How does cancer impact sexuality?

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A substantial number of men and women with cancer report some negative effect of the disease or its treatment on their sexual lives.
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Sexual response: Sexual response is often categorized into several components or dimensions, all of which can be affected by cancer and cancer treatment. Sexual desire refers to the experience of sexual thoughts, fantasies, daydreams, or desire for sexual activity. Sexual arousal comprises physiological and psychological events in preparation to engage in or continue sexual activity, including erection of the penis, lubrication of the vagina, and subjective feelings of excitement or anticipation. Orgasm is a peak of physiological and psychological arousal usually accompanied by rhythmic pelvic muscular contractions and intense pleasure, often (but not always) followed by resolution of sexual arousal and feelings of relaxation and well-being. In men, orgasm is usually accompanied by emission and ejaculation of semen.

Sexuality is not merely the sum of sexual responses but also comprises a person’s self-concept as a sexual person, preferences for sexual partners and sexual activities, interactions with current and potential future partners, and experience within a sexual culture. Sexual values, ideals, and scripts are often rooted early in life and develop over a period of many years. In the face of serious illness, deeply held sexual beliefs can help or hinder recovery toward a satisfying sexual life.

Effects of cancer on sexuality: Generally, the effects of cancer on sexuality are both physical and psychological. The emotional distress of living with cancer can take an even larger toll when combined with the physical impact of the disease. Tumors of certain size and location can directly affect physical aspects of sexual function, particularly when they interfere with nerve and blood vessel pathways important to sexual function. More commonly, however, sexual function is affected by treatment-related side effects such as fatigue, 94462293nausea, changes to physical appearance, and pain. In advanced cancers, the discomfort and fatigue associated with disease are also likely to limit sexual expression.

Effects of treatment on sexuality: Although the effects of any cancer and its treatment can threaten to cause sexual dysfunction, certain types of cancers are especially high risk. Cancers of the reproductive organs (such as the cervix, ovary, uterus, vagina, prostate, testicle, penis) are associated with a high rate of sexual problems that often persist after treatment because of the potential for damage to nerves, blood vessels, and other tissues involved in sexual responses. Other cancers of the pelvic region and lower abdomen, such as bladder, colorectal, and anal cancers, may also affect sexual function due to the organs’ proximity to and shared neurovascular environment with the reproductive system. In women, breast cancer may affect sexual function through negative effects on body image, particularly when the breasts are strongly connected with sexual attractiveness and femininity, and through post-treatment alteration of pleasurable breast sensations.

Chemotherapy: In addition to fatigue and other general physical symptoms, systemic chemotherapy can cause changes to testicular and ovarian function that decrease the production of sex hormones (testosterone and estrogen). These changes may result in decreased sexual desire and problems with sexual arousal, such as erectile dysfunction and poor vaginal lubrication. Although in men the hormonal effects of chemotherapy often reverse after treatment, women are susceptible to permanent loss of ovarian function. Other effects of chemotherapy include irritation of mucous membranes, including the lining of the vagina and the mouth, which can interfere with kissing, oral sex, and vaginal penetration.

Surgery: Surgical treatment of pelvic and lower abdominal cancers can damage nerves and occasionally blood vessels that are important to sexual arousal responses. Despite advances in surgical techniques to reduce pelvic nerve damage, erectile and ejaculatory dysfunctions remain common in men after procedures such as radical prostatectomy, radical cystectomy, and abdominoperineal resection. In women, sexual arousal problems, orgasm problems, and painful intercourse are common for a year or more after radical hysterectomy, though the effects of other abdominal surgeries on sexual function may be less severe than in men. Surgical menopause after removal of the ovaries may also affect short-term and long-term sexual function. Partial or complete removal of external genital tissue (such as vulvectomy or penectomy) perhaps poses the greatest threat to sexual function, though penile and vulvar cancers are rare.

Radiation: Radiation to the pelvic region can cause sexual difficulties by damaging nerves and blood vessels that control genital function and by affecting testicular and ovarian function, causing difficulties similar to those caused by other treatments. Furthermore, in women pelvic radiation can cause vaginal inflammation, sores, and scarring. This damage may lead to permanent shortening or collapse of the vaginal canal, limiting vaginal penetration because of pain and physical limitations. The severity of radiation side effects depends on the dose of radiation received and the extent of the irradiated region. Unlike surgery, the effects of radiation progress over a period of time.

Hormonal therapy: Adjuvant hormonal treatments, such as tamoxifen, for certain cancers have become more common. Effects are similar to those of other causes of decline in sex hormone levels and include changes in sexual interest and arousal.

Prognosis and treatment for sexual problems: Sexual problems often resolve over time or with treatment. The quality of sexual function before diagnosis and treatment is an important predictor of sexual recovery, as are age, general health status, and the partner’s receptiveness to further sexual activity. When aggressive treatment causes significant physical damage, adjustment to long-term changes in sexual function is necessary.

It is important not to underestimate the effects of psychological and relationship factors on sexual function. Although physical changes resulting from disease or treatment can be devastating, psychological adaptation to these changes may be the ultimate limiting factor in recovery. Ongoing problems with depression or anxiety can inhibit sexual desire and hinder efforts to resume sexual activity. Changes in appearance, health, fertility, or physical functioning may cause a sense of decreased self-worth, anxiety about recurrence, feelings of unattractiveness, and concern about a partner’s rejection or abandonment. Sexual problems may also have origins in intimacy problems and conflict between sexual partners. Finally, rigid or unrealistic expectations of sexual activity or a lack of knowledge about sexuality can create barriers when recovery necessitates changes to the sexual repertoire. Individual, couple, or group therapy is helpful in addressing these issues. In many cases the resumption of a fulfilling sex life hinges on building confidence and intimacy between partners, reevaluating beliefs about sexuality and sexual personhood, and orienting the patient and partner toward experiencing pleasure and satisfaction rather than achieving a specific goal (such as maintaining a full erection or always having an orgasm with sexual activity).

The use of sexual aids such as lubricants and vibrators can enhance sexual enjoyment in patients who have altered sexual function after cancer. Medical interventions for sexual problems are available, although it is inadvisable to pursue these options in lieu of counseling or psychotherapy. Medical treatment options are diverse and include local or systemic hormonal supplementation (although with some cancers hormonal treatment is contraindicated), the use of prescription medications for erectile dysfunction (such as Viagra, or sildenafil; Cialis, or tadalafil; Levitra, or vardenafil), penile injection therapy, and penile and clitoral vacuum devices. Invasive surgical options are less common. Reconstructive surgery, when possible, may improve body image. Penile prosthesis surgery can partially restore erectile function when other treatments have failed or are unacceptable. Although reparative surgery may address neurological or vascular causes of sexual dysfunction, current evidence to support this approach is limited.

Sexuality is increasingly viewed as an important element of quality of life, but more often than not, health care providers are hesitant to discuss sexual issues with their patients. Referral to a provider with special expertise in sexual problems can be helpful. Although there is no recognized medical specialty in sexual medicine, physicians with expertise in sexual problems are represented in several fields, including urology, gynecology, psychiatry, and endocrinology. The American Association of Sex Educators, Counselors, and Therapists (AASECT) also provides referrals and certification for mental health professionals with special expertise in human sexuality.


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