Sexuality and Reproductive Issues (PDQ®): Supportive care - Patient Information [NCI]

Sexual Problems as a Side Effect of Cancer

Many types of cancer and treatments for cancer can cause sexual side effects.

Many types of cancer and cancer treatments can affect sexual function. These changes may be temporary or permanent. Sexual problems are common in patients with the following types of cancer:

• Breast cancer.
• Gynecologic cancers.
• Prostate cancer.

Less is known about how other types of cancer affect sexuality.

Both sexual desire and ability can be affected.

The most common sexual problems for cancer patients include the following:

• Loss of desire for sexual activity in both men and women.
• In men, problems getting and keeping an erection.
• In women, pain during intercourse.

Less common problems in men include the following:

• Being unable to ejaculate.
• Ejaculation going backward into the bladder.
• Being unable to reach orgasm.

Less common problems in women include the following:

• Pain or numbness in the genitals.
• Trouble reaching orgasm.

Unlike many other physical side effects of cancer treatment, sexual problems may not get better within the first year or two after cancer treatment. The problems may get worse over time and can get in the way of returning to normal life. That is why it is important to get help with learning to adapt to changes in sexual function.

You and your partner decide what is normal for you.

Sexuality involves both the body and the mind. "Normal" sexual functioning covers a wide range. You and your partner define what is normal for you. Your "normal" may be affected by the following:

• Gender.
• Age.
• Attitudes about sex.
• Religious values.
• Cultural values.

Sexual function can be an important part of your quality of life. Talk with your doctor if you have problems or concerns about your sexual function. If your doctor cannot talk with you about sexual problems, ask for information from other places or for the name of a doctor who is comfortable talking with you about them.

Factors Affecting Sexual Function in Cancer Patients

Certain cancer treatments can affect sexual function.

Surgery

Surgery for the following cancers can cause body changes that have sexual side effects:

• Breast cancer: Sexual function after breast cancer surgery depends on the type of surgery. Compared to surgery to remove the whole breast, surgery to save or reconstruct the breast seems to have little effect on sexual function (including how often women have sex, the ease of reaching orgasm, or overall sexual satisfaction). Women who have surgery to save the breast are more likely to continue to enjoy breast caressing. However, having a mastectomy (surgery to remove part or all of the breast) has been linked to a loss of interest in sex.
• Rectal cancer: Problems with sexual and bladder function are common after surgery for rectal cancer. Surgery for rectal cancer can injure the nerves in the pelvic cavity. Nerves can be damaged when their blood supply is affected or when the nerves are cut. Nerve injury is the main cause of problems with erection, ejaculation, and orgasm.
• Prostate cancer: Surgery for prostate cancer (radical prostatectomy) is being done with newer nerve-sparing techniques. Recovery of erectile function usually happens within a year after having a radical prostatectomy. However, recovery of erectile function after radiation therapy is slow and happens over two or three years. Brachytherapy (internal radiation therapy using radioactive implants) is being used more often to treat prostate cancer. There is less effect on ejaculation and erectile function with brachytherapy alone than when external radiation and/or hormone therapy are added. Many patients have trouble with orgasm after treatment for prostate cancer with radical prostatectomy or radiation therapy. Talk with your doctor about problems with orgasm, changes in penis length, and urinary incontinence during orgasm.
• Testicular cancer: Most studies suggest that problems with sexual function after testicular cancer and its treatment (such as surgery to remove the testicle) are usually short-term. Function usually returns to about the same level as in men who do not have testicular cancer.
• Other pelvic tumors: Men who have surgery to remove the bladder, colon, and/or rectum may get erectile function back sooner if nerve-sparing surgery is used. The sexual side effects of radiation therapy for pelvic tumors are similar to those after prostate cancer treatment. Women who have surgery to remove the uterus, ovaries, bladder, or other organs in the abdomen or pelvis may have pain and loss of sexual function depending on the amount of tissue or organ removed. With counseling and other medical treatments, these patients may get normal sensation back in the vagina and genital areas and be able to have intercourse and reach orgasm without pain.

Chemotherapy

For both men and women, chemotherapy is linked to loss of sexual desire and having intercourse less often. Common side effects of chemotherapy can affect your sexual self-image and make you feel unattractive. Side effects may include the following:

• Nausea.
• Vomiting.
• Diarrhea.
• Constipation.
• Mucositis (sores in the mouth from an inflamed lining of the digestive system).
• Losing or gaining weight.
• Losing hair.
• Changes in taste and smell.

In women, chemotherapy can cause the following problems:

• Pain with intercourse.
• Trouble reaching orgasm.
• Decreased estrogen, which can cause the following problems:
  • Vaginal shrinking, thinning, and loss of elasticity (the ability to stretch and then go back to its original shape).
  • Vaginal dryness.
  • Hot flashes.
  • Urinary tract infections.
  • Mood swings.
  • Feeling very tired.
  • Being easily bothered.

Older women who receive chemotherapy have an increased risk of ovarian cancer.

In men, chemotherapy can cause the following problems:

• Loss of sexual desire.
• Problems making testosterone.

Radiation therapy

Radiation therapy can cause side effects that may decrease sexual desire. Side effects may include the following:

• Feeling very tired.
• Nausea.
• Vomiting.
• Diarrhea.

In women, radiation therapy to the pelvis can cause changes to the lining of the vagina. The vagina may become narrow and scar tissue may form, which can cause pain with intercourse, painful pelvic exams, infertility, and other long-term problems.

In men, radiation therapy can cause problems getting and keeping an erection. Sexual changes happen slowly over six months to one year after radiation therapy. Men who had problems with erectile dysfunction before getting cancer may be more likely to have sexual problems after being diagnosed and treated for cancer.

Other risk factors in men that cause sexual changes include the following:

• Smoking.
• Heart disease.
• High blood pressure.
• Diabetes.

Hormone therapy

Hormone therapy can stop or slow the growth of certain cancers, such as prostate and breast cancer. This is done by using hormones made in a laboratory or other drugs to block the body's natural hormones. However, lower hormone levels can cause sexual problems.

Men who get hormone therapy for prostate cancer may have the following problems:

• Decreased sexual desire.
• Erectile dysfunction.
• Trouble reaching orgasm.

Women older than 45 years who are treated with tamoxifen may have slightly more of the following problems:

• Hot flashes.
• Night sweats.
• Vaginal discharge.
• Vaginal pain.
• Decreased sexual desire.
• Trouble reaching orgasm.

Other drug therapy

Drug therapy, such as opioids for pain and drugs to treat depression, can cause sexual side effects. Cancer patients may get drug therapy that affects the nerves, blood vessels, and hormones that control normal sexual function. Drug therapy may also affect their alertness and moods.

Your thoughts and feelings can affect your sexual function.

Misbeliefs

Misbeliefs about cancer might make you confused or unsure about sex when you are recovering from cancer. Common misbeliefs about cancer include the following:

• Past sexual activities caused the cancer.
• Having sex will make the cancer come back.
• Having sex will pass the cancer on to your partner.

Misbeliefs like these can keep you from enjoying sex again. Talk with your doctor to find out the facts so that you can feel more comfortable.

Depression

Depression is more common in cancer patients than in people who do not have cancer. Common symptoms of depression include loss of sexual desire and a decrease in sexual pleasure. Treatment for depression may lessen your sexual problems. (See the PDQ summary on Depression for more information.)

Self-image

Cancer and cancer treatment may cause physical changes, such as hair loss or weight gain from chemotherapy or body changes from surgery. You may not like how you look and you may not want to have sex. Let your health care team know your concerns. You can get help adjusting to body changes caused by cancer and its treatment.

Patients with colostomies or ileostomies need to find a sexual position that does not place weight on the ostomy. Information is available from national organizations related to sexual function.and ostomates.

Stress

The stress of cancer diagnosis and treatment can make relationship problems that you already have even worse. Your sexual relationship can also be affected. Patients who do not have a committed relationship may stop dating because they fear being rejected when a new partner finds out they have cancer. Your feelings about your sexuality before being diagnosed with cancer will affect adjustment after cancer treatment. If you had positive feelings about sex, you may be more likely to continue sex after cancer treatment. Cancer can be hard on any relationship. It is important to get help if stress is causing a problem for you.

Assessing Sexual Function in Cancer Patients

Your doctor will talk with you to find out what may be causing your sexual problems and how these problems affect your life.

As part of the assessment, your doctor will talk with you alone or with both you and your partner. You may be asked the following questions:

• Do you have any problems or concerns related to sexuality?
• How often do you feel a desire to have sex?
• Do you enjoy sex?
• Do you have enough energy for sex?
• Do you become sexually aroused (for men, are you able to get and keep an erection, or for women, does your vagina expand and become lubricated)?
• Are you able to reach orgasm during sex? What types of stimulation can cause an orgasm (for example, self-touch, use of a vibrator, shower massage, partner caressing, oral stimulation, or intercourse)?
• Do you have pain during sex? Where do you feel the pain? What does the pain feel like? What kinds of sexual activity cause pain? Does this cause pain every time? How long does the pain last?
• When did your sexual problems begin? Was it around the same time that you were diagnosed with cancer or had cancer treatment? Did you have sexual problems before you were diagnosed with cancer?
• Are you taking any medicines? Did you start taking any new medicines or did the doctor change the dose of any medicines around the time that your sexual problems started?

Your doctor may ask questions about your relationship with your partner.

You may be asked the following questions if you have a partner:

• How long were you with your partner before you were diagnosed with cancer?
• How stable was your relationship?
• How did your partner react when you were diagnosed with cancer?
• Are you concerned about how your partner may be affected by your treatment?

You and your partner may have sexual problems and concerns and fears about your relationship. It is important that you and your partner talk about these things with a doctor you feel comfortable with.

Your doctor may also ask you about your lifestyle.

You may be asked the following questions about your lifestyle:

• Do you smoke? If yes, how much and how often do you smoke? If no, have you smoked in the past?
• Do you drink alcohol? If yes, how much and how often?
• Do you take prescription or over-the-counter medicines? If yes, what kinds and how much?

Sexual assessment may include a physical exam and other tests.

The following tests and procedures may be done:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.
• Blood tests: Tests done on a sample of blood to measure the amount of certain substances in the blood or to count different types of blood cells. Blood tests may be done to look for signs of disease or agents that cause disease, to check for antibodies or tumor markers, or to see how well treatments are working.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
• Measurement of nighttime erections: A test to check whether a man is having erections during sleep. If there are good erections during sleep, there is probably no physical cause for his erection problems. Nighttime erections are measured during sleep using the following:
  • Snap gauge: A device made of plastic rings fitted around the penis, which break when there is an erection.
  • Electronic monitoring: A device that records the number of erections that occur and how long and rigid they are.
• Blood hormone studies: A procedure in which a blood sample is checked to measure the amounts of certain hormones released into the blood by organs and tissues in the body. An unusual (higher- or lower-than-normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.

Treatment of Sexual Problems in Cancer Patients

Good communication can help you and your partner continue sex after cancer treatment.

You may be afraid or anxious about having sex after cancer treatment. Fear and anxiety can cause you to avoid intimacy, touch, and sexual activity. Your partner may also be afraid and anxious that starting sexual activity will make you feel pressured or cause you pain. Even when a couple has been together a long time, talking about these things is important. Honest communication of feelings, concerns, and preferences can help.

You can learn ways to adapt to changes in sexual function.

Health professionals who specialize in treating sexual problems can give you the names of organizations that offer support. They can also tell you about educational materials such as Internet sources, books, pamphlets, and DVDs. These resources can help you learn ways to adapt to changes in sexual function.

Counseling may make it easier for you to cope with changes in your body and your sex life after cancer.

Sexual counseling may help you. Counseling may be for you alone, with you and your partner, or in a group.

Medical treatments may help improve sexual function.

You may be helped by medical treatments such as hormone replacement, drugs, medical devices, or surgery.

Fertility Issues

Cancer treatments may cause infertility.

Radiation therapy and chemotherapy may cause infertility (being unable to have children). This may be temporary or permanent. The risk of infertility as a side effect of cancer treatment depends on the following:

• Gender.
• Age at time of treatment.
• Type and dose of radiation therapy and/or chemotherapy.
• Where in the body the radiation is given.
• Whether you had one type of therapy or more than one.
• How long ago you had treatment.

Ask your doctor if your cancer or its treatment may cause infertility or sexual side effects. Your doctor can tell you what changes may happen. A child may be too young to understand issues about infertility or sexuality. Parents can decide what they want their child to know about these issues.

If you are concerned about your ability to have children, find out what you can do before treatment.

Talk to your doctor before treatment if you are concerned about the effects of cancer treatment on your ability to have children. Your doctor can recommend a counselor or fertility specialist who can tell you your options and help you and your partner make a decision. Options may include freezing sperm, eggs, or ovarian tissue before cancer treatment.

Chemotherapy can affect fertility.

The following chemotherapy agents have been shown to affect fertility:

• Busulfan.
• Melphalan.
• Cyclophosphamide.
• Cisplatin.
• Chlorambucil.
• Ifosfamide.
• Mustine.
• Carmustine.
• Lomustine.
• Vinblastine.
• Cytarabine.
• Nitrosoureas.
• Procarbazine.

Fertility is likely to get better the longer you have been off chemotherapy. If you are taking chemotherapy, your age is an important factor. In women older than 40 years, adjuvant hormone therapy increases the risk that chemotherapy will cause infertility.

Radiation therapy to the abdomen or pelvis can cause infertility.

A man's age and the amount of radiation given directly to the testicles affects his risk of infertility. Lower doses of radiation and using lead shields to protect the testicles can help men keep their fertility. Sperm counts usually take 10 to 24 months to return to the level they were before radiation therapy. Usually, the higher the radiation dose, the longer it takes to recover. If the body is not making hormones normally, hormone therapy may help restore fertility. Radiation given to boys who have not reached puberty can cause problems with fertility.

Radiation therapy to the ovaries may cause infertility in women of any age. High doses of radiation in women younger than 26 years may cause early menopause. Lower doses of radiation can cause infertility in women older than 40 years. Regaining fertility is more likely if radiation to the ovaries is given before puberty. Doctors are sometimes able to protect the ovaries during radiation therapy.

Current Clinical Trials

Check NCI's list of cancer clinical trials for U.S. supportive and palliative care trials about sexuality and reproductive issues, sexual dysfunction, fertility assessment and management and cryopreservation that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Changes to This Summary (12 / 09 / 2013)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

This summary was completely reformatted and some content was added.

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Last Revised: 2013-12-09

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