The National Cancer Institute (NCI) estimates that sexual dysfunction rates among cancer survivors range anywhere between 40% and 100%. Survivors of both sexes often experience a loss of desire and the inability to reach orgasm. Females also report dyspareunia (pain with intercourse) and a loss or change in genital sensation, while men suffer from erectile dysfunction, anejaculation (absence of ejaculation), and retrograde ejaculation (ejaculation going backward into the bladder).
Sexual dysfunction stems from both physiological and psychological causes, so treatment requires a comprehensive approach. Additionally, sexual problems often last much longer than other side effects of cancer treatment, so sexual health remains an issue well into survivorship.
Michael Krychman, MD, medical director of Sexual Medicine at Hoag Memorial Presbyterian Hospital, and executive director, Southern California Center for Sexual Health and Survivorship Medicine, discussed sexual dysfunction at the Second Annual National Coalition of Oncology Nurse Navigators (NCONN) Conference in December 2010. Although Krychman’s information pertained to breast cancer, he said his message applied to all patients with cancer.
BREAST CANCER AND SEXUAL DYSFUNCTION
The NCI estimates that 50% to 90% of breast cancer survivors have some form of sexual issue. Some of the more upsetting comments Krychman has heard from his patients include, “Yes, I’m thankful to be alive, but I am dead down there,” and “They never told me I would feel like this.” In his presentation, Krychman addressed some of the causes and treatments of sexual dysfunction in breast cancer survivors.
Breast Cancer Treatments and Sexual Health
Krychman said that despite treatment advances that preserve more of the breast, surgical intervention still affects sexual functioning. Evidence from several reviews suggests that breast conservation or reconstruction does not greatly impact preservation of sexual function versus mastectomy. “We would assume that those having breast conservation [surgery] do better sexually than those that have a mastectomy, but that is not necessarily the case,” said Krychman. Although those receiving conservative operations are more likely to enjoy breast caressing, the two groups do not differ on issues such as coital frequency, ease of orgasm, and overall sexual satisfaction.
Side effects of radiation treatment that can cause sexual dysfunction include volume loss, retraction, fatigue, dryness of skin and erythema, loss of normal sensation, discoloration, skin thickening and fi brosis, lymphedema exacerbation, range of motion diffi culties, and alopecia. Krychman also mentioned that some patients and their partners still mistakenly believe the patient becomes radioactive and that intimacy could cause radiation poisoning.
Krychman listed several side effects of chemotherapy that can disrupt sexual functioning, including premature ovarian failure, amenorrhea, menopausal syndrome, bone marrow suppression, mucus membrane irritation, neurological changes, vaginal muscosal erythrodysesthesia, alopecia (public and private), weight changes, nausea/vomiting, diarrhea/ stomatitis, and fatigue. Chemotherapy can also induce a fl are-up in patients with genital herpes or genital warts.
According to the NCI’s Website, research suggests the antiestrogen tamoxifen may reduce sexual desire and the ability to reach orgasm. Also, treatment with aromatase inhibitors may cause vaginal dryness and dyspareunia.
Treating Sexual Dysfunction
Comprehensive Wellness Centers
Comprehensive wellness facilities such as Dr Krychman’s Southern California Center for Sexual Health and Survivorship Medicine offer sexual medicine and counseling to cover both physiological and psychological concerns. Patients with cancer often struggle to fi nd an outlet for their sexual issues, and these centers provide access to the proper treatments while maintaining complete discretion.
Due to the uncertainties and disagreements surrounding hormone therapy, Krychman discussed hormonal treatment for sexual dysfunction within the context of individual risk assessment. Personalized cancer treatment has been the longtime goal in oncology, and Krychman stressed that sexual dysfunction issues require the same approach. Manipulating hormone levels may be too risky in one individual but exactly the right treatment in another.
Krychman cited data demonstrating that several common therapies are used to treat other medical issues despite presenting their own set of risks. For example, beta-carotene therapy, calcium CHD supplements, and aspirin, can increase the risk of lung cancer, stroke, and GI bleeding, respectively. Likewise, the risk of using a hormonal treatment for sexual dysfunction may be worthwhile for specifi c patients.
Low Dose Vaginal Estrogen Treatment
Minimally absorbed local vaginal estrogen products such as Estring (estradiol vaginal ring), Vagifem (a vaginal estradiol tablet), and Premarin Vaginal Cream (an estrogen mixture) raise estrogen levels, which could enhance sexual function and desire in patients with breast cancer, said Krychman. He sited a small, 7-patient study of Vagifem by Kendall et al to suggest treatments can increase estrogen levels. The study concluded Vagifem, at least in the short term, “reverses the estradiol suppression achieved by aromatase inhibitors in women with breast cancer and is contraindicated.”
Krychman said, “Surgical oncologists, medical oncologists, gynecologists, and patients will often disagree about [the] safety [of estrogen therapy].” When he discussed Kendall et al’s study at ASCO shortly after its release, about half the medical oncologists in the audience strongly objected to any estrogen use.
Again, Krychman stressed the importance of individual risk assessment. While some women’s estrogen levels may skyrocket, others could experience increased sexual function with manageable estrogen levels. When using estrogen treatment, Krychman recommends implementing a management plan that includes closely monitoring estradiol levels and any abnormal bleeding.
Although some studies such as Barton and colleagues 2007 research suggest testosterone therapy has no impact on sexual dysfunction, others suggest the treatment may help some patients. The longterm safety effects of testosterone treatment are unknown, so personalized risk assessment, as with all hormonal treatments, is Krychman’s recommended approach. He currently sees 50 mostly late-stage patients with breast cancer who are taking testosterone. Thus far, their hormone levels have remained at acceptable levels.
Hormones Are Not the ‘Be-All and End-All’
At the end of his segment on hormone therapies, Krychman concluded, “Women are not ruled sexually by hormones.” He sees women who have no estrogen or testosterone and they have functioning, satisfying sex lives, while others with normal hormone levels experience sexual dysfunction. Sexual issues often stem from emotional or social issues unrelated to hormones, and resolving these issues is the key to treating some patients.
Psychological Issues and Behavior Modification
The effects of cancer treatment can greatly damage a woman’s sexual self-esteem—her image of herself as a sexy, desirable woman. The process can also induce depression, anxiety, and stress that reduce the desire for intimacy. Treatment and counseling can help patients manage the psychological issues affecting their sexual health.
Sexual issues can also arise from simply not making sex a big enough priority. “Often the patient will say, ‘I’m consumed with cancer. I’m consumed with appointments— I’m going from one appointment to the next,’” Krychman said. Reprioritizing and modifying behavior patterns will help patients make time for intimacy.
Depression and low sexual function often overlap, and Krychman said buproprion (Wellbutrin) may address both symptoms. Buproprion is a norepinephrine and dopamine uptake inhibitor that is not associated with the sexual side effects of other antidepressants, such as selective serotonin reuptake inhibitors (SSRIs). In addition to boosting a patient’s mood, buproprion may improve libido. Krychman noted that treating sexual dysfunction with buproprion is an off-label use.
Complementary therapies such as acupuncture and yoga are often prescribed to individuals with sexual dysfunction. Patients with cancer may fi nd them useful in alleviating the pain, stress, depression, and/or anxiety that is affecting their sexual health.
Krychman discussed mechanical products (dilators, vibrators) and fl uids that women can use to help rehabilitate their sexual desire and functioning. The self-help tools are highly individualized, both in comfort level and effectiveness. Insurance may cover some of the items. Comprehensive Wellness Centers can help patients obtain these products with maximum discretion, Krychman said.
HOW CAN NURSE NAVIGATORS HELP?
Although cancer treatment has come a long way, patient and physician discomfort and misinformation still lead to a suppression of sexual problems. A survey by Marwick published in the Journal of the American Medical Association (1999;281:2173- 2174) found that while 85% of adults want to discuss sexual functioning with their physician, 71% believe their physician lacks the desire and time to discuss sexual issues, 68% worry they would embarrass their physician, and 76% feel treatments do not exist for their sexual dysfunction.
Krychman sees a tremendous opportunity for oncology nurse navigators (ONNs) to bridge this communication gap and help patients overcome these obstacles. “As frontline providers, [you] have to start the dialogue because a majority of physicians will not talk about it,” Krychman told NCONN attendees.
When broaching the topic with patients, ONNs should remain sensitive to the various factors that contribute to a patient’s sexuality, including age, gender, sexual orientation, personal attitudes, and religious and cultural values. Krychman also said ONNs can be direct when initiating the conversation, saying something to the effect of, “It’s important to take care of you as a complete person, I’m going to ask you some questions about sexual function.”
The bottom line is that sexual health is a major quality of life component in patients with cancer. Through mindfulness, screening, education, and follow-up, ONNs can ensure their patients receive the comprehensive treatment they need.