Synonyms
• Sexual health after cancer
• Sex after cancer
• Sexuality
Subdivisions
General Discussion
After a cancer diagnosis and treatment, many women experience a change in their sexual health. Seventy percent of women with breast cancer (1), 65%-90% of patients with gynecological cancer (2), and 60% of women with rectal cancer (3) report long term sexual health problems. These issues may be unexpected, as discussions about impact of cancer treatment on sexual function are still not the norm. In addition, women diagnosed with cancer are less likely than men to receive information about the impact on their sexual health (4).
Signs & Symptoms
After cancer diagnosis and treatment, sexual problems can involve biological changes, psychological effects, and changes in interpersonal relationships. Some women may experience the effects of lowered estrogen due to cancer treatments resulting in menopausal symptoms including hot flashes, joint aches, vulvovaginal dryness, and decreased vaginal lubrication. Pain with sex is another common concern. Many women experience a loss of interest in sex – a change that can be distressing. Relationships and social roles can shift, which can cause changes in intimate relationships.
Signs and symptoms of sexual problems after cancer
• Vaginal dryness
• Shortening and narrowing of vagina (vaginal stenosis)
• Decreased clitoral sensation
• Decrease or loss of orgasm
• Decreased lubrication
• Pain with sex
• Decreased libido/desire/interest in sex
• Body image concerns
• Relationship concerns
• Decreased saliva
• Loss or decrease sensation of breasts and nipples
Causes
Cancer treatment can involve chemotherapy, surgery, radiation, hormone blocking treatments, stem cell transplants, and targeted therapies. Each of these treatment modalities can induce sexual dysfunction.
Chemotherapy
Chemotherapy given to a premenopausal woman can induce premature menopause resulting in hot flashes, vulvovaginal dryness, and decreased lubrication. Many women experience a change in libido after cancer treatments, which can be very distressing for some. Chemotherapy can also cause fatigue, neuropathy, hair loss which can impact sexuality.
Surgery
Surgery for gynecological cancer can cause early menopause if the ovaries are removed and can also result in discomfort due to scarring. Some surgical procedures including vulvectomy for vulvar cancer can damage the clitoris or its innervation (5). Breasts and nipples play a significant role in arousal and orgasm for many women and removal of the breast or nipple for treatment of breast cancer can significantly impact arousal and orgasm (6). Surgery for colorectal cancer may result in an ostomy, which can affect body image.
Radiation
Pelvic radiation can cause vaginal stenosis – the narrowing and shortening of the vagina. In pre-menopausal woman, pelvic radiation can also induce premature menopause. Radiation treatments for head and neck cancer can reduce saliva production, which impacts kissing and oral sex.
Affected Populations
Any person going through cancer treatment could experience changes in sexual function through the impact of the cancer and the treatments. People diagnosed with the conditions listed below or who had the treatments listed below may be at risk for sexual health problems.
• Gynecological cancer
• Breast cancer
• Colorectal cancer
• Chemotherapy
• Pelvic radiation
• Pelvic surgery
• Surgery on breasts
• Hormone blocking treatments (tamoxifen, aromatase inhibitors)
• Stem cell transplant
Diagnosis
Evaluation of sexual health concerns after a cancer diagnosis might involve a bio- psycho- social assessment. Diagnosis of some of these concerns can be made after a discussion with a medical or mental health professional. For some of the physical concerns, a genital or pelvic exam may be performed. At times, a referral to pelvic floor physical therapist for an evaluation of the pelvic floor may be helpful (6).
Standard Therapies
Genitourinary syndrome of menopause
Vaginal dryness, vulvar dryness or itching, and decreased genital lubrication are some of the symptoms of the genitourinary syndrome of menopause. Vaginal moisturizers used at least three times a week can improve the symptoms of vulvovaginal dryness (7). Hyaluronic acid containing vaginal moisturizers have been shown to improve symptoms of vaginal dryness (8). The purpose of vaginal moisturizers is to maintain moisture in the tissues and they are effective when used regularly – not just with sex.
Lubricants are used to reduce friction and discomfort during sexual activities. There different types of lubricants including water based and silicone-based options. Water based lubricants are compatible with silicone sex toys and condoms, however may dry out faster. Silicone based lubricants may be longer lasting and are compatible with condoms, but should not be used with silicone sex toys. Oil based lubricants may degrade condoms.
Topical estrogen is an appropriate treatment for many people with symptoms of vaginal dryness. Those with hormone responsive cancers, such as estrogen receptor positive breast cancer, can discuss the risks and benefits (9) of local topical hormone treatments with their oncologists. These treatments are not contraindicated and the use of topical hormone treatments in patients with estrogen positive breast cancer is addressed in guidelines and statements from multiple national medical organizations, including American Society of Clinical Oncology (8), American College of Obstetricians and Gynecologists (9), and National Menopause Society(10).
Pain with sex
Pain with sex (dyspareunia) can be caused by pelvic floor dysfunction. Working with a pelvic floor physical therapist can help to diagnose this condition and physical therapy directed at the pelvic floor can help to relieve pain with sex. Therapy can include external exercises for the back, hips, and core, breathing exercises, internal manual therapy, bio-feedback, use of devices aimed to relieved trigger points within the pelvic floor. Vaginal stenosis is the narrowing and shortening of the vagina and can cause pain with attempted vaginal penetration or complete impossibility of vaginal penetration. Treatment with vaginal dilators of increasing sizes can be used to improve vaginal stenosis. Vaginal dilators can also be used to prevent the development vaginal stenosis after pelvic radiation (11).
Low libido
Low libido is a common and often distressing issue after cancer treatment. There can be may be contributing factors that should be addressed first, including pain with sex, loss of pleasure or enjoyment of sex, or issues in the relationship. Psychosocial counseling, including working with a sex therapist, can address low libido (7). There are some simple behavioral changes that may improve libido. For concerns about body image and relations after cancer diagnosis, psychosocial counseling can be helpful.
Investigational Therapies
Medications for Low Libido
There are FDA approved medications for hypoactive sexual desire disorder in pre-menopausal women –flibanserin (12) and bremelanotide (13). The effectiveness in people who develop low libido as a result of cancer treatments is not known. Currently, there is a clinical trial evaluating the feasibility of studying one of these medications, flibanserin in women with a diagnosis of breast cancer (14).
Bionic Breast
After mastectomy, there is a loss of sensation of breast and nipples which can lead to issues with body image, arousal, pleasure, and orgasm. Research is underway to design a bionic breast – technology using sensors implanted under the skin to pass electrical stimuli to nerves to re-create sensation of the breasts (15).
Support Available
References
1. Jing L, Zhang C, Li W, Jin F, Wang A.Incidence and severity of sexual dysfunction among women with breast cancer: a meta-analysis based on female sexual function index. Support Care Cancer.2019;27(4):1171-1180. doi:10.1007/s00520-019-04667-7
2. Huffman LB, Hartenbach EM, Carter J,Rash JK, Kushner DM. Maintaining sexual health throughout gynecologic cancer survivorship: A comprehensive review and clinical guide. Gynecologic Oncology.2016;140(2):359-368. doi:10.1016/j.ygyno.2015.11.010
3. Bregendahl S, Emmertsen KJ, Lindegaard JC, Laurberg S. Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study. Colorectal Dis. 2015;17(1):26-37.doi:10.1111/codi.12758
4. Taylor J, Ruggiero M, Maity A, et al. Sexual Health Toxicity in Cancer Survivors: Is There a Gender Disparity in Physician Evaluation and Intervention? International Journal of Radiation Oncology*Biology*Physics. 2020;108(3):S136.doi:10.1016/j.ijrobp.2020.07.872
5. Malandrone F, Bevilacqua F, Merola M, etal. The Impact of Vulvar Cancer on Psychosocial and Sexual Functioning: A Literature Review. Cancers. 2021;14(1):63. doi:10.3390/cancers14010063
6. Lindau ST, Abramsohn EM, Baron SR, etal. Physical examination of the female cancer patient with sexual concerns:What oncologists and patients should expect from consultation with a specialist. CA Cancer J Clin. 2016;66(3):241-263. doi:10.3322/caac.21337
7. Carter J, Lacchetti C, Andersen BL, et al. Interventions to Address Sexual Problems in People With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline. J Clin Oncol. 2018;36(5):492-511.doi:10.1200/JCO.2017.75.8995
8. Carter J, Baser RE, Goldfrank DJ, et al. A single-arm, prospective trial investigating the effectiveness of anon-hormonal vaginal moisturizer containing hyaluronic acid in postmenopausal cancer survivors. Support Care Cancer. 2021;29(1):311-322.doi:10.1007/s00520-020-05472-3
9. ACOG Committee Opinion No. 659: The Use of Vaginal Estrogen in Women With a History of Estrogen-Dependent Breast Cancer. Obstet Gynecol. 2016;127(3):e93-e96. doi:10.1097/AOG.0000000000001351
10. Faubion SS, Larkin LC, Stuenkel CA, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women’s Sexual Health. Menopause.2018;25(6):596-608. doi:10.1097/GME.0000000000001121
11. Damast S, Jeffery DD, Son CH, et al .Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology. Practical Radiation Oncology. 2019;9(6):479-491. doi:10.1016/j.prro.2019.07.001
12. Joffe HV, Chang C, Sewell C, et al. FDAApproval of Flibanserin — Treating Hypoactive Sexual Desire Disorder. N Engl J Med. 2016;374(2):101-104. doi:10.1056/NEJMp1513686
13. Kingsberg SA, Clayton AH, Portman D, et al. Bremelanotide for the Treatment of Hypoactive Sexual Desire Disorder: Two Randomized Phase 3 Trials. Obstetrics & Gynecology.2019;134(5):899-908. doi:10.1097/AOG.0000000000003500
14. A Study of Flibanserin in Breast Cancer Survivors on Tamoxifen or Aromatase Inhibitors - Full Text View -ClinicalTrials.gov. Accessed February 3, 2022.https://clinicaltrials.gov/ct2/show/NCT03707340
15. Lindau ST, Bensmaia SJ. Using Bionics to Restore Sensation to Reconstructed Breasts. Front Neurorobot.2020;14:24. doi:10.3389/fnbot.2020.00024
