your gynecologist and oncologist (Roth, Carter, & Nelson, 2010).

Pain During Intercourse

Women who experience pain during intercourse that is not related to dryness, often find that vaginal dialators can be helpful in expanding the vaginal opening, increasing vaginal elasticity and breaking down scar tissue. There is some suggestion that combining the use of a vaginal dilator with pelvic floor exercises may increase the benefits. There is evidence that receiving some brief education from a nurse or another practitioner familiar with vaginal dilation often increases the likelihood that you will use the dilator and will therefore increase the chances of seeing results (Roth, Carter, & Nelson, 2010).

Erectile Dysfunction - Medications

For men with erectile problems, medications such as Viagra and Cialis can be helpful. It is important to ensure that muscles and tissue have had a chance to heal after surgery before assuming that these medications may not be effective for you. It is also important to work with your physician to ensure that the medication you are taking is being prescribed at the correct dose for you. In addition to taking the medication, manual and/or psychological stimulation is needed in order to achieve an erection that is firm enough to allow for penetration. Even if you are not able to achieve an erection, you are still able to experience orgasm so if the medications do not work for you then other types of sexual intimacy may be required to achieve orgasm (Roth, Carter, & Nelson, 2010).

For men who have been treated for prostate cancer, a penile injection of medications that cause the blood vessels in the penis to dilate can be very effective. Again, it is important to work with your doctor to ensure that you are using the medication properly and at the right dose. Many couples find that adapting their sexual routine to incorporate or work around the administration of this medication is helpful. Similar medications can also be delivered via a suppository that fits into the opening of the penis. The advantage of the suppository is the avoidance of the injection; however, some men find that the medication creates a burning or painful experience (Roth, Carter, & Nelson, 2010).

Erectile Dysfunction Mechanical Devices

Some men prefer the use of mechanical devices rather than medication options. Vacuum erection devices fit over the penis and are pumped to create an erection. Erections achieved using this type of device tend to be more rigid and may feel different. Adjustments to a couple's romantic routine will help to incorporate the device. Another option is using a penile implant or prosthesis, which is either unfolded or pumped to quickly create an erection. These methods require good training and instructions in order to be the most effective. They also require patience and changes in sexual practices to create a positive experience (Roth, Carter, & Nelson, 2010).

Couples Therapy

It is important to understand that facing a life-threatening illness can impact a couple's ability to openly communicate about issues related to sex either during or after treatment. Therefore, engaging the help of a therapist can increase the success of sexual rehabilitation. Therapy can provide a place for the couple to acknowledge and process the losses that have come with cancer and its treatment and to have the opportunity to grieve these losses (Roth, Carter, & Nelson, 2010).

For couples that face challenges associated with changes in the way they relate and communicate or who had other problems that were present prior to cancer, general couple's therapy is likely to be the best first step. If the issues focus more on overcoming the changes in your sexual relationship as a result of cancer treatment then sex therapy is likely to be more helpful. For some the root of the problem is unclear and that is understandable. In that case, it may be best to start with sex therapy. Sex therapy will focus on issues of communication around sex, identification of sexual positions to enhance the sexual intimacy while reducing pain or discomfort and ways to improve intimacy that are not focused solely on sexual intercourse (Roth, Carter, & Nelson, 2010).

 

Dr. Stephanie Davidson is a licensed, clinical health psychologist specializing in the use of cognitive-behavioral, humanistic and existential approaches to treat patients with a range of medical and mental health challenges. She has a strong interest in mindfulness-based interventions to heal the body and mind. Dr. Davidson specializes in the treatment of oncology and hematology patients and their families where she works to address challenges related to diagnosis, treatment, survivorship and grief and loss.

Please feel free to call the Rowan Center for Behavioral Medicine for further information 818-446-2522 or email info@rowancenterla.com.

 

References

Averyt, J. C. & Nishimoto, P. W. (2014). Addressing sexual disfunction in colorectal cancer survivorship care. Journal of Gastrointestinal Oncology, 5(5). 388-394 doi: 10.3978/j.issn.2078-6891.2013.059

Bober, S. L. & Varela, V. S. (2012). Sexuality in adult cancer survivors: Challenges and intervention. Journal of Clinical Oncology, 30(30). 3712-3719 doi: 10.1200/JCO.2012.41.7915

Roth, A. J., Carter, J., & Nelson, C. J. (2010). Sexuality after cancer. In Holland J. C. , Breitbart, W. S., Jacobsen, P. B. et al, (Eds.), Psycho-oncology (2nd ed.; 245-250). New York: Oxford University Press, Inc.