Purpose of This PDQ Summary
The Prevalence and Types of Sexual Dysfunction in People With Cancer
Factors Affecting Sexual Function in People With Cancer

Treatment-Related Factors Secondary to Surgery         Breast cancer         Colorectal cancer         Prostate cancer         Other pelvic tumors Treatment-Related Factors Secondary to Systemic Chemotherapy Treatment-Related Factors Secondary to Radiation Treatment-Related Factors Secondary to Hormone Therapy Psychological Factors

Assessment of Sexual Function in People With Cancer

General Factors Affecting Sexual Functioning Evaluated in Assessment         Current sexual status         Premorbid sexual functioning Psychosocial Aspects of Sexuality         Relationship status         Psychological status Medical Aspects of Sexuality

Pharmacological Effects of Supportive Care Medications on Sexual Function

Effect of Opioids on Sexual Function Selective Serotonin-Reuptake Inhibitors

Treatment of Sexual Problems in People With Cancer
Fertility Issues

Chemotherapy Radiation Preventive Strategies Procreative Alternatives

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Purpose of This PDQ Summary

This PDQ cancer information summary provides comprehensive, peer-reviewed information for health professionals about sexuality and reproductive issues that cancer patients may experience during or after treatment. This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board.

Information about the following is included in this summary:

• Treatment-related factors.
• Assessment.
• Treatment.
• Fertility issues.

This summary is intended as a resource to inform and assist clinicians and other health professionals who care for cancer patients during and after cancer treatment. It does not provide formal guidelines or recommendations for making health care decisions. Information in this summary should not be used as a basis for reimbursement determinations.

This summary is also available in a patient version, which is written in less technical language, and in Spanish.

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The Prevalence and Types of Sexual Dysfunction in People With Cancer

Sexuality is a complex, multidimensional phenomenon that incorporates biologic, psychologic, interpersonal, and behavioral dimensions. It is important to recognize that a wide range of normal sexual functioning exists. Ultimately, sexuality is defined by each patient and his/her partner within a context of factors such as gender, age, personal attitudes, and religious and cultural values.

Many types of cancer and cancer therapies are frequently associated with sexual dysfunction. Across sites, estimates of sexual dysfunction after various cancer treatments have ranged from 40% to 100% posttreatment.[1] Research suggests that about 50% of women who have had breast cancer experience long-term sexual dysfunction,[2,3] as do a similar proportion of women who have had gynecologic cancer.[4] For men with prostate cancer, erectile dysfunction (erections inadequate for intercourse) has been the primary form of sexual dysfunction investigated. Prevalence rates of erectile dysfunction have varied. In general, those studies that have used patients’ self-reports have found higher rates of erectile dysfunction ranging from 60% to 90% after radical prostatectomy and between 67% and 85% following external-beam radiation therapy.[5-8] Erectile dysfunction appears to be least prevalent with brachytherapy and most prevalent when cryotherapy is used to treat localized prostate cancer.[9] For Hodgkin lymphoma and testicular cancer, 25% of people who have had these cancers are left with long-term sexual problems.[3,10] Several articles summarize the literature on sexuality and cancer, with a particular emphasis on cancer sites that have a direct impact on sexual functioning.[11-13]

An individual’s sexual response can be affected in a number of ways, and the causes of sexual dysfunction are often both physiological and psychological. The most common sexual problems for people with cancer are loss of desire for sexual activity in men and women, erectile dysfunction in men, and dyspareunia (pain with intercourse) in women.[3] Men may also experience anejaculation (absence of ejaculation), retrograde ejaculation (ejaculation going backward to the bladder), or the inability to reach orgasm. Women may experience changes in genital sensations due to pain or a loss of sensation and numbness, as well as a decreased ability to reach orgasm. Loss of sensation can be as distressing as painful sensation for some individuals.[14] In women, premature ovarian failure as a result of chemotherapy or pelvic radiation therapy is a frequent antecedent to sexual dysfunction, particularly when hormone replacement is contraindicated because the malignancy is hormonally sensitive.[2] Most often, orgasm remains intact for men and women, though it may be delayed secondary to medications and/or anxiety.

Unlike many other physiological side effects of cancer treatment, sexual problems do not tend to resolve within the first year or two of disease-free survival;[2,7,15-19] rather, they may remain constant and fairly severe. Although it is unclear how much sexual problems influence a survivor’s rating of overall health-related quality of life, these problems are clearly bothersome to many patients and interfere with a return to normal posttreatment life. In a qualitative study of 48 men (130 approached) with erectile dysfunction after treatment for prostate cancer, quality of life was significantly affected, including areas such as the quality of sexual intimacy, everyday interactions with women, sexual fantasy life, and perceptions of their masculinity. Patients who participated in a randomized trial that compared radical prostatectomy with watchful waiting were asked to complete a questionnaire regarding symptoms, psychological functioning, and quality of life. Although the frequency of sexual thoughts was similar in both groups, the prevalence of erectile dysfunction (changes in voluntary erection in sexual situations, erection on awakening, and spontaneous erections) was higher in the radical prostatectomy group (80%) than in the watchful-waiting group (45%). Among men who underwent radical prostatectomy, 56% were moderately or greatly distressed by the decline in sexual function, as compared with 40% of men in the watchful-waiting group.[20,21] Assessment, referral, intervention, and follow-up are important for maximizing quality of life and survival.[2,17]

References

1. Derogatis LR, Kourlesis SM: An approach to evaluation of sexual problems in the cancer patient. CA Cancer J Clin 31 (1): 46-50, 1981 Jan-Feb.  [PUBMED Abstract]
   
   
2. Ganz PA, Rowland JH, Desmond K, et al.: Life after breast cancer: understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16 (2): 501-14, 1998.  [PUBMED Abstract]
   
   
3. Schover LR, Montague DK, Lakin MM: Sexual problems. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1997, pp 2857-2872. 
   
   
4. Andersen BL: Quality of life for women with gynecologic cancer. Curr Opin Obstet Gynecol 7 (1): 69-76, 1995.  [PUBMED Abstract]
   
   
5. Walsh PC, Epstein JI, Lowe FC: Potency following radical prostatectomy with wide unilateral excision of the neurovascular bundle. J Urol 138 (4): 823-7, 1987.  [PUBMED Abstract]
   
   
6. Talcott JA, Rieker P, Clark JA, et al.: Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol 16 (1): 275-83, 1998.  [PUBMED Abstract]
   
   
7. Smith DS, Carvalhal GF, Schneider K, et al.: Quality-of-life outcomes for men with prostate carcinoma detected by screening. Cancer 88 (6): 1454-63, 2000.  [PUBMED Abstract]
   
   
8. Stanford JL, Feng Z, Hamilton AS, et al.: Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 283 (3): 354-60, 2000.  [PUBMED Abstract]
   
   
9. Robinson JW, Moritz S, Fung T: Meta-analysis of rates of erectile function after treatment of localized prostate carcinoma. Int J Radiat Oncol Biol Phys 54 (4): 1063-8, 2002.  [PUBMED Abstract]
   
   
10. Arai Y, Kawakita M, Okada Y, et al.: Sexuality and fertility in long-term survivors of testicular cancer. J Clin Oncol 15 (4): 1444-8, 1997.  [PUBMED Abstract]
    
    
11. Auchincloss SS: Sexual dysfunction in cancer patients: issues in evaluation and treatment. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 383-413. 
    
    
12. Lamb MA: Sexuality and Sexual Functioning. In: McCorkle R, Grant M, Frank-Stromborg M, et al., eds.: Cancer Nursing: A Comprehensive Textbook. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1996, pp 1105-1127. 
    
    
13. Ofman US, Auchincloss SS: Sexual dysfunction in cancer patients. Curr Opin Oncol 4 (4): 605-13, 1992.  [PUBMED Abstract]
    
    
14. Havenga K, Maas CP, DeRuiter MC, et al.: Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer. Semin Surg Oncol 18 (3): 235-43, 2000 Apr-May.  [PUBMED Abstract]
    
    
15. Fosså SD, Woehre H, Kurth KH, et al.: Influence of urological morbidity on quality of life in patients with prostate cancer. Eur Urol 31 (Suppl 3): 3-8, 1997.  [PUBMED Abstract]
    
    
16. Helgason AR, Adolfsson J, Dickman P, et al.: Factors associated with waning sexual function among elderly men and prostate cancer patients. J Urol 158 (1): 155-9, 1997.  [PUBMED Abstract]
    
    
17. Litwin MS, Hays RD, Fink A, et al.: Quality-of-life outcomes in men treated for localized prostate cancer. JAMA 273 (2): 129-35, 1995.  [PUBMED Abstract]
    
    
18. Relander T, Cavallin-Ståhl E, Garwicz S, et al.: Gonadal and sexual function in men treated for childhood cancer. Med Pediatr Oncol 35 (1): 52-63, 2000.  [PUBMED Abstract]
    
    
19. Broeckel JA, Thors CL, Jacobsen PB, et al.: Sexual functioning in long-term breast cancer survivors treated with adjuvant chemotherapy. Breast Cancer Res Treat 75 (3): 241-8, 2002.  [PUBMED Abstract]
    
    
20. Steineck G, Helgesen F, Adolfsson J, et al.: Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 347 (11): 790-6, 2002.  [PUBMED Abstract]
    
    
21. Bokhour BG, Clark JA, Inui TS, et al.: Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction". J Gen Intern Med 16 (10): 649-55, 2001.  [PUBMED Abstract]
    
    

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Factors Affecting Sexual Function in People With Cancer

Sexual dysfunction may be multifactorial; both physical and psychological factors contribute to its development. Physical factors include functional damage secondary to cancer therapies, fatigue, and pain. In addition, cancer therapy such as surgery, chemotherapy, radiation therapy, and bone marrow transplantation may have a direct physiologic impact on sexual function.[1] Medications used to treat pain, depression, and other symptoms may contribute to sexual dysfunction. Psychological factors include misbeliefs about the origin of the cancer, guilt related to these misbeliefs, coexisting depression, changes in body image after surgery, and stresses to personal relationships that occur secondary to cancer.[2,3] Increasing age is often believed to be associated with decreased sexual desire and performance; however, in one study, elderly men reported that sex remains important to their quality of life, that performance can be maintained into the 70s and 80s, and that altered sexual function is distressing.[4]

A number of cancer treatments have a direct physiologic impact on sexual function. As treatment success has improved for some sites, attempts have been made to modify treatment to reduce sexual morbidity. Several predictors of postoperative sexual functioning include patient’s age, premorbid sexual and bladder functioning, tumor location, tumor size, and extent of surgical resection.

Sexual function after localized treatment for breast cancer has been the subject of a good deal of research. Several reviews concur that breast conservation or reconstruction have only a minor impact in preserving sexual function compared with a mastectomy alone.[5,6] Women who have breast conservation, in particular, are more likely to continue to enjoy breast caressing, but groups typically do not differ on less subtle variables such as the frequency of sex, ease of reaching orgasm, or overall sexual satisfaction. A cross-sectional survey of younger women (aged 50 years or younger) with breast cancer found in multivariate analyses that having a mastectomy was associated with greater problems in interest in sex; chemotherapy was associated with greater sexual dysfunction.[7] Other studies confirm that sexual quality of life is disrupted more among those receiving chemotherapy, those who have undergone total mastectomies, those whose cancers were detected at later stages, and those with more depressive symptoms near the time of diagnosis.[8] Adjuvant tamoxifen therapy increases the rate of hot flashes, night sweats, and vaginal discharge, and increases the risk of premature menopause in women older than 45 years by approximately 10%. Furthermore, though rates of sexual activity with a partner did not decline, women taking tamoxifen reported slightly increased rates of difficulty with sexual arousal and achieving orgasm.[9,10]

Few studies evaluate sexuality in women with breast cancer that recurs. One longitudinal study compared women who were recently diagnosed with recurrent cancer with matched patients who were disease free. The recurrence group had less frequent intercourse, although there were no differences in sexual or relationship satisfication. As noted in other studies of women with breast cancer, sexual changes were more common among younger patients.[11]

Sexual and urinary dysfunctions are recognized complications of resection for rectal cancer. The main cause of sexual dysfunction from surgical resection appears to be injury to the autonomic nerves in the pelvis along the distal aorta from blunt pelvic resection or undefined cutting. Incidence of genitourinary dysfunction depends on the type of surgery performed (i.e., the plane of dissection, the degree of preservation of the autonomic nerves, and the extent of pelvic dissection).[12,13] Nerve injury can occur via direct injury, by vascular damage to the vasa nervosa, or where the blood supply to the nerves that enter laterally is disrupted with traction or devascularization.[14]

The neuroanatomy for sexual functioning requires an intact autonomic nervous system, which includes an interaction between the parasympathetic and sympathetic nervous systems. Erection (parasympathetic-mediated response) is governed by impulses traveling along the nervi erigentes that arise from the second, third, and fourth sacral nerves,[15] whereas ejaculation depends on sympathetic control. The sympathetic fibers originate from the lower thoracic and upper lumbar segments of the spinal cord. These fibers descend along the aorta, forming the superior hypogastric plexus near the aortic bifurcation. The plexus divides into two trunks, which enter the pelvis along its lateral walls as the hypogastric nerves. The parasympathetic fibers to the pelvis join the hypogastric nerves on each pelvic wall to form the pelvic plexuses.[15] One study provided a more extensive review of the anatomy of the pelvic autonomic nerves and the relation of these nerves to the mesorectal fascial planes.[16] Damage to the hypogastric (sympathetic) nerves or sacral splanchnic (parasympathetic) nerves, or both, during surgical resection are the most likely cause of urinary and sexual dysfunction.[17] Pelvic plexus preservation is necessary to maintain erectile functioning, and both hypogastric nerve and pelvic plexus preservation are necessary to maintain ejaculate function and orgasm.[18]

In men, there is controversy whether the newer nerve-sparing technique for radical prostatectomy is more or less successful in preserving erectile function than definitive radiation therapy for localized prostate cancer. A 1994 survey of practice patterns found that 95% of randomly-sampled urologists considered surgery the treatment of choice for clinically localized prostate cancer in men younger than 70 years.[19] As follow-up studies of large groups of men undergoing radical prostatectomy have accumulated, estimates of the number who recover functional erections (firm enough to allow penile-vaginal penetration on most occasions) range from 10% to 40%, with estimates of functional erections following external-beam radiation therapy ranging from 15% to 33%.[20-24] Retrospective cohort studies have provided evidence indicating superior potency results with bilateral nerve-sparing surgical techniques.[25,26] One research group suggested that much of the superiority of nerve-sparing over standard surgical technique in preserving potency is an artifact of selection bias.[27] The men selected to receive nerve-sparing surgery are those with the best potential to recover adequate erections. A systematic literature review using MEDLINE and CANCERLIT from January 1997 to June 2003 concluded that patient selection and surgical technique are the major determinants of postoperative erectile function in patients receiving treatment for localized prostate cancer. For properly selected patients undergoing a nerve-sparing radical prostatectomy by an experienced surgeon, unassisted or medically assisted erections postoperatively should be achieved.[28]

Other studies suggest that three-dimensional conformational radiation therapy may be superior to radical prostatectomy in preserving erectile function.[21,29-34] Rates of potency are typically in the 30% to 60% range, with conformal therapy superior to older techniques.[21,35-37] Men who are older and in poor health, however, are often directed into radiation therapy, so that researchers often report posttreatment sexual function only for the subgroup that began with good erections. Furthermore, long-term follow-up is needed in comparing surgery with radiation therapy because recovery of erectile function typically occurs within a year or so after radical prostatectomy, whereas the damaging impact of radiation on erectile function is slow and gradual, with declines still being observed as long as 2 or 3 years after treatment. A retrospective cohort study of men treated with either radical prostatectomy or external-beam radiation therapy (EBRT) revealed significantly greater prevalence of erectile dysfunction in the surgery group at 5 years after diagnosis (79.3% vs. 63.5%).[38] The mechanism of injury to erectile function also differs between surgery and radiation therapy. Radical prostatectomy damages nerves that direct blood flow into the penis, ultimately decreasing oxygenation of these tissues and increasing collagen deposits that interfere with the penile tissue relaxation essential for firm erection.[39] Radiation therapy appears to damage the arterial system that transports blood to the penis.[40] A retrospective review of population-based data suggests that the choice of primary treatment for prostate cancer is not associated with 2-year general health-related quality-of-life outcomes.[41]

Prostate brachytherapy with permanent radioactive implants is an increasingly popular choice for the treatment of prostate cancer. Two isotopes are commonly used: iodine 125 (¹²⁵I) and palladium 103 (¹⁰³Pd).[42] With brachytherapy, ejaculation is preserved and age (91% of men younger than 50 years) correlates with return of sexual function.[43] However, a decline in potency as a function of time following treatment is expected in patients treated with brachytherapy.[42] One study found an actuarial preservation of potency after brachytherapy alone of 79% at 3 years and 59% at 6 years.[44] Another study found lower rates, with 57% of men fully potent or with mild erectile dysfunction at baseline remaining so at 30 months postbrachytherapy.[45] Potency rates after brachytherapy are significantly influenced by the addition of EBRT and/or neoadjuvant hormonal deprivation. Patients who received brachytherapy alone had a 5-year potency rate of 76%, compared with a potency rate of 56% for those treated with brachytherapy and EBRT. Patients who received a combination of EBRT, neoadjuvant hormonal deprivation, and brachytherapy had a 5-year potency rate of 29%.[42]

The etiology of erectile dysfunction following brachytherapy is unknown; however, radiation damage to nerve bundles and vascular structures has been proposed as a cause.[42] One study investigated retrospectively the relationships between the dose of radiation to structures putatively involved in prostate brachytherapy–induced erectile dysfunction and incidence of postbrachytherapy erectile dysfunction. This study found no increased risk of erectile dysfunction with increasing dose to the crus or neurovascular bundle, proposing a possible dose-response relationship between the risk of erectile dysfunction and radiation dose to the bulb.[46]

Nerve-sparing approaches to surgery appear to enhance recovery of erections at least to some degree after radical cystectomy [47,48] and colorectal surgery.[49,48] Although the sexual side effects of definitive radiation therapy for pelvic malignancies other than prostate cancer have not been well researched, outcomes similar to those after prostate cancer treatment would be expected when the dosage and field affect the pelvic vascular bed.

Pelvic surgeries in women include hysterectomy/oophorectomy, cystectomy, vulvectomy, and abdominoperineal resection and often involve removal of a portion of the vagina or other parts of the female genital anatomy. Older studies indicated that few women reported dyspareunia or loss of orgasmic capacity after radical hysterectomy;[50,51] however, a newer prospective study of women with early-stage cervical carcinoma who had undergone radical hysterectomy compared with control women reported severe orgasmic problems and uncomfortable sexual intercourse due to reduced vaginal size during the first 6 months after surgery. Throughout the first 2 years after surgery, the women reported persistent lack of sexual interest and lubrication.[52] Radical cystectomy for bladder cancer is more often associated with pain from reduced vaginal depth and caliber resulting from resection of the entire anterior vaginal wall. These patients may resume pain-free intercourse, normal sensation, and orgasm with the help of counseling, hormone therapy, and use of vaginal dilators.[53] Conservation of vaginal tissue may reduce some of these problems. Decreased morbidity has been reported from sparing of vulvar tissue with a partial vulvectomy versus radical vulvectomy, yet the amount of tissue resected has not been a good predictor of postoperative sexual satisfaction.[54] Rather, it is the quality of a woman’s relationship with her partner that correlates with sexual function.[55] Women who undergo abdominoperineal resection may also report pain with intercourse related to loss of cushioning from removal of the posterior vaginal wall. In addition, pelvic adhesions or scarring may contribute to dyspareunia after an anterior/posterior resection. Radical resection of recurrent pelvic tumors in women (pelvic exenteration) involves partial or complete removal of the vagina and levator muscles. Vaginal reconstruction produces satisfactory function and aesthetic results in some patients.[56]

Chemotherapy is associated with loss of desire and decreased frequency of intercourse for both men and women. Common side effects experienced after chemotherapy include nausea, vomiting, diarrhea, constipation, mucositis, weight changes (gain or loss), and altered sense of taste and smell.[3] These symptoms often leave individuals feeling asexual. Alopecia is often one of the most distressing side effects with associated changes in body image.[57] Loss of pubic hair can also be particularly uncomfortable, which, in turn, promotes asexual feelings.

For women, cytotoxic agents are associated with vaginal dryness, dyspareunia, reduced ability to reach orgasm, and for older women, greater risk of ovarian cancer.[3,58-60] Premature ovarian failure secondary to chemotherapy or radiation brings the sudden onset of menopausal symptoms, and women who experience sudden loss of estrogen and androgen production from the ovaries experience a number of associated sexual changes. Sexual symptoms associated with estrogen deprivation include vaginal atrophy, thinning of the vulvar tissues and vagina, loss of tissue elasticity, decreased vaginal lubrication, hot flashes, increased frequency of urinary tract infections, mood swings, fatigue, and irritability. In addition, for younger women with breast cancer, menopausal symptoms as a result of therapy contribute to poorer health perception and quality of life.[61] A study of the psychosocial aspects of the transitional period between the end of primary breast cancer treatment and survivorship enrolled 558 women. They were treated with surgery (either mastectomy or lumpectomy) with and without chemotherapy, and the health outcomes examined included physical, emotional, and sexual functioning, as well as mood and symptoms. Sexual functioning was worse for women who received chemotherapy, regardless of the type of prior surgery (i.e., mastectomy or lumpectomy). These problems with sexual function were likely related to problems with vaginal lubrication and a change in menopausal status, both of which are more common in those receiving chemotherapy.[62] Because of concerns over causing recurrence of breast cancer, hormone replacement therapy is often not recommended for women who have become menopausal during treatment.[63]

In women with malignancies of other types, however, estrogen replacement therapy can usually reverse many sexual problems. Providers should discuss with women the risks and benefits of hormone replacement therapy with consideration of each women’s individual risk profile. The impact of menopause on sexual functioning and the arousal phase of the sexual response in particular are often not communicated to women who struggle to understand these changes in their sexual responsiveness. Women who have graft-versus-host disease (GVHD) after bone marrow transplantation may develop vaginal strictures and adhesions that interfere with intercourse.[64]

For men, chemotherapy agents rarely play an obvious role in erectile dysfunction.[3] Some cytotoxic agents may cause nerve damage, but few reports indicate permanent loss of erections upon completion of treatment. Sexual dysfunction, including loss of desire and erectile dysfunction, is more common after bone marrow transplant, often associated with autonomic neuropathy or GVHD.[65,66] Systemic chemotherapy in men occasionally interferes with testosterone production in the testicles.[67] For those men who have damage to the testicles from chemotherapy, testosterone replacement may be necessary to restore sexual function.[3] More rarely, neurotoxic chemotherapies have been observed to interfere with ejaculation of semen at orgasm, presumably because of damage to autonomic nerves involved in the contractions of the prostate, seminal vesicles, and bladder neck.[68]

Like chemotherapy, radiation can produce side effects such as fatigue, nausea and vomiting, diarrhea, and other symptoms that can reduce feelings of sexuality. In particular, pelvic radiation often irritates the intestinal lining and may cause diarrhea. The fatigue and change in bowel habits associated with radiation likely contribute to loss of libido and decreased sexual activity reported for both men and women.

For women, pelvic radiation also causes changes in the vagina. Both external-beam radiation and implants damage the vaginal epithelium and basal layer of the mucosa, leading to vaginal stenosis and vascular fibrosis. These factors can then lead to long-term sexual dysfunction, painful pelvic examinations, dyspareunia, potential gonadal toxicity, infertility, and low-birth-weight pregnancy outcomes in survivorship.[69,70] A longitudinal prospective study of sexual function and vaginal changes after radiation therapy for cervical cancer found persistent sexual dysfunction and adverse vaginal changes throughout the 2 years after radiation therapy during which the women were followed; 85% had low or no sexual interest, 35% reported moderate to severe lack of lubrication, 55% had mild to severe dysfunction, and 30% were dissatisfied with their sexual life.[71] Women who receive radiation should be educated regarding the use of vaginal dilators. Vascular compromise can be temporary or permanent.[72] For men with rectal cancer, pelvic radiation has been associated with difficulties attaining or maintaining erection.[73,74] The exact etiology of sexual dysfunction after radiation therapy remains unknown [14] but likely relates to arterial damage of the penile arteries, limiting blood flow needed for successful erection.[40] Proposed etiologies include pudendal or sympathetic nerve injury, vascular occlusion of penile arteries, or decreased levels of testosterone. Often, sexual changes are insidious, with changes occurring from 6 months to 1 year after radiation as fibrosis develops. There is a greater risk of sexual morbidity in men who already have compromised quality of erections before cancer diagnosis. Other risk factors that contribute to greater risk of sexual morbidity include cigarette smoking, history of heart disease, hypertension, pretreatment potency, and/or diabetes.[75]

Hormone therapy for prostate cancer involves reducing circulating androgens as close to zero as possible. Because androgens also act in the brain to promote sexual desire, about 80% of men report a profound decrease in sexual interest, typically accompanied by erectile dysfunction and difficulty reaching orgasm.[76-79] Younger men, however, are sometimes able to continue adequate sexual function. With an increasing number of younger men diagnosed with asymptomatic but advanced prostate cancer found through prostate specific antigen (PSA) screening, more attention has been given to preventing some of the sexual morbidity of treatment. Some centers have experimented with delaying hormone therapy until the onset of symptoms,[80] giving intermittent hormone therapy as needed to suppress PSA,[81] or using a combination of finasteride and an androgen-receptor blocker instead of hormone treatments that totally eliminate androgen production.[82] It is not yet clear, however, whether men who try these modified treatment regimens are compromising the length of their survival.

Tamoxifen for breast cancer, described as an antiestrogenic drug, actually acts like a weak estrogen in the genital tract.[83] The medication has anecdotally been reported to be associated with vaginal dryness and excessive vaginal lubrication, soreness, as well as occasional decrease in sexual desire and orgasmic delay.[84,10] The results of the few studies to examine women’s actual sexual function while taking tamoxifen are not conclusive or easily compared because each study utilized different measures and statistical analyses. One study found no difference in reported sexual problems among women taking tamoxifen and women who received no systemic therapy, when adjusted for age.[6] Another study similarly found no significant effect of tamoxifen on sexual functioning utilizing a different measure and examining the effect only in women aged 50 years and older.[63] Another study found that use of tamoxifen did not make a significant independent contribution to the prediction of impact on sexuality.[85] Results from a study with a limited sample size of women taking tamoxifen, however, noted a differential estrogen effect by age, such that an estrogen effect was seen on the vaginal smears of 34 of 49 participants and was more common in older patients (P = .054). The presence of an estrogen effect was correlated with negative reactions during sex (P = .02) and vaginal dryness or tightness (P = .046). This study raised the possibility that tamoxifen may have antagonist effects on the vagina of younger women and estrogen agonist effects on postmenopausal women.[86] Prospective study of sexual functioning with evaluation of physiologic status (e.g., vaginal mucosa and hormone levels) before and after introduction of systemic therapy continues to be warranted. The impact of tamoxifen on sexuality and mood is still not clearly understood.

Loss of interest in sex is likely to be secondary to psychological factors. It is not uncommon for both men and women to believe, though incorrectly, that past sexual activity, an extramarital affair, sexually transmitted disease, or abortion has caused their cancer. Some believe, again incorrectly, that sexual activity may promote a recurrence of their tumor. This misbelief is especially common in individuals with a malignancy of the pelvic or genital area. These individuals may need reassurance that cancer is not transmissible via sexual contact. Women with squamous cell carcinoma of the cervix have often read or been told that this cancer is associated with the sexually transmitted human papillomavirus.[87] Guilt about past sexual activity or concern about potential harm to a partner are issues that should be addressed in these patients. The health care provider can clarify that it is the virus and not the cancer that is transmissible through sexual contact.

Loss of sexual desire or a decrease in sexual pleasure is a common symptom of depression. Depression is 15% to 25% more prevalent in patients with cancer than in the healthy population;[88] therefore, an assessment to rule out depression is an important part of evaluating sexual dysfunction. Sometimes people present with complaints of sexual dysfunction, feeling less stigmatized having a physical medical problem than they do by acknowledging that they are depressed. Treating depression can be helpful in alleviating sexual dysfunction. Attention should be paid to the sexual side effects of antidepressants in clinical decision making. (Refer to the PDQ summary on Depression for more information.)

Changes in body image may interfere with sexual desire in some cancer survivors, but the impact of disfiguring cancer treatments, such as mastectomy, has been exaggerated. For example, breast conservation may result in better self-rated physical attractiveness in women compared with mastectomy alone, but these groups of women do not differ in their sexual activity or satisfaction. On the other hand, weight gain after chemotherapy for breast cancer may be underestimated as a factor that decreases a woman’s feelings of attractiveness.[89] Having an ostomy for elimination of stool or urine can also affect a man’s or woman’s sense of being sexually attractive. Specific coping strategies have been suggested to overcome these problems.[90]

The stress of cancer diagnosis and ongoing therapy can exacerbate underlying marital tensions. This can likewise affect the sexual relationship. Men or women who do not have a committed relationship also have to face the potential trauma of being rejected by a new partner who learns about his or her history of cancer.[3] Some avoid all dating relationships out of fear of such rejection. One premorbid personality factor that may play a role in whether a man or woman stays sexually active after cancer is the sexual self-schema (i.e., whether an individual regards his or her own sexuality in a positive light). Women with negative sexual self-schemas were less likely to resume sex or have good sexual function after treatment for gynecological cancer.[91] One of the most important factors in adjusting after cancer is the person’s feelings about his or her sexuality before cancer. That does not mean, however, that this is not a good opportunity to help a person explore those issues.

References

1. Watson M, Wheatley K, Harrison GA, et al.: Severe adverse impact on sexual functioning and fertility of bone marrow transplantation, either allogeneic or autologous, compared with consolidation chemotherapy alone: analysis of the MRC AML 10 trial. Cancer 86 (7): 1231-9, 1999.  [PUBMED Abstract]
   
   
2. Schover LR, Montague DK, Lakin MM: Sexual problems. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1997, pp 2857-2872. 
   
   
3. Schover LR: Sexuality and Fertility After Cancer. New York, NY: John Wiley and Sons, 1997. 
   
   
4. Helgason AR, Adolfsson J, Dickman P, et al.: Sexual desire, erection, orgasm and ejaculatory functions and their importance to elderly Swedish men: a population-based study. Age Ageing 25 (4): 285-91, 1996.  [PUBMED Abstract]
   
   
5. Schover LR: Sexuality and body image in younger women with breast cancer. J Natl Cancer Inst Monogr (16): 177-82, 1994.  [PUBMED Abstract]
   
   
6. Schover LR, Yetman RJ, Tuason LJ, et al.: Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustment, body image, and sexuality. Cancer 75 (1): 54-64, 1995.  [PUBMED Abstract]
   
   
7. Avis NE, Crawford S, Manuel J: Psychosocial problems among younger women with breast cancer. Psychooncology 13 (5): 295-308, 2004.  [PUBMED Abstract]
   
   
8. Beckjord E, Campas BE: Sexual quality of life in women with newly diagnosed breast cancer. J Psychosoc Oncol 25 (2): 19-36, 2007.  [PUBMED Abstract]
   
   
9. Ganz PA: Impact of tamoxifen adjuvant therapy on symptoms, functioning, and quality of life. J Natl Cancer Inst Monogr (30): 130-4, 2001.  [PUBMED Abstract]
   
   
10. Mourits MJ, Böckermann I, de Vries EG, et al.: Tamoxifen effects on subjective and psychosexual well-being, in a randomised breast cancer study comparing high-dose and standard-dose chemotherapy. Br J Cancer 86 (10): 1546-50, 2002.  [PUBMED Abstract]
    
    
11. Andersen BL, Carpenter KM, Yang HC, et al.: Sexual well-being among partnered women with breast cancer recurrence. J Clin Oncol 25 (21): 3151-7, 2007.  [PUBMED Abstract]
    
    
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34. Robinson JW, Dufour MS, Fung TS: Erectile functioning of men treated for prostate carcinoma. Cancer 79 (3): 538-44, 1997.  [PUBMED Abstract]
    
    
35. Beard CJ, Propert KJ, Rieker PP, et al.: Complications after treatment with external-beam irradiation in early-stage prostate cancer patients: a prospective multiinstitutional outcomes study. J Clin Oncol 15 (1): 223-9, 1997.  [PUBMED Abstract]
    
    
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37. Roach M 3rd, Chinn DM, Holland J, et al.: A pilot survey of sexual function and quality of life following 3D conformal radiotherapy for clinically localized prostate cancer. Int J Radiat Oncol Biol Phys 35 (5): 869-74, 1996.  [PUBMED Abstract]
    
    
38. Potosky AL, Davis WW, Hoffman RM, et al.: Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: the prostate cancer outcomes study. J Natl Cancer Inst 96 (18): 1358-67, 2004.  [PUBMED Abstract]
    
    
39. 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. J Urol 158 (4): 1408-10, 1997.  [PUBMED Abstract]
    
    
40. Zelefsky MJ, Eid JF: Elucidating the etiology of erectile dysfunction after definitive therapy for prostatic cancer. Int J Radiat Oncol Biol Phys 40 (1): 129-33, 1998.  [PUBMED Abstract]
    
    
41. Penson DF, Feng Z, Kuniyuki A, et al.: General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Results from the prostate cancer outcomes study. J Clin Oncol 21 (6): 1147-54, 2003.  [PUBMED Abstract]
    
    
42. Woolsey J, Miller N, Theodorescu D: Permanent interstitial brachytherapy for prostate cancer: a current review. World J Urol 21 (4): 209-19, 2003.  [PUBMED Abstract]
    
    
43. Ravery V: Brachytherapy versus radical prostatectomy. BJU Int 87 (2): 141-3, 2001.  [PUBMED Abstract]
    
    
44. Stock RG, Kao J, Stone NN: Penile erectile function after permanent radioactive seed implantation for treatment of prostate cancer. J Urol 165 (2): 436-9, 2001.  [PUBMED Abstract]
    
    
45. Ponholzer A, Oismüller R, Somay C, et al.: The effect on erectile function of 103palladium implantation for localized prostate cancer. BJU Int 95 (6): 847-50, 2005.  [PUBMED Abstract]
    
    
46. Wright JL, Newhouse JH, Laguna JL, et al.: Localization of neurovascular bundles on pelvic CT and evaluation of radiation dose to structures putatively involved in erectile dysfunction after prostate brachytherapy. Int J Radiat Oncol Biol Phys 59 (2): 426-35, 2004.  [PUBMED Abstract]
    
    
47. Marshall FF, Mostwin JL, Radebaugh LC, et al.: Ileocolic neobladder post-cystectomy: continence and potency. J Urol 145 (3): 502-4, 1991.  [PUBMED Abstract]
    
    
48. Kessler TM, Burkhard FC, Studer UE: Clinical indications and outcomes with nerve-sparing cystectomy in patients with bladder cancer. Urol Clin North Am 32 (2): 165-75, 2005.  [PUBMED Abstract]
    
    
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52. Jensen PT, Groenvold M, Klee MC, et al.: Early-stage cervical carcinoma, radical hysterectomy, and sexual function. A longitudinal study. Cancer 100 (1): 97-106, 2004.  [PUBMED Abstract]
    
    
53. Schover LR, von Eschenbach AC: Sexual function and female radical cystectomy: a case series. J Urol 134 (3): 465-8, 1985.  [PUBMED Abstract]
    
    
54. Andersen BL, Turnquist D, LaPolla J, et al.: Sexual functioning after treatment of in situ vulvar cancer: preliminary report. Obstet Gynecol 71 (1): 15-9, 1988.  [PUBMED Abstract]
    
    
55. Weijmar Schultz WC, van de Wiel HB, Bouma J, et al.: Psychosexual functioning after the treatment of cancer of the vulva. A longitudinal study. Cancer 66 (2): 402-7, 1990.  [PUBMED Abstract]
    
    
56. Mirhashemi R, Averette HE, Lambrou N, et al.: Vaginal reconstruction at the time of pelvic exenteration: a surgical and psychosexual analysis of techniques. Gynecol Oncol 87 (1): 39-45, 2002.  [PUBMED Abstract]
    
    
57. Fobair P, Stewart SL, Chang S, et al.: Body image and sexual problems in young women with breast cancer. Psychooncology 15 (7): 579-94, 2006.  [PUBMED Abstract]
    
    
58. Broeckel JA, Thors CL, Jacobsen PB, et al.: Sexual functioning in long-term breast cancer survivors treated with adjuvant chemotherapy. Breast Cancer Res Treat 75 (3): 241-8, 2002.  [PUBMED Abstract]
    
    
59. Morales L, Neven P, Timmerman D, et al.: Acute effects of tamoxifen and third-generation aromatase inhibitors on menopausal symptoms of breast cancer patients. Anticancer Drugs 15 (8): 753-60, 2004.  [PUBMED Abstract]
    
    
60. Burwell SR, Case LD, Kaelin C, et al.: Sexual problems in younger women after breast cancer surgery. J Clin Oncol 24 (18): 2815-21, 2006.  [PUBMED Abstract]
    
    
61. Ganz PA, Greendale GA, Petersen L, et al.: Breast cancer in younger women: reproductive and late health effects of treatment. J Clin Oncol 21 (22): 4184-93, 2003.  [PUBMED Abstract]
    
    
62. Ganz PA, Kwan L, Stanton AL, et al.: Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial. J Natl Cancer Inst 96 (5): 376-87, 2004.  [PUBMED Abstract]
    
    
63. Ganz PA, Rowland JH, Desmond K, et al.: Life after breast cancer: understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16 (2): 501-14, 1998.  [PUBMED Abstract]
    
    
64. Schubert MA, Sullivan KM, Schubert MM, et al.: Gynecological abnormalities following allogeneic bone marrow transplantation. Bone Marrow Transplant 5 (6): 425-30, 1990.  [PUBMED Abstract]
    
    
65. Baruch J, Benjamin S, Treleaven J, et al.: Male sexual function following bone marrow transplantation. Bone Marrow Transplant 7 (Suppl 2): 52, 1991.  [PUBMED Abstract]
    
    
66. Wingard JR, Curbow B, Baker F, et al.: Sexual satisfaction in survivors of bone marrow transplantation. Bone Marrow Transplant 9 (3): 185-90, 1992.  [PUBMED Abstract]
    
    
67. Gradishar WJ, Schilsky RL: Effects of cancer treatment on the reproductive system. Crit Rev Oncol Hematol 8 (2): 153-71, 1988.  [PUBMED Abstract]
    
    
68. Nijman JM, Schraffordt Koops H, Oldhoff J, et al.: Sexual function after surgery and combination chemotherapy in men with disseminated nonseminomatous testicular cancer. J Surg Oncol 38 (3): 182-6, 1988.  [PUBMED Abstract]
    
    
69. Green DM, Whitton JA, Stovall M, et al.: Pregnancy outcome of female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Am J Obstet Gynecol 187 (4): 1070-80, 2002.  [PUBMED Abstract]
    
    
70. Frumovitz M, Sun CC, Schover LR, et al.: Quality of life and sexual functioning in cervical cancer survivors. J Clin Oncol 23 (30): 7428-36, 2005.  [PUBMED Abstract]
    
    
71. Jensen PT, Groenvold M, Klee MC, et al.: Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys 56 (4): 937-49, 2003.  [PUBMED Abstract]
    
    
72. Lamb MA: Sexuality and Sexual Functioning. In: McCorkle R, Grant M, Frank-Stromborg M, et al., eds.: Cancer Nursing: A Comprehensive Textbook. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1996, pp 1105-1127. 
    
    
73. Marijnen CA, van de Velde CJ, Putter H, et al.: Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 23 (9): 1847-58, 2005.  [PUBMED Abstract]
    
    
74. Heriot AG, Tekkis PP, Fazio VW, et al.: Adjuvant radiotherapy is associated with increased sexual dysfunction in male patients undergoing resection for rectal cancer: a predictive model. Ann Surg 242 (4): 502-10; discussion 510-1, 2005.  [PUBMED Abstract]
    
    
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Assessment of Sexual Function in People With Cancer

No clear guidelines address sexuality during the stages of disease and its treatment. When therapeutic decisions are being made, providers should offer education and information to patients, ideally with the partner present, regarding known risks of sexual morbidity associated with cancer treatments. Oncology professionals should assist patients and their partners by asking specific open-ended questions to validate the importance of sexual health concerns, thus providing an environment in which the patient and couple are encouraged and feel safe to express personal concerns. Assessment should be sensitive to the subtle ways in which changes in sexual function affect men’s self-image and masculine identity.[1] Providers should examine their own thoughts and feelings regarding sexuality. When providers are not comfortable addressing issues of sexuality, their patient’s concerns should not be ignored or dismissed. Referrals should be offered to alternate resources. Although some patients may not want to discuss their sexual health, providers should at least offer the option, conveying that sex is an appropriate topic to cover during future visits.

Because sexual function is one important aspect of quality of life, the follow-up oncology visit is a key opportunity for health care providers to assess whether a cancer patient is experiencing sexual problems. Although it would be ideal if an oncologist carried out the sexual assessment, time constraints and lack of training or comfort in discussing sexual issues often interfere with this goal. Furthermore, many people who have finished their cancer treatment have their routine follow-up care with a primary practitioner rather than an oncology specialist. At least in oncology settings, it may be helpful to designate and train a member of the team, such as an oncology nurse or social worker, as the expert on sexuality issues. That provider can take responsibility for asking about a variety of quality-of-life issues, including relationships and sexuality. A minimal sexual assessment might consist of asking the following question: “Many cancer survivors notice changes or problems in their sex lives after cancer treatment. Do you have any problems or concerns related to sexuality?” Simple problems can be handled with immediate reassurance or advice, but the oncology team should also build a network of specialists willing to help cancer patients with sexual issues, including mental health professionals trained in sex therapy, gynecologists familiar with women’s concerns about hormone replacement or dyspareunia, urologists who specialize in treating male sexual dysfunction, and infertility specialists who can treat younger patients who are interested in having children.

The literature contains a number of articles and resources that address sexual assessment,[2] with many specific to cancer patients.[2-5] The Kaplan model provides a useful interview guide to evaluate sexual problems in healthy and medically ill individuals, focusing on the chief complaint, sexual status, psychiatric status, family and psychosocial history, relationship assessment, summary and recommendations.[6] Kaplan’s model has been applied to oncology settings, with brief descriptions of the assessment for each part of the interview.[3,7] The PLISSIT (permission, limited information, specific suggestions, and intensive therapy) model [8] is another model of assessment and intervention commonly used as a framework for sexual rehabilitation in cancer care and medical illness.[5,9-12]

Once a possible sexual problem has been identified, the most important assessment tool for the oncology health provider is a clinical interview with an individual man or woman, or with a couple.[13] The following brief list of factors known to impact current sexual functioning should be included in an assessment; the patient’s specific sexual concerns or needs at the time dictate the approach and content of the discussion.

In the evaluation of an individual’s sexual function, the initial phase of assessment serves to clarify the nature of the individual’s problem and/or complaint. A variety of aspects of current sexual function should be addressed, including the frequency of experiencing spontaneous desire for sex; ease of feeling subjective pleasure with sexual stimulation; and signs of physiological arousal, including the ability to achieve and maintain a firm erection for a man, and vaginal expansion and lubrication for a woman. The ability to reach an orgasm is another important measure of sexual function. It is helpful to ask what types of sexual stimulation can trigger an orgasm (i.e., self-touch, use of a vibrator or shower massage, partner caressing, oral stimulation, or intercourse). Pain in the genital area that occurs with sexual activity should be described in detail: “Where is the pain? What does it feel like? What kinds of sexual activity trigger it? Does it happen every time? How long does it last?” When these lines of inquiry elicit a sexual problem, the interviewer should ask when the problem began, especially whether a cancer diagnosis or particular treatment occurred close in time to onset of the problem. Because many people who have cancer take prescription medications that can interfere with sexual function, including antihypertensives, antidepressants, or psychotropic medications, the interviewer should find out whether a new medication or change of dosage was prescribed at the problem’s onset.

An individual’s past (pre-illness) sexual development, preferences, and experience are vital to assessment of sexual status. The level of sexual functioning before diagnosis and treatment, interest, satisfaction, and importance of sexual functioning in the relationship all influence the patient’s potential distress related to current sexual status. Individuals who have already experienced sexual difficulties may be especially vulnerable to the effects of treatment.[14] Clinicians should be careful not to make assumptions regarding the patient’s previous sexual experience or the importance of sexual expression.

The patient may or may not have an available partner at the time of diagnosis. Sexuality should be taken no less seriously by the clinician or the patient if there is no partner. For patients with a partner, the clinician should consider and discuss the duration, quality, and stability of the relationship before diagnosis. Additionally, as many patients fear rejection and abandonment, the clinician should inquire about the partner’s response to the illness and the patient’s concerns about the impact of treatment on the partner.[15-17] Partners share many of the same reactions as patients in that their most significant concerns typically relate to loss and fear of death. Moreover, the partner’s physical, sexual, and emotional health should be considered relative to his/her previous and current sexual status in a complete assessment. A clinician should recognize that most couples experience difficulty discussing sexual preferences, concerns, and fears even under ideal circumstances and that sexual communication problems tend to worsen with illness and threat of death.

The affective spectrum during cancer treatment ranges from disbelief to clinical depression and typically changes over time. Anxiety and depression are the two most common affective disruptions among patients with cancer and both have been found to have deleterious effects on sexual functioning.[3-5,7,18] A clinician should be aware of current mental status and any history of depression or other psychiatric disorder, previous psychotherapy, treatment with psychotropic medication, and/or hospitalizations. Current use of psychotropic medications should also be reviewed with respect to impact on sexual function. Cancer treatment can produce changes to the body that negatively impact body image and self-esteem.[4,5,19] Commonly, patients have difficulty seeing themselves as sexually attractive during and after treatment. Identifying body-image disturbances is important to incorporate into goals of care and rehabilitation. Frequently, the couple experiences changes of social roles during treatment. An individual’s identity and sense of worth may be threatened when role changes occur.[4,15] The partner’s participation in the patient’s physical care often negatively impacts feelings of sexuality. Younger couples, more than older couples, may be vulnerable to problems with playing alternative or new domestic roles and experiencing the myriad life and financial stressors associated with treatment.[4]

The clinician should ascertain past medical history with a particular emphasis on other concurrent medical illness for which the patient is receiving treatment. Comorbidity contributes to risk of sexual dysfunction and additional decrease in social and role functioning, mental health, and health perceptions. Medical illnesses that impact the endocrine, vascular, and nervous systems are all known to have a potential deleterious effect on the sexual response cycle.[13,20,21] Diabetes, hypertension, vascular disease, multiple sclerosis, and many other disorders impact sexual function, particularly the quality of erections in men. Two textbooks extensively review the impact of chronic illness and disability on sexual function.[13,21] Lifestyle factors, including smoking and substantial alcohol consumption, are also risk factors of sexual morbidity. In men, cigarette smoking may induce vasoconstriction and penile venous leakage;[20] in large amounts, alcohol is a strong sedative-hypnotic producing decreasing libido and transient erectile dysfunction.[20]

Pharmacologic treatment for cancer and chronic illness in general is often a necessary and integral component of health maintenance. Some pharmacologic treatments, however, may have direct or indirect deleterious effects on sexual function through multiple physiologic and psychologic pathways. Pharmacologic agents that may negatively affect sexual response are addressed in the section on pharmacologic effects. A number of resources provide further delineation of the mechanisms for changes in sexual function associated with these agents and include listings of specific medications and known effects on sexual function.[4,22-24]

Brief questionnaires that measure sexual dysfunction may be helpful, particularly when screening larger groups of cancer patients for sexual dysfunction or when conducting research on sexuality as an aspect of quality of life. The International Index of Erectile Function (IIEF, 15 items) and the Brief Sexual Male Functioning Inventory (BMSFI, 11 items) are well-validated scales measuring aspects of sexual function and satisfaction in men.[25,26] Sexual problems can also be identified with a briefer five-item scale, the Sexual Health Inventory for Men (SHIM), which is a validated self-report scale that can be used to identify erectile dysfunction in a variety of clinical settings.[26] For women, there are several brief measures with established psychometric properties that assess sexual functioning and satisfaction: the Brief Index of Sexual Functioning for Women (BISF-W, 22 items), the Sex History Form (SHF, 46 items), the Changes in Sexual Functioning Questionnaire (CSFQ, 35 items), the Derogatis Interview for Sexual Functioning (DISF/DISF-SR, 25 items), the Female Sexual Function Index (FSFI, 19 items), and the Golombok-Rusk Inventory of Sexual Satisfaction (GRISS, 28 items).[27,28,13] These scales vary in their reliability, validity, method of attainment (i.e., patient vs. clinician rates; structured vs. semistructured), type and number of symptoms assessed, and time frame of assessment. To accurately reflect changes over time, one must obtain systematic assessment of premorbid, baseline, and follow-up levels of sexual function and satisfaction.

In addition to paper-and-pencil self-report measures of sexuality, some medical evaluations of the adequacy of the physiological response are available.[29] For men, some of the more useful evaluations include the Rigiscan, a computerized electronic instrument that measures the adequacy of nocturnal erections; penile ultrasound studies to document hemodynamics of erection; and hormonal assays. In women, the use of the vaginal maturation index to measure estrogenization, a careful pelvic examination to identify sources of pain that occur during sexual activity, and hormonal assays are most common. More sophisticated measures of vaginal blood flow or sensory thresholds have been studied but have not gained wide acceptance.

Review of the literature highlights the need for prospective studies with longer-term follow-up, validated measures, and larger sample sizes. In particular, issues of sexual recovery in women have received too little clinical attention and research.

References

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