genglob magazine

In part one of this series cancer and sexuality we briefly covered three topics:

What is sexuality?

What is a normal sexual response?

How can my cancer and cancer treatment affect my sexuality?

We continue the series today covering the third question in detail on how can cancer and cancer treatment affect the sexuality. This section contains more information on sexual changes caused by:

• Cancer Treatment in Women
• Cancer Treatment in Men
• Cancer Treatment Side Effects
• Emotional Effects
• Anxiety and Depression

Cancer Treatment in Women

It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Talk with your doctor to see whether it is safe for you to participate in sexual activities. Be aware that:

• If you are having sex during chemotherapy, you may wish to use barrier protection, such as condoms or dental dams (for oral sex), since chemicals can be found in vaginal fluid. Ask your doctor how long your particular chemotherapy stays in the bloodstream. It can range from hours to days.
• Radiation to you from an external machine does not make you radioactive or endanger a partner in any way. If you have a type of radiation therapy that involves using a source of radiation that stays in your body over time, there may be a short period (a few days or less) when your doctors want you to avoid sexual activity until the strongest radiation has left the body.
• Sex can be a problem if you have heavy bleeding in the genital area from cancer, if you have recently had surgery, or if your immune system is weak.

Cancer treatment can cause a variety of sexual changes. Even though the causes may be different—surgery, chemotherapy, hormone treatment, and radiation—the resulting changes are often similar.

• Surgery
• Chemotherapy
• Hormone Treatment
• Radiation

Cancer Treatment in Women: Surgery

• Some pelvic surgeries change the vagina. For example, radical hysterectomy shortens the vagina. When the bladder or colon is removed, parts of the vaginal wall may also be removed, making the vagina narrower. Loss of tissue around the vagina removes its “cushioning,” and scar tissue may form in the area. These changes can sometimes cause pain with deep thrusting and penetration or in certain intercourse positions.
• When both ovaries are removed in a younger woman, she will have an abrupt menopause. The most typical result is vaginal dryness and pain, but some women experience a loss of sexual desire, as well. Also, the loss of the hormone estrogen reduces the blood supply of the vagina and thins the vaginal walls. The result is that the vagina feels dry and tight, especially during penetration.  It is unclear why many women who have sudden menopause lose some desire for sex. It may be because of the loss of androgens, hormones produced by the ovaries. However, several studies have found that a woman’s androgen levels after cancer can not predict her desire for sex. Many women find that if sex hurts, they stop looking forward to it, which interferes with desire. Medications, fatigue, and nausea also can be part of the problem.
• If some or all of the vulva is removed, a woman may lose some important erotic zones, especially if the clitoris is included. The vaginal entrance also may be narrowed, making penetration painful or difficult.
• After surgery on the breasts to remove a tumor, or a mastectomy to remove one or both breasts, a woman may lose the ability to feel sexual pleasure from nipple caressing. The loss of pleasure may lessen sexual desire or arousal, or caressing an untreated breast may trigger distracting thoughts about breast cancer.

Cancer Treatment in Women: Chemotherapy

• In women who have not yet reached menopause, chemotherapy can damage the ovaries, causing sexual changes. Alkylating chemotherapy drugs, especially at high doses, can destroy the function of ovaries so that they no longer produce hormones. This will cause sudden menopause, which is usually permanent. Women who stop having menstrual periods may experience vaginal dryness, pain, and a loss of desire, just like women whose ovaries were removed in surgery or damaged by radiation therapy.
• Lower doses of chemotherapy may temporarily stop a woman’s periods. They may resume, along with hormone production, especially if a woman is under age 35 when she is treated.
• If chemotherapy causes mucositis (mouth soreness), it also may cause soreness in the vagina, making sexual intercourse extremely painful.
• If chemotherapy causes neuropathy (tingling or numbness) in the hands and feet, it also may cause numbness in the clitoris, though this has not been proved.

Cancer Treatment in Women: Hormone Treatment

• Some hormone treatments may cause sexual changes, but they are less likely to do so than chemotherapy.
• Most studies of women taking tamoxifen after breast cancer find that the hormone does not interfere with sexual desire. Since tamoxifen acts like a weak estrogen in the genital system, many women find it helps with vaginal dryness, although some women experience vaginal irritation.
• Raloxifene, which is also taken after breast cancer to prevent recurrence, also does not interfere with sexual desire in women, though it is less likely than tamoxifen to help with menopausal vaginal dryness.
• Aromatase inhibitor medicines, such as Arimidex, are increasingly taken to prevent breast cancer recurrence. Unfortunately, this class of medicines is likely to lead to vaginal dryness and pain with sex, but lubricants and moisturizers can help.

Cancer Treatment in Women: Radiation

• Radiation to the pelvis can damage the ovaries, leading to the same problems with vaginal dryness or pain as when both ovaries are removed in surgery or damaged by chemotherapy. A lower dose of radiation may cause less damage such that a young woman may recover menstrual periods. At higher doses, the menopause is permanent. (Post-menopausal women may experience a lack of desire because of the loss of androgens, hormones produced by the ovaries.)
• Radiation can do direct damage to the vagina. Inflammation in the vagina can cause the walls to stick together during healing, or it can result in narrow bands of scar tissue along the vaginal canal.
• Some women develop radiation ulcers, painful sores that take a long time to heal.

Cancer Treatment in Men

It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Talk with your doctor to see whether it is safe for you to participate in sexual activities. Be aware that:

• If you are having sex during chemotherapy, you may wish to use barrier protection, such as condoms or dental dams (for oral sex), since chemicals can be found in semen. You may want to ask your doctor how long your chemotherapy drugs will stay in your bloodstream, since it can range from hours to several days.
• Radiation to you from an external machine does not make you radioactive or endanger a partner in any way. If you have radiation therapy using implants in your body, such as seed implants for prostate cancer, there may be a brief period where your doctors want you to avoid sexual activity until the strongest radiation has left the body. After that you are not in danger of harming a partner or any other person who gets close to you.
• Sex can be a problem if you have heavy bleeding in the genital area from cancer, if you have recently had surgery, or if your immune system is very weakened.

Erectile dysfunction, also known as impotence, is when a man cannot get or maintain a firm erection. Some men experience erectile dysfunction because of cancer treatment. Erectile dysfunction also is much more common with aging, especially for men who are smokers, are overweight, or have diabetes, high blood pressure, or heart disease. Men who are already having some mild erection problems may find these get worse with cancer treatment.

Cancer treatment can cause a variety of sexual changes:

• Surgery
• Hormone therapy
• Radiation
• Chemotherapy

Cancer Treatment in Men: Surgery

• The most common types of cancer surgeries that cause erectile dysfunction are those that remove the prostate, prostate and bladder, or the lower part of the colon and rectum. These operations often cut or bruise important nerves that direct blood flow into the penis. Even though surgeons try to spare the nerves, many men end up with erection problems. (Nerve-sparing techniques work best for younger, healthy men who are having firm, reliable erections before cancer diagnosis.).
• If the prostate and the seminal vesicles (the small glands behind the prostate) are surgically removed, a man will experience “dry” orgasms, meaning that he will not ejaculate semen. The muscles still pump at the base of the penis, and the feeling of orgasmic pleasure still occurs, but about half of men say their orgasm feels weaker. A man can reach orgasm without having an erection, but it may take practice to find the right kind of stimulation.
• Some men with testicular cancer have an operation to remove the lymph nodes in their abdomen (retroperitoneal lymphadenectomy) or to remove some nodes that remain enlarged after chemotherapy. These surgeries sometimes damage the nerves involved in ejaculation, also resulting in dry orgasm.
• Another surgery that may damage these nerves is sigmoidectomy, done to remove colon cancer in the sigmoid colon.
• If both of the testicles are removed, a man will experience loss of desire for sex since testosterone, the hormone that helps men feel desire, is made in the testicles. This hormone can stimulate prostate cancer cells, so the goal of the surgery is to stop its production. About 20 percent of men, especially those under age 60, can still get erections and have orgasms after removal of both testicles, although it takes more effort and stimulation.

Cancer Treatment in Men: Hormone Treatment

• Many men with advanced prostate cancer do not have their testicles removed but instead take hormone therapy designed to “turn off” the testicles so that they do not produce testosterone. The sexual side effects are very much the same as described above with surgery to remove the testicles.
• Some men take hormone therapy for only a few months around the time of surgery or radiation therapy for prostate cancer. Unfortunately, in some men, sexual side effects of the hormones persist, and things do not go back to normal. This is also a limitation of using “intermittent” hormone therapy, in which hormones are given until a man’s PSA blood test result (a test for prostate-specific antigen, a sign of prostate cancer) goes down to near zero. Then the man can stop the hormones for a few months. Some men recover sexually, but others continue to experience loss of desire and erection problems during the months off hormones.

Cancer Treatment in Men: Radiation

• Men who have radiation treatment in the pelvic area may develop erectile dysfunction because the radiation causes a gradual scarring in the tissue in the target area, which may include small blood vessels and nerves that are involved in erection. The changes after radiation therapy tend to be gradual, often not appearing until a few months after the treatment is over. The higher the dose of radiation near the base of the penis, the more likely it is that there will be a problem.
• Radiation treatment also can cause pain during ejaculation. Pain is most often temporary due to irritation of the urethra (tube that carries urine or semen) right after radiation therapy. Sometimes pain occurs later and is caused by a tight band of scar tissue in the urethra, called a stricture.  Radiation aimed near the prostate and seminal vesicles typically reduces semen to only a few drops.

Cancer Treatment in Men: Chemotherapy

After chemotherapy, only a few men experience new sexual changes. Sometimes high doses of drugs that can cause nerve damage result in erectile dysfunction or in dry orgasm, but this is much less common than after surgery or pelvic radiation therapy.

Men who get high doses of chemotherapy, especially if they are having a stem cell or bone marrow transplant, sometimes end up with low testosterone levels, even several years after treatment. They may notice loss of interest in sex and erection problems. A simple blood test can find this problem, and replacement hormones can be given.

Cancer Treatment Side Effects

Cancer treatment side effects, such as fatigue, nausea, vomiting, diarrhea, constipation, hair loss—including pubic hair—weight changes, scars, and sensitivity to tastes and smells may leave you feeling exhausted and uncomfortable. These side effects consume so much energy that sex may be the very last thing on your mind.

Fortunately, patients have options to help relieve their symptoms, and many patients take medicines to treat pain, nausea, anxiety, depression, or other symptoms. However, many of these medicines can decrease sexual desire, which combined with the effects of cancer treatment, may cause you to feel indifferent toward sex. Furthermore, many medicines taken for depression or anxiety may make it harder to reach orgasm.

Some of the medicines also may affect your mental state—how alert or sharp you feel, your mood, and how you interact with people—and so you may not be thinking or communicating clearly. This can negatively affect how you relate to your partner, making sexual contact difficult.

Therefore, if you are experiencing any symptoms or side effects—whatever the cause—ask your doctor or another member of your healthcare team to work with you to find other remedies or strategies to help you feel better.

Emotional Effects

Often during cancer treatment, patients’ needs for intimacy and affection increase. Unfortunately, this happens when relationships may be strained by worry and concern.

Your emotions have a big impact on your sexuality. The way you feel about your body and yourself can influence how you interact with others. You may feel inadequate, out of sync with your partner, and not sure about what to do to feel better

The following are examples of ways that your emotions may affect your sexuality:

• Changes in your appearance may be stressful and cause you to feel unattractive or self-conscious. These changes may make you unable to focus on sexual excitement and pleasure. Surgery that changes your appearance can be especially difficult.
• Feeling negative emotions like anger or guilt may keep you or your partner from wanting to have sex.
• Feeling afraid may distract you and cause you not to care about sex.
• Being fearful of “giving your partner cancer” may affect your ability to be close to your partner. (You cannot give anyone cancer, nor can people “catch” cancer from you. For more information about what causes cancer, talk to your doctor.)
• Often patients’ partners feel fearful of causing harm or pain, so you may feel confused or worried if your partner keeps you at a distance.
• Feeling “stressed out” may cause your sexual desire to decrease.
• Tension, anxiety, or trouble getting in the mood for sex can slow down the ability to reach orgasm.
• You may feel helpless and frustrated by changes beyond your control.
• You may be upset about or grieving changes in your fertility.
• You may fear rejection and decide to pull away before your partner can hurt you.
• You may feel embarrassed that your partner has had to act as your caretaker when you were ill and have trouble switching back to feeling like lovers.
• You may lose desire toward your partner because of a conflict between the two of you. Perhaps you feel desire when you see a sexy love scene in a movie but not when you get into bed with your partner.

Anxiety and Depression

Although most sexual changes after cancer are caused by physical changes, some result from anxiety or depression. Therefore, it is important to have depression and anxiety assessed before having any sexual changes evaluated or treated. This is also important since anxiety and depression share some common symptoms with treatment side effects.

Fortunately, the anxiety and depression many people feel during cancer treatment fades with time for most. But if the emotional reaction to cancer does not improve within a few months of treatment, patients may benefit from some counseling, which can be as effective as medication for depression and anxiety. Also, it’s important to know that some medicines prescribed to treat depression or anxiety can have sexual side effects.

Anxiety

Anxiety about cancer can preoccupy your thoughts, interfering with your ability to enjoy many activities, including sex. Worry and fear about the future may make it hard to share intimacy and affection. Anxiety is a treatable condition, however, responding to both counseling and medicine. Symptoms can be physical or emotional and include:

• Feeling apprehensive or fearful
• Feeling worried
• Feeling that things are “out of control” or endless
• Feeling irritable, restless or edgy
• Feeling stressed or tense, sometimes physically in the muscles with neck or backache
• Having fast or irregular heartbeats
• Sweating
• Having an unsettled stomach, possibly with diarrhea or nausea
• Shaking or trembling
• Having nightmares or vivid images during waking hours of a particularly traumatic part of your cancer treatment

Depression

Depression is also treatable. It affects 15 percent to 25 percent of cancer patients and about 25 percent of cancer survivors. Depression is more than just crying and feeling sad; it can affect your quality of life, including your sexuality. In fact, loss of desire is a classic symptom of depression. Other emotional and physical symptoms include:

• Feeling sad, drained, restless, irritable, or anxious
• Losing interest in activities that you used to enjoy
• Feeling hopeless, helpless, guilty, or worthless
• Losing emotional expression—as if your emotional reactions are inappropriate or nonexistent
• Withdrawing socially from family, friends, pets, and other loved ones
• Experiencing problems with thinking clearly, such as having trouble concentrating, remembering, or making decisions
• Losing your appetite with weight loss, or overeating and gaining weight
• Having disrupted sleep, such as insomnia (sleeplessness), oversleeping, or waking up early
• Abusing drugs or alcohol
• Having thoughts of death or suicide