MD Anderson Cancer Center
Date: June 2011
We basically joke about it. We laugh. We have a good time together. We enjoy being together. We hold hands. And if that's the extent of our sexual life, then so be it.
If you got a choice whether to live or to be the greatest sexual performer on earth, maybe you might want to think about that living part.
Hello. I'm Minerva Perez. These comments from patients certainly struck a cord with me. I imagine they did for you too. When you're first diagnosed with cancer you suddenly have a lot of decisions to make and you have to cope with many changes in your life. Your sexual health may not be high on your lists of concerns.
When you get the diagnosis of cancer, the last thing on your mind may be sexuality. And in fact, it may not be a priority for the first month or two or three. But, you know, it's a part of who we are and eventually will be. So you don't want to be there 3, 4, 6 months later looking back and regretting not having addressed it.
For some people, having a treatment that has the best chance of preserving their sex life is upfront, a huge consideration. For many people, it doesn't become a big issue until they're feeling enough better that they go, "Hey, you know, I'm alive. I have a life to live and this problem is a big problem and now what do I do?"
People are so concerned about their life. The existential questions that come up, life and death, that sexuality often is a back burner item for them. It is later on in the treatment when they're dealing with some of the other side effects and now it's becoming clearer to them that yes I'm going to survive this. And here are all the ways that it's back with my life. And that's when the sexuality issues get more on the table.
They're very focused when they're diagnosed with cancer on living. And that's the main thought they have. I want to live. I want to do whatever it takes to live. It's not until they've gone through the treatment toward the end of it where quality of life issue surface.
And for, me the gradual losing of the sexual desires wasn't a major concern. But then it got to a point that I went, "Okay, what is wrong?"
Many patients are reluctant to talk about sexual issues for a variety of reasons. They may be embarrassed, ashamed or afraid. But it's important to be honest with yourself as well as with your doctor to communicate about any problems or concerns you may have to help your doctor find the best solutions and choices for you.
I firmly believe that sex and the potential for sexual problems should be brought up when a patient is learning about their treatment that they're going to have. And if the treatment has a fairly high chance of changing a man or woman’s sex life, I think that needs to be part of the whole treatment planning process.
If you want to initiate a conversation about sexuality and cancer, here are some general questions you might ask when you first meet with your health care team. How do you think my cancer treatment will change my sexual health or sex life? Will sexual activity harm me or my partner? Will I still be able to have children after treatment? And should I be using birth control during my cancer treatment?
The element of being able to have those conversations on the front and with your health provider is certainly an extra that we really all want to have.
If it's presented to you in the beginning of your treatment as checklist, then you know in the back of your mind, "Hey, you know what, they asked me that question and maybe if I need something, I can go back because there's such--now that I'm dealing with that entity of my feelings."
I think it's important if the problem bothers you to bring it up to your provider. It could be the doctor, the nurse, the physician assistant. But bring it up to somebody and say, you know, my life, my sex life is just not the same.
It really is our responsibility as oncology professionals to make sure that we bring up these topics and let people know that it is very legitimate part of their quality of life and that there is help available.
For women, cancer and its treatments may cause short-term or long-term side effects that may affect sexuality. These side effects include fatigue, nausea, vomiting, diarrhea or constipation, hair loss including genital hair, weight changes, scarring and changes in taste and smell. It is important to remember that each patient is different and will respond differently to side effects. If you’ve had surgery that involves the vagina, the vagina can become narrow, less deep and scar tissue can form. If a woman's ovaries are removed before menopause, it will result in the loss of estrogen causing sudden and early menopause or premature ovarian failure. This failure may cause a loss of desire, vaginal dryness, tightness and or pain with sex. After breast surgery, you may lose sexual pleasure from the nipple. Chemotherapy can also change your sexual heath. Chemotherapy can affect the mucous membranes inside the mouth and vagina causing soreness and making sex painful. Some chemotherapy drugs can damage the ovaries inhibiting hormone production. Sudden and early menopause is often permanent especially if a woman is 35 or older. Some hormone treatments may also cause vaginal irritation and dryness. Radiation may also cause this same side effect.
When woman have cancer and they have not yet gone into menopause. If they have chemotherapy that's very toxic to the ovaries or if they have a big dose of radiation to the pelvis near the ovaries or if they have both their ovaries removed, just part of maybe treatment for ovarian cancer for example, then they go into abrupt menopause and they tend to have worse symptoms than they would have in natural menopause. There are many ways to help woman with side effects of various treatments. For example, after mastectomy, breast reconstruction can help you regain a positive self-image. If you've had pelvic radiation, you may need to learn about using a vaginal dilator to help keep the vagina from scarring and shrinking. And to help with vaginal dryness, you can use water-based or silicon-based lubricant or a vaginal moisturizer. These are sold over the counter at most drug stores. If lubricants or moisturizers do not help, you maybe be able to use a low-dose vaginal estrogen.
Woman as a rule with breast cancer have to be creative and think of like vaginal lubricants which are used during sexual activity or vaginal moisturizers. They have to be water soluble and cannot stimulate estrogen at all. And there are some oncologists who allow their patients with breast cancer to use vaginal preparations of estrogen. They’ll usually tell you this might increase the risk of recurrence but my experience has been that the women that are interested in this will go ahead and want to use it because they say it's my quality of life. This is the chance of my cancer coming back. That's a chance, but my everyday life and my relationship has been impaired and I want things to improve.
As in the case with women, men also can suffer sexual side effects from cancer and its therapies. General side effects include fatigue, stomach upset, hair loss, weight changes and changes in taste and smell. Erectile dysfunction, however, is the major concern especially for those who are facing surgeries that remove the prostate, the prostate and bladder, and those surgeries that remove the lower part of the colon and rectum. These surgeries may cut or bruise nerves that directly affect the penis. Even though doctors try to keep the nerve safe during these types of surgical procedures, many men are concerned about erection problems afterwards.
Doing the surgery there was a possibility of being able to save a portion of the nerves which would in effect allow me to be able to function sexually but in a less of a capacity.
I told them exactly what the problem was. And of course they did--you know, they did various tests. And of course one of those was--you know, it was penile injections and they found that the pluming worked okay. I mean it worked fine. So I had a choice of you know, just doing injections or a vacuum device and so that has worked.
Depending on your type and stage of cancer and the scope of the surgical procedure, it may take time perhaps even 1 to 2 years before you can get an erection. There are several methods for treating these problems. Some prescription medications can be given to increase the blood flow into the penis and help erections recover. Some are pills that many men need more effective medications injected into the shaft of the penis. Another choice is a plastic tube that fits over the penis and helps the penis become erect by a vacuum device with a suction pump. Another way to have erections is to have surgery to put in a penile implant which includes a pump. Special bands or rings may also help you keep an erection when used in conjunction with the pump device. Other types of cancer treatments can also affect a man's sexuality. Some hormone treatments often used for men with advanced prostate cancer turn off testosterone production in the testicles thus leaving a man with a loss of sexual desire. Men who have radiation treatment to the pelvic area also may have erectile dysfunction. The target area can form scar tissue and damage the blood vessels and nerves that cause erections. Radiation also can permanently reduce semen to only a few drops. Studies have shown that some men base their treatment decisions upon which treatment is less likely to affect the quality of their erections. This sometimes goes against choosing the treatment which most likely would save their lives.
What you will find out that the actual physicality of sexuality is only one component. And that there are a lot of different areas that one can explore and that it will perhaps maybe even bring you closer in the whole process. So if you got a choice whether to live or to be the greatest sexual performer on earth, maybe you might want to think about that living part.
I was more concerned with staying alive, you know, of surviving, you know, the cancer.
Just as physical changes from cancer treatment can affect your sex life so can a poor self-image as well as feelings of anxiety or depression. Cancer often represents loss and change. Loss of health, physical attractiveness and sometimes loss of the support of loved ones.
Women, even without breast cancer with other types of cancer, their body image is affected especially while they're going through treatment because chemotherapy changes the color of your skin, the texture, the hair falls out and they don't feel very sexual. They don't feel like sexual people and not very interested in sexual activity.
Body image was something I have thought about it before going to surgery. And I didn't know how that was going to affect our sexuality because your breasts are a very important part of your sexuality and as a woman that's your womanhood.
People talk a lot about body image. I think there's a subgroup of women who always put a lot of emphasis on their physical attractiveness. And if their cancer treatment changes the way they look, then they may be very upset about that and that may really, you know, change their interest in being sexual with the partner. I think for most women body image is a little bit less of an issue than has been suggested and for men too actually.
While, many patients are able to maintain positive attitudes, depression can at times affect your quality of life along with your sexuality. In fact, loss of desire for sex is a classic symptom of depression as is loss of interest in things you used to enjoy, having trouble concentrating or withdrawing from family and friends. It's important to know that symptoms of depression can be treated with counseling and with medications. Please ask for help when you need it. And remember, there are people who are there for you who want to help.
If you or your loved one has had cancer, you should be aware of the importance of good communication, talking to each other, being a good listener, sharing fears as well as hopes and physical touch.
The role of the spouse or the partner is one of the greatest untapped and undervalued resources.
You don't have to have sex every night to feel close. Sometimes we just hold each other and I always told him that the best place in the world is your arms. That's the safest place. And so I think it's a lot to do with how your spouse is--handling this whole journey with you.
And I tell my patients, you know, you have to kind of take time to explore with yourself and with your partner of this new you. And things may feel different and things will probably will feel differently. But it doesn't mean that they're going to be worse it's just going to be different for both of you.
I'm one of those people that if it's bothering me I'm going to talk about it. And it was bothering me to know how he feels about me, you know, when we make love. And that's very important. I need to know that.
If you have gone through a time without having sex, you or your partner may be slow to try again. You may feel nervous. Your partner maybe afraid of hurting you or you may feel a loss of interest in sex. A lot of those women may lose interest 'cause sex has become painful. And if it hurts, you aren't going to look forward to doing it. There's also the fatigue factor. A lot of women after intensive chemotherapy for example have chronic fatigue. And when you're tired out it's hard to get in the mood for sex.
Many of them cannot have hormone replacement, you know, to give them back the estrogen that they have lost. And they feel at loss at the point and they don't know what--like what do we do to get back to this relationship with this person who is probably stuck with them through pretty scary times. You know have seen them bald, have seen them vomiting, has seen them feeling not so good, you know, has held their hand, and has been there for them to support them through very, very scary times. So it's only natural to want to give back.
If you are single you may have concerns about dating. You may worry about telling someone about your cancer.
In fact I just saw a woman a while ago who said, you know "Who wants to date me? You know I have scars. Even though I have two breasts I have scars." And when do you tell the person? Do you tell them right off the bat, I want to let you know I've had breast cancer or I had leukemia or whatever. Or do you wait until you know there maybe something going there then you say, "Now we've had several dates you need to know that I have a history of cancer." So there's no right answer.
When you build a level of trust in friendship, you should feel comfortable telling your new partner about your cancer. Talking can help you build a relationship based on honesty and trust.
Studies have shown that men whose part--female partners had breast cancer, they gave them a list of things that they were really concerned about. The main thing they were concerned about is that their partner be alive and be healthy. Sexuality concerns were not even in the top 5 because they were so concerned and this is after treatment that they stay healthy and that the cancer not come back.
My husband who has also experienced cancer is going through the same thing. And we joke about it. We basically joke about it. We laugh. We have a good time together. We enjoy being together. We hold hands. And if that's the extent of our sexual life then so be it. But it took us awhile to get there.
Thinking about the future and children can be really hard while coping with cancer. However, most choices for protecting your fertility need to take place before you start treatment. You may also want to talk to a fertility specialist. For both men and women, being able to father a child or get pregnant after treatment is affected by: age at the time of cancer treatment, type of treatment, kind and dose of chemotherapy used, amount and target area of radiation, type and amount of surgery, whether one or multiple cancer treatments are used, how long treatment lasts. For women there are several ways to protect your fertility before treatment begins but most choices are still being researched. For men, fertility preservation usually involves simply collecting semen and freezing it in a sperm bank. In some cases, however, sperm cells can also be collected from a man's testicles after cancer treatment.
Because each person's situation is different, it is important to talk to your doctor about your options. When adolescences in young adults are diagnosed with cancer, it's important that they know how the disease or its treatments might affect their future fertility. At the age of 12, Abigail Armstrong was diagnosed with osteosarcoma, a bone cancer in her left leg. She had a limb-salvage surgery and several rounds of chemotherapy.
At that point, the most important thing for me was for Abigail to live. Abigail needed to live. And I didn't want to discuss fertility and stuff with her because she needed to cross one bridge at a time.
I was at a young age so I didn't really even know what fertility was. It was like being in first grade and someone explaining a college math problem to me.
A lot of times patients don't know to ask the questions about what are some for the long term effects or the potential survivorship effects. And so they don't know to ask or even think to ask that their fertility may be impacted.
There are options for preserving fertility in both males and females. For young females, cancer and its treatment may cause ovarian failure or premature menopause either immediately after treatment or within a few years. Those who have gone through puberty do have options including freezing eggs obtained from the ovary or fertilizing those eggs with sperm in the lab and then freezing the embryos that result. There are many ethical and legal considerations involving these methods. These are issues you need to talk about with your oncology team. Young male patients faced a risk the treatment will destroy the cells in the testicles that create sperm.
So males are affected because the testicle--the cells in the testicle that develop or make sperm are basically killed or decreased in function or affected by the chemotherapy or radiation.
Sperm banking before treatment is an option to boys and young men typically starting from about the ages of 14 to 16. But some boys can bank as young as 12 or 13. The patient will go to a sperm bank where he will provide a semen sample which is frozen and stored.
Sperm banking prior to any chemotherapy, radiation, surgery is very, very important in order to ensure the best specimen is provided. Because even just one dose of chemotherapy or radiation can affect the quality of the semen analysis of the sperm and the ability to be able to bank.
My doctor came out to me and he took me aside and pulled my parents 'cause he knew it was a touchy subject and he said "Cole I notice this is all so sudden. Everything is going on so fast but with chemotherapy comes some, some things that come with it. There was a possibility that I would be not fertile anymore so it did mean a lot. And I had talked to my parents about it and I talked to my doctor in Tulsa about it, and he definitely recommended sperm banking. At first I was like "Well, I'm not going to do it." And I thought about it and I was like, "Yeah, I do want to do that. I don't know why I wouldn't" because it's, you know, everybody wants to have a family one day.
As with adolescences and young adult cancer patients, the risk of infertility with younger children is dependent upon age, gender, the type of cancer and the type of treatment. Options for this younger group are still experimental so it is very important to discuss the fertility risks of your child's treatment with your child's doctor prior to treatment beginning.
I think about growing up and like--and living life. And I hope that one day that I will have like a house full of boys and one little girl that I can spoil.
I'm very, very happy that I did it. And I'm very happy because I know that even if I am infertile or if I'm not able to produce I still have these sperm cells banked. And that they're there if I need them.
Whether you're a male or female going through treatment, there are several things you should know about sex, birth control and pregnancy. First, you should be able to have sex during cancer treatment unless your doctor tells you that it is not safe. Second, use birth control to avoid getting pregnant during cancer treatment because it could harm the fetus. Third, use birth control for at least 6 months after your treatment to avoid becoming pregnant. Depending on your treatment, however, you may need to use birth control for longer than 6 months. Fourth, chemotherapy and radiation to the pelvis may damage the genes in a man's sperm or a woman's eggs. However, sperm and eggs can repair their genes in the first couple of years after treatment. Finally, if you are pregnant and diagnosed with cancer, doctors can treat many cancers safely during pregnancy. Also, healthy babies have been born after a pregnant woman has had chemotherapy.
Some women after chemotherapy may actually hit menopause at a very young age so that biological clock may actually be shortened by quite a bit after cancer treatment therapy. And it's hard to know how long that biological clock will be. It can be anywhere from 6 months to a couple of years to 5 years down the road.
If you don't have any resources, ask your doctor and keep asking. Or if the doctor doesn't listen, ask the nurse, ask the nurse practitioner, you know, ask the patient advocate. Hey, is there somebody. I'm having some issues. Is there somebody that I can see?
There are many support programs and services available at MD Anderson including support groups, sexuality counseling, a free consumer health library and many community resources.
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