Mark Hoffman, MD

The advent of cancer affects multiple domains of a patient’s life. An area that tends to be under-recognized by oncologists, and accordingly unaddressed, involves the detrimental effects of the disease on the patient’s sexual functioning.

After diagnosis and during treatment, fatigue and other side effects caused by therapy, as well as depression — engrafted on pre-existing and ongoing work and family roles &mdash; often serve to decrease or negate sexual desire.

Cancer can be detrimental to female sexual functioning when organs such as the breast, cervix, uterus and vulva undergo surgery or radiotherapy. As an example, placing radiation cylinders into the vagina may cause the organ to shorten and narrow. Use of dilators and exercises prescribed by the radiation oncologist can help address this issue.

Physical changes such as hair loss from chemotherapy or the placement of an ostomy can impair sexual desire by causing perceived loss of attractiveness.

Another problematic issue is that chemotherapy given to pre-menopausal women to prevent recurrence of breast cancer may induce premature menopause, causing estrogen withdrawal symptoms such as hot flashes and vaginal dryness. In addition, localized estrogen receptor (ER)-positive breast cancer may be prevented from spreading by inducing a low-estrogen state. Many post-menopausal women are given the drugs anastrozole and letrozole, which can cause vaginal dryness and resultant pain with intercourse. Premenopausal women are now also being given specific types of hormonal therapy that induce premature menopause, resulting in similar symptoms.

Although many patients are reluctant to bring these issues up with their oncologists, they should understand that their doctors are comfortable discussing sexual function and can provide help. By the same token, oncologists must remember to ask their patients about sexual health and, ideally, be able to refer them to appropriate specialists as needed.

A significant decrease in hair loss from certain types of chemotherapy is possible with cold cap technology, and one system (DigniCap) has been approved by the FDA.

With regard to vaginal dryness in women with a history of ER-positive cancer, any medication, whether oral or topical, containing estrogen could increase the risk of recurrence. That’s why non-estrogenic lubricants such as Replens, RepHresh and Good Clean Love Almost Naked are the mainstay of therapy.

Of note, a drug called Osphena (ospemiphene) is marketed as a “non-estrogen” pill for the alleviation of painful intercourse. However, this drug has some estrogenic effects, and its safety in women with a history of ER-positive cancer has not been established.

For patients with significant vaginal dryness/atrophy, a laser system called Monalisa Touch, pioneered in Italy, has just become available in the U.S. The laser treatments increase vaginal hydration and lubrication by stimulating cells to produce collagen. This therapy is not widely available and not yet insurance-approved.

Finally, a drug called Addyi (flibanserin) has been approved for the treatment of Hypoactive Sexual Desire Disorder (HSDD) in premenopausal women. HSDD is characterized by an acquired reduction in sexual desire that causes distress and difficulty with relationships that is not accounted for by other conditions. This drug has not been studied specifically in cancer survivors, and thus its benefit and safety in this population have not been established.

Once identified, patients with sexual issues should be referred to health care professionals who can work with oncologists to optimize the patient’s sexual functioning. These can include gynecologists, psychologists, psychiatrists and sex therapists.

The goals of sex therapy are to improve sexual functioning and intimacy and address associated psychological issues. In order to fully help, sex therapists work with patients individually and also together with their partners, first to ascertain the vitality of the sexual relationship prior to the diagnosis of cancer, and then to renegotiate sexuality and intimacy. Both partners have to be open and honest, communicating their comfort and desire to engage in sexual activity. For example, partners commonly disclose their fears and anxieties relating to hurting the patient, or their feelings of guilt about wanting to increase sexual intimacy.

Cognitive behavioral therapy can be useful for women suffering from anxiety, depression and the low self-esteem that can stem from hair loss, involuntary weight loss and altered anatomy/physiology of sexual organs due to cancer or its treatment. For example, after breast reconstruction, a change in sensitivity of the breast can lead to feelings of frustration, anger and guilt, in that the client does not feel the same sensation as she did in the past. A sex therapist can teach the client to alter those reactions by adjusting to and accepting her body changes. Another tactic is to work on changing the partner’s perception of the sexual playing field, for example by asking the patient to discuss fantasies with her partner or to try on a wig with lingerie or a costume.

The couple can also partake in sensate focus activities. This entails the partners exploring each other’s bodies to find erotic and sensual areas. The human body has an abundant nerve supply. Finding alternate areas of pleasure can reestablish intimacy. 

—Mark Hoffman, M.D., is an attending physician at Northwell Health System’s Monter Cancer Center and associate professor of medicine at Hofstra Medical School. His daughter, Rachel Hoffman, L.M.S.W., is a Ph.D. candidate in human sexuality at Widener University, cofounder of sexpertise.org and a therapist at the Long Island institute of Sex Therapy.

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