Background    With more than 14 million cancer survivors in the United States, sexual dysfunction related to disease and/or therapy is an increasingly prevalent problem (1). This Fast Fact will review strategies to address and clinically manage this complex quality-of-life issue. See Fast Fact #284 for more information on opioid induced androgen deficiency.

Demographics    Although all cancer patients and survivors are at risk for sexual dysfunction, those with malignancies involving sexual or pelvic organs and those undergoing treatments that affect sexual hormones appear to be at highest risk. Almost half of prostate cancer patients report severe levels of sexual concerns (2,3); over half of breast cancer survivors report persistent difficulties in sexual functioning (4). Manifestations of sexual dysfunction include physical symptoms (e.g. erectile dysfunction, dyspareunia), emotional symptoms (e.g. disinterest in sex, poor body image), and interpersonal challenges (e.g. change in relationship roles from sexual partners to caregiver-patient).

Assessment    Despite high prevalence, assessment is not routinely performed in oncology or primary care offices. Barriers include patient/provider reluctance to discuss the topic, lack of assessment training, and lack of standardized sexuality questionnaires (5-7). When sexuality is addressed, there is often a mismatch of priorities between patient (often focused on coping with sexual changes and loss of intimacy) and provider (often focused on contraception, fertility, and menopausal issues)(5,8). Because patients usually do not seek treatments on their own, experts recommend incorporating open-ended questions which normalize such concerns into routine clinical assessments. For example, “Many patients who have been treated for cancer experience sexual problems; do you have similar experiences (5,9)?” When sexual dysfunction is detected, a more thorough history should include phase(s) of sexual response cycle affected, association with cancer diagnosis/therapy, concomitant symptoms, and whether the symptoms affect masturbation and/or sexual activity with partner (9).

Management strategies    Providers should attend to comorbid aggravating factors of sexual function such as thyroid dysfunction, long-term chronic opioid therapy, and use of anti-depressants such as SSRIs. Most patients prefer physiological over psychological solutions; however, clinical research outcomes for many of the physiological therapies are mixed (8).

Physiological  

• Vaginal dilators are often recommended to prevent stenosis after pelvic radiation, but clinical evidence of efficacy and tolerability are lacking (10).
• Preliminary evidence supports the use of vaginal estrogen replacement therapy (i.e. low-dose estradiol rings, estradiol creams or conjugated estrogen creams) for vaginal dryness and dyspareunia, but long-term efficacy and safety have not been established (11,12). Thus, non-hormonal vaginal moisturizers and lubricants are often first line therapy for these symptoms (13).  Oral hormone replacement is often avoided due to the increased risk of breast cancer.
• Short-term (< 12 months) testosterone replacement may be helpful in select patients with testosterone deficiency, but it should be prescribed with caution due to concern for an increased risk in prostate cancer (14). See Fast Facts #284.
• Oral PDE-5 inhibitors (such as sildenafil), vacuum erection devices, penile prosthesis, and intracavernous injections (such as alprostadil) have been shown to be effective in iatrogenic erectile dysfunction from cancer therapy (15-19).
• Some experts advise that patients should avoid sexual intercourse if the malignancy is present in the genital tract, if the patient is still healing from genital surgery, or if neutropenia (ANC<1000) and/or thrombocytopenia (platelets<50,000) is present to minimize the bleeding and infection risk.
• Patients commonly ask if chemotherapy can cause adverse effects in partners with whom they are sexually intimate.  Available medical evidence suggests that this risk is minimal to non-existent.  

Psychological

• Although attrition levels are high, participation in more than 3 sessions of cognitive behavioral stress management, relaxation training, sexual education, or sexual counseling may reduce sexual dysfunction in cancer patients or survivors (8).
• Partner participation during therapy may help enhance sexual intimacy and body image (20).
• Some experts recommend flexible coping strategies.  Flexible coping focuses on identifying the cognitive and behavioral changes which have occurred around the construct of sexuality. Then, rather than utilizing a strict definition of sexual intercourse as the goal to sexual activity, individuals are encouraged to reimagine sexual activity as a continuum of non-intercourse to intercourse intimacy activities as they become accustomed to their sexual changes (21).

Summary   Providers caring for cancer survivors often miss sexual dysfunction, which is a prevalent cause of distress and quality of life impairment. Routine open-ended questions exploring sexual function should help to more broadly identify these issues in cancer patients.

References:

1.         DeSantis CE, Lin CC, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2014. CA: a cancer journal for clinicians. Jul-Aug 2014;64(4):252-271.

2.         Gore JL, Gollapudi K, Bergman J, Kwan L, Krupski TL, Litwin MS. Correlates of bother following treatment for clinically localized prostate cancer. The Journal of urology. Oct 2010;184(4):1309-1315.

3.         Parry C, Lomax JB, Morningstar EA, Fairclough DL. Identification and correlates of unmet service needs in adult leukemia and lymphoma survivors after treatment. Journal of oncology practice / American Society of Clinical Oncology. Sep 2012;8(5):e135-141.

4.         Bartula I, Sherman KA. Screening for sexual dysfunction in women diagnosed with breast cancer: systematic review and recommendations. Breast cancer research and treatment. Sep 2013;141(2):173-185.

5.         Hordern AJ, Street AF. Communicating about patient sexuality and intimacy after cancer: mismatched expectations and unmet needs. The Medical journal of Australia. Mar 5 2007;186(5):224-227.

6.         Park ER, Bober SL, Campbell EG, Recklitis CJ, Kutner JS, Diller L. General internist communication about sexual function with cancer survivors. Journal of general internal medicine. Nov 2009;24 Suppl 2:S407-411.

7.         Flynn KE, Reese JB, Jeffery DD, et al. Patient experiences with communication about sex during and after treatment for cancer. Psycho-oncology. Jun 2012;21(6):594-601.

8.         Brotto LA, Yule M, Breckon E. Psychological interventions for the sexual sequelae of cancer: a review of the literature. Journal of cancer survivorship : research and practice. Dec 2010;4(4):346-360.

9.         Althof SE, Parish SJ. Clinical interviewing techniques and sexuality questionnaires for male and female cancer patients. The journal of sexual medicine. Feb 2013;10 Suppl 1:35-42.

10.       Miles T, Johnson N. Vaginal dilator therapy for women receiving pelvic radiotherapy. The Cochrane database of systematic reviews. 2010(9):CD007291.

11.       Biglia N, Peano E, Sgandurra P, et al. Low-dose vaginal estrogens or vaginal moisturizer in breast cancer survivors with urogenital atrophy: a preliminary study. Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology. Jun 2010;26(6):404-412.

12.       Dew JE, Wren BG, Eden JA. A cohort study of topical vaginal estrogen therapy in women previously treated for breast cancer. Climacteric : the journal of the International Menopause Society. Mar 2003;6(1):45-52.

13.       Al-Baghdadi O, Ewies AA. Topical estrogen therapy in the management of postmenopausal vaginal atrophy: an up-to-date overview. Climacteric : the journal of the International Menopause Society. Apr 2009;12(2):91-105.

14.       Cui Y, Zong H, Yan H, Zhang Y. The effect of testosterone replacement therapy on prostate cancer: a systematic review and meta-analysis. Prostate cancer and prostatic diseases. Jun 2014;17(2):132-143.

15.       Sherer BA, Levine LA. Current management of erectile dysfunction in prostate cancer survivors. Current opinion in urology. Jul 2014;24(4):401-406.

16.       Padma-Nathan H, McCullough AR, Levine LA, et al. Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. International journal of impotence research. Sep-Oct 2008;20(5):479-486.

17.       Ramsawh HJ, Morgentaler A, Covino N, Barlow DH, DeWolf WC. Quality of life following simultaneous placement of penile prosthesis with radical prostatectomy. The Journal of urology. Oct 2005;174(4 Pt 1):1395-1398.

18.       Brison D, Seftel A, Sadeghi-Nejad H. The resurgence of the vacuum erection device (VED) for treatment of erectile dysfunction. The journal of sexual medicine. Apr 2013;10(4):1124-1135.

19.       Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. The Journal of urology. Oct 1997;158(4):1408-1410.

20.       Scott JL, Kayser K. A review of couple-based interventions for enhancing women’s sexual adjustment and body image after cancer. Cancer journal. Jan-Feb 2009;15(1):48-56.

21.       Reese JB, Keefe FJ, Somers TJ, Abernethy AP. Coping with sexual concerns after cancer: the use of flexible coping. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. Jul 2010;18(7):785-800.

Authors Affiliations    National Cancer Institute; NIH, Bethesda, MD; MedStar Washington Hospital Center, Washington, DC

Conflict of Interest: The authors have disclosed no relevant conflicts of interest.

Version History: First published electronically on April 2015.