Treatment of Sexual Problems in People With Cancer
Although research is beginning to clarify the frequency and types of sexual problems people
with cancer experience, few treatment programs for sexual dysfunction in
cancer patients have been designed or tested. Programs that integrate medical and psychological modalities aimed at the treatment of sexual dysfunction in those who have had cancer are warranted. Additionally, these programs must be cost-effective and accessible to people with cancer.
Many patients are fearful or anxious of their first sexual experience after
treatment and can often begin a pattern of sexual avoidance. If the patient is
concerned about sending mixed signals to his or her partner, this can lead to
avoidance of general intimacy and touch. The partner may also contribute
to the generalized avoidance of intimacy through his or her reluctance to initiate
any behavior that may be perceived as pressure to be more intimate or may contribute to any potential physical discomfort from greater expression of
physical intimacy. Providers need to reassure patients and their significant
others that even when intercourse is difficult or impossible, their sex lives
are not over. The couple can give and receive pleasure and satisfaction by
expressing their love and intimacy with their hands, mouths, tongues, and lips.
Providers should encourage the couple to express affection in alternative ways
(e.g., hugging, kissing, nongenital touching) until they feel ready to resume sexual
activity. The couple should be encouraged to communicate honest feelings,
concerns, and preferences.
If a man cannot attain an erection firm enough for penetration,
and/or if intercourse is painful for a woman, some couples may be willing to find
alternative ways to bring each other to orgasm and express sexual intimacy.
Sensate focus exercises of noncoital pleasuring,[1,2] based on principles of
sensuous massage, give couples an experience of sexual expression that allows
them to be physically close and intimate without pressure and anxiety that can
be associated with anticipation of intercourse. The structure and ground rules
of sensate focus can help bypass performance anxiety (self-consciousness and
self-evaluation) and enable the couple to lose themselves in the current
experience of pleasurable touch. These exercises also help the couple
communicate about potentially problematic or emotionally sensitive areas of the
body. Providers should determine a couple’s openness to modification of their
sexual technique.
As many patients will experience anticipatory anxiety about re-establishing
sexual intimacy with their partner and potential uncertainty of their own
sexual response, the potential advantages of self-stimulation can be explored.
Self-stimulation has the advantage of allowing the individual to become
comfortable with his/her sexual response and arousal without the added pressure
of performance anxiety commonly heightened by concern for their partner’s
pleasure, reactions, concerns, and/or fears. For many individuals, a
cognitive reframing of masturbation to self-stimulation or self-pleasuring
allows the individual to accept this activity as part of the process in sexual
rehabilitation. For others, this behavior may still be a resilient and
persistent taboo for cultural and religious reasons.
For those couples who wish to have sexual intercourse, sexual positions that
place no weight on a scar or ostomy and positions that allow better
control of depth of penetration can be explored. The side-by-side position
(spooning) in which the man is behind the woman, or the L-shaped position, with
both partners lying down, torsos at right angles and legs entwined, are two
possibilities. Comprehensive pamphlets on sexuality and cancer, for both men
[3] and women,[4] provide illustrations of sexual positions and other
self-help information.
For patients with colostomies or ileostomies, pamphlets are available from
national organizations related to resuming sexual activity including topics
such as sex and the female ostomate, sex and the male ostomate, and gay and
lesbian ostomates. Providers can educate patients on limiting food intake
before anticipated sexual activity, watching the types of food consumed, and
planning times for intimacy when a bowel movement is less likely. Although the
ostomy pouch is typically changed when about one-third full, patients should be
taught to empty the pouch sooner when anticipating sexual intimacy. Patients may fear that the ostomy bag will interfere with
sexual intimacy, become dislodged, or cause damage to the stoma. An empty and
flat ostomy bag will not become dislodged from the stoma and can be rolled up
or taped down so that it will not get in the way of sexual intimacy.
Decorative covers may also be worn.[5,6] A much greater selection of products
for ostomates exists today than in years past, including disposable pouches, reusable pouches that
empty from the bottom or top while still attached, pouches with filters to
control odors, and pouches that hang sideways instead of down for physical
activity. Patients concerned about potential odor can use deodorant tablets or
liquids in the bottom of the pouch or as recommended by the manufacturer.[6]
Providers can help educate couples by offering practical suggestions to
overcome changes in responsiveness to sexual stimulation. Couples should allow
plenty of time for sexual expression with sufficient foreplay to develop the
fullest possible sexual arousal. For some couples, early morning may be a good
restful time for sexual expression. Conditions that facilitate sexual pleasure
should be explored and may include relaxation, dreams, fantasy, deep breathing,
and recalling positive experiences with the partner.
Erection problems are the most common sexual dysfunction for which men seek
help after cancer treatment. Many men with erectile dysfunction are able to
have an orgasm with oral or manual stimulation; many partners are satisfied and
orgasmic with noncoital stimulation. If the desire for intercourse remains,
there are several treatment options available for erectile dysfunction
depending on the cause and degree of dysfunction. Only a small percentage of
men with erection problems seek help.[7,8] With the advent of
sildenafil (Viagra), a phosphodiesterase-5 (PDE-5) inhibitor to treat erection problems,[9] the
percentage of men who enter into the treatment system for erection problems has
increased. Despite the publicity about the effectiveness of sildenafil, it
works best in men with the mildest forms of erectile dysfunction. Many men
will not be able to achieve adequate erections by taking this drug alone. Sildenafil use allows about 72% of patients with nerve-sparing prostatectomy and 15% of patients with non–nerve-sparing prostatectomy to achieve vaginal intercourse.[10] About 12% of sildenafil responders lose efficacy by 3 years.[11] In a
study of brachytherapy in the treatment of localized prostate cancer,
sildenafil improved potency in 62% to 70% of patients.[12] Patients who were not being treated with
androgen therapy had a significantly better response.[13] Similarly, of men
who became impotent after brachytherapy for prostate cancer,[14] 85% to 88% responded
with improved erectile function when taking sildenafil. Reported potency rates after prostate brachytherapy are high; a 3-year follow-up study demonstrated that 80% of patients were able to have adequate erections for satisfactory sexual activity with or without siladenafil.[15] Sildenafil has also improved erectile function for patients with partial parasympathetic nerve disruption from rectal surgery.[16,17] No other treatment
for erectile dysfunction has a high rate of patient acceptance. Sildenafil has been studied in a novel primary prevention modality using nightly administration after a bilateral nerve-sparing prostatectomy. This approach effected a sevenfold improvement in return of spontaneous, normal erectile function 2 months after discontinuation of the drug.[18] The authors state that this effect appears to be mediated by properties unique to sildenafil that include improved endothelial function and neuronal regeneration and neuroprotection.[18] Published data also suggest that early use of sildenafil after radical retropubic prostatectomy may preserve intracoporeal smooth muscle content;[19] although this effect on the return of potency is not known, maintaining the pro-erectile ultrastructure is integral to rehabilitating post–radical retropubic prostatectomy erectile function.[19] Data on the efficacy of early postoperative erectile treatment rely on very few randomized trials. Larger randomized trials with at least 2 years of follow-up are needed before definitive conclusions can be drawn about the true efficacy of rehabilitative sexual therapy for postoperative erectile function, as the natural recovery of erectile function has been reported to take as long as 2 years.[20]
Currently, there are three U.S. Food and Drug Administration (FDA)–approved PDE-5 inhibitors on the market: Viagra (sildenafil), Levitra (vardenafil), and Cialis (tadalafil). Although all three of these oral medications are PDE-5 inhibitors, they are not the same. No head-to-head comparison trials have been published. It appears, however, that all three agents are similar in efficacy, helping 60% to 70% of patients with erectile dysfunction.[21-23] However, comparisons of the efficacy of the PDE-5 inhibitors are complicated by the heterogeneity of the populations studied, the varied primary cancer therapies employed, different timing in measuring outcomes in the clinical trials, and variance in the endpoints used to determine efficacy. Furthermore, most of these trials were industry sponsored.
The major contraindications for use of a PDE-5 inhibitor are concurrent use of nitrates or the alpha-blockers terazosin (Hytrin) and doxazosin (Cardura). The major difference in the three approved inhibitors is that tadalafil has a considerably longer serum half-life, which provides both a larger window of opportunity and potential side effects.[21,22] There is far more research on the use of sildenafil than on the use of the other PDE-5 inhibitors in oncology patients, as it was approved in 1998; vardenafil and tadalafil were approved in 2003. Tadalafil was investigated in the treatment of erectile dysfunction following bilateral nerve-sparing radical retropubic prostatectomy. Results from this randomized, double-blind, placebo-controlled, multicenter study found that 71% of patients randomly assigned to receive tadalafil reported improved erections.[24] Vardenafil had been investigated in the treatment of erectile dysfunction after radical retropubic prostatectomy and following nerve-sparing radical prostatectomy.[25,26] In post–radical retropubic prostatectomy patients, the average intercourse success rate per patient receiving 20 mg of vardenafil was 74% in men with mild to moderate erectile dysfunction and 28% in men with severe erectile dysfunction, compared with 49% and 4% for placebo.[25] Patients receiving 10-mg and 20-mg doses of vardenafil following nerve-sparing radical prostatectomy reported significantly greater intercourse satisfaction, orgasmic function, and overall satisfaction rate with hardness on the International Index of Erectile Function (IIEF), compared with those receiving placebo.[26]
Therapies such
as penile injections, vacuum devices, or intraurethral medication have
extremely high dropout rates, and of men who seek help at clinics for erectile
dysfunction, only about one-third feel long-term satisfaction, despite trying a
mean of two different treatment modalities.[27-30] For men who have a suboptimal response to oral therapies after radical retropubic prostatectomy, the use of combined intracorporal injection (ICI) and a PDE-5 inhibitor has been shown to improve erectile function. One retrospective study found that among men who experienced erectile dysfunction after nerve-sparing retropubic prostatectomy, 68% who combined ICI with either sildenafil or vardenafil reported improved erectile function. On follow-up, 36% of these patients used ICI therapy only intermittently, as they reportedly felt that this was adequate for good results.[31]
Rates of long-term
satisfaction are superior for penile prosthesis surgery,[32-34] but with less
invasive and permanent treatments available, fewer men choose this treatment
modality, particularly after undergoing intensive cancer therapy.[35] The role of
the man’s partner in prompting him to try a treatment or to keep on using it is
also poorly understood. When erectile functioning is impaired, counseling
should initially focus on obtaining sexual pleasure and satisfaction without
erections or intercourse. For men with postsurgical erectile dysfunction,
there is the possibility for improved function over time as nerves may
potentially regenerate for up to 2.5 years after surgery.[6]
Providers should educate patients that opting to use no medical intervention to restore
erections is also a valid choice. Comprehensive reviews of the current
management of erectile dysfunction are available.[36-40] Also, several authors
[37,41,42] provide further discussion on the management of inhibited sexual
desire and other male sexual dysfunctions.
When women experience changes in arousal, most notably vaginal dryness and
irritation, vaginal moisturizers (e.g., Replens) and water-based lubricants
(e.g., Astroglide and K-Y Liquid) should be suggested, especially in women who
cannot use estrogen replacement. The approval of the estradiol-releasing vaginal ring (Estring),
containing a slow-release preparation, 2 mg of micronized 17-beta-estradiol, may also provide a less risky alternative to systemic estrogen
replacement for women with postmenopausal vaginal atrophy.[43,44] Estring has
demonstrated a decreased recurrence of urinary tract infections in
postmenopausal women and a significant maturing effect on vaginal and urethral
mucosal cells, decreasing the urogenital symptoms of postmenopausal women.[45]
Another alternative to local estrogen replacement is the first-available 25-μg 17-beta-estradiol vaginal tablet (Vagifem). A recent study comparing
Vagifem tablets to 1.25-mg conjugated equine estrogen
vaginal cream (Premarin) found both to be equivalent in relieving symptoms of atrophic
vaginitis, with patients who received Vagifem experiencing less endometrial
proliferation or hyperplasia. This study also found that women rated vaginal
tablets more favorably than vaginal cream.[46] The long-term safety of the use of vaginal estrogens by women who should avoid estrogens has not been determined.
If changes in arousal are also associated with the endocrine changes of
menopause, the option and evaluation of hormone replacement should be
discussed. Some women may experience discomfort with penetration around the
vaginal entrance and can learn to relax the pubococcygeus muscles with
Kegel exercises.[36,47,48] Women who have lost vaginal depth or caliber as a
result of pelvic surgery, radiation therapy, or graft-versus-host disease may
also benefit from a program of inserting vaginal dilators of gradually
increasing sizes, and at the same time, learning exercises to better relax the
muscles surrounding the vaginal entrance.[36,49] Some women may also benefit, at
least in the short term after cancer treatment, from lubricant or anesthetic
gels to prevent pain in tender, dry vulvar areas.[50] The FDA approved a nonpharmaceutical device to aid sexual arousal in women. The EROS
clitoral therapy device (EROS-CTD) creates a gentle suction over the clitoris
to increase blood flow and sensation. This device is only available
by prescription and is clinically indicated for the treatment of female sexual
dysfunction. It is expected to be particularly effective in postmenopausal
women, women who have had hysterectomies, and those women who have
surgically induced menopause.[51] The efficacy of EROS therapy has been supported by several small pilot studies,[52-54] one of which specifically examined its efficacy in alleviating the symptoms of sexual dysfunction among women with a history of irradiated cervical cancer.[53] Three months posttherapy, this study found statistically significant improvements in all domains evaluated, which included increased sexual desire, arousal, lubrication, orgasm, sexual satisfaction, and reduced pain. Additionally, follow-up gynecological examinations revealed improved vaginal elasticity, mucosal color, and moisture and decreased bleeding and ulceration. Randomized controlled trials are warranted to fully assess the benefits of EROS therapy.
More specific information for the evaluation and treatment of female sexual
dysfunction, including painful intercourse (i.e., dyspareunia), vaginismus, inhibited
orgasm, and sexual arousal and desire disorders, is available in other
resources.[37,47,55,56]
For both men and women, a persistent and complex sexual problem is loss of
desire for sex after cancer treatment. In men who have not had prostate cancer
and have clinically low levels of serum testosterone, replacement by injection
or patch is often effective in restoring normal sexual function. Testosterone
replacement tends to have little effect, however, if given to a man whose own
hormone levels fall within the normal range. Safety, dosage, and delivery
systems for androgen replacement in women need to be studied. Numerous studies have evaluated the use of transdermal testosterone in various populations.[57-63] These populations include women who have hypoactive sexual desire disorder who have had oopherectomies, who are naturally postmenopausal, who are premenopausal, and who have a history of cancer. These studies used doses ranging from 150 μg to 10 mg daily. Most of the studies in women have used concomitant estradiol supplementation if estrogen levels fell outside the normal premenopausal range and found that testosterone supplementation significantly improved libido outcomes. The only published study in cancer survivors did not use concomitant estradiol supplementation.[64] This clinical trial showed that in 150 female cancer survivors randomly assigned to receive either 10 mg of transdermal testosterone daily or placebo for 4 weeks, there was no statistically significant difference in improvement in sexual desire—despite the fact that androgen levels improved significantly in the women receiving testosterone and remained unchanged in those getting placebo. Therefore, it is not clear that testosterone alone, in the absence of estrogen, can positively impact libido. For women who have
breast cancer, the safety of giving androgens is unknown. Serum androgens can
be aromatized to estrogen. Data from epidemiologic studies can lead one to believe there may be an increased risk of breast cancer with higher concentrations of endogenous androgens.[65,66] However, endogenous androgens present over a life span do not equal exogenous androgen supplementation for a woman with low androgen concentrations. One small study evaluating the effects of testosterone supplementation on breast tissue found that the addition of testosterone to estrogen and progesterone inhibited the breast proliferation exhibited in the group that received estrogen, progesterone, and placebo.[67] Therefore, many unanswered questions remain about sufficient androgen levels for adequate sexual function as well as short- and long-term safety. To date, there are no compelling data to support the use of testosterone alone to improve libido in women who are estrogen deficient.
Because loss of desire often is multifactorial, an approach that includes
psychological assessment and treatment is usually optimal. An experienced
mental health professional can rule out a mood disorder as a factor in loss of
desire and can explore the interactions of factors such as changes in
relationship dynamics, loss of physical well-being, changes in sexual
self-concept, and negative body image. The effects of prescription medications,
chemical dependency, or hormonal abnormalities can be recognized and targeted
for change. Unfortunately, there is no true aphrodisiac medication that can
restore sexual desire in the presence of a normal hormonal environment.
In general, a variety of treatment modalities are available for sexual
dysfunction after cancer. For many problems, providing information and
suggestions for behavior change in a self-help format may be sufficient.
Education can be provided via books,[36] pamphlets,[3,4] CD-ROMs, videos, peer counselors,[68] or
Internet interactions. For men and women with more complex and severe
problems, professional intervention will be more effective. Future research
needs to explore which treatment components are most effective with particular
groups of patients. Sexual counseling can be provided for individuals,
couples, or groups. The effectiveness of these different formats has not been
compared for people with cancer. It is also not known whether brief counseling
can enhance the impact of medical treatments, such as those used to overcome
erectile dysfunction or dyspareunia.
There is limited research about the impact of support groups on sexual outcomes for men with prostate cancer. It is likely that associations between better outcomes and participation in support groups reflect baseline sociographic and clinical differences between those who participate in support groups and those who do not.[69]
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