Sexuality and Reproductive Issues (PDQ®)
This patient summary on the sexual side effects from cancer and cancer treatment is adapted from the summary written for health professionals by cancer experts. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. Better treatment of many cancers has resulted in more patients experiencing longer periods of disease-free survival. In addition, the side effects associated with cancer and cancer treatments have also become more prevalent.
The Prevalence and Types of Sexual Dysfunction in People With Cancer
Sexuality is a complex characteristic that involves the physical, psychological, interpersonal, and behavioral aspects of a person. Recognizing that "normal" sexual functioning covers a wide range is important. Ultimately, sexuality is defined by each patient and his/her partner according to sex, age, personal attitudes, and religious and cultural values.
Many types of cancer and cancer therapies can cause sexual dysfunction. Research shows that approximately one-half of women who have been treated for breast and gynecologic cancers experience long-term sexual dysfunction. Men who have been treated for prostate cancer report problems with erectile dysfunction that varies depending on the type of treatment. Less is known about how other types of cancer, especially other solid tumors, affect sexuality.
An individual's sexual response can be affected in many ways. The causes of sexual dysfunction are often both physical and psychological. The most common sexual problems for people who have cancer are loss of desire for sexual activity in both men and women, problems achieving and maintaining an erection in men, and pain with intercourse in women. Men may also experience inability to ejaculate, ejaculation going backward into the bladder, or the inability to reach orgasm. Women may experience a change in genital sensations due to pain, loss of sensation and numbness, or decreased ability to reach orgasm.
Unlike many other physical side effects of cancer treatment, sexual problems may not resolve within the first year or two of disease-free survival. These problems may even increase over time and can interfere with the return to a normal life. Patients recovering from cancer should discuss their concerns about sexual problems with a health care professional.
Factors Affecting Sexual Function in People With Cancer
Both physical and psychological factors contribute to the development of sexual dysfunction. Physical factors include loss of function due to the effects of cancer therapies, fatigue, and pain. Surgery, chemotherapy, and radiation therapy may have a direct physical impact on sexual function. Other factors that may contribute to sexual dysfunction include pain medications, depression, feelings of guilt from misbeliefs about the origin of the cancer, changes in body image after surgery, and stresses due to personal relationships. Getting older is often associated with a decrease in sexual desire and performance, however, sex may be important to the older person's quality of life and the loss of sexual function can be distressing.
Surgery can directly affect sexual function. Factors that help predict a patient's sexual function after surgery include age, sexual and bladder function before surgery, tumor location and size, and how much tissue was removed during surgery. Surgeries that affect sexual function include breast cancer, colorectal cancer, prostate cancer, and other pelvic tumors.
Sexual function after breast cancer surgery has been the subject of much research. Surgery to save or reconstruct the breast appears to have little effect on sexual function compared with surgery to remove the whole breast. Women who have surgery to save the breast are more likely to continue to enjoy breast caressing, but there is no difference in areas such as how often women have sex, the ease of reaching orgasm, or overall sexual satisfaction. Having a mastectomy, however, has been linked to a loss of interest in sex. Chemotherapy has been linked to problems with sexual function.
Sexual and bladder dysfunctions are common complications of surgery for rectal cancer. The main cause of problems with erection, ejaculation, and orgasm is injury to nerves in the pelvic cavity. Nerves can be damaged when their blood supply is disrupted or when the nerves are cut.
Newer nerve-sparing techniques for radical prostatectomy are being debated as a more successful approach for preserving erectile function than radiation therapy for prostate cancer. Long-term follow-up is needed to compare the effects of surgery with the effects of radiation therapy. Recovery of erectile function usually occurs within a year after having a radical prostatectomy. The effects of radiation therapy on erectile function are very slow and gradual occurring for two or three years after treatment. The cause of loss of erectile function differs between surgery and radiation therapy. Radical prostatectomy damages nerves that make blood vessels open wider to allow more blood into the penis. Eventually the tissue does not get enough oxygen, cells die, and scar tissue forms that interferes with erectile function. Radiation therapy appears to damage the arteries that bring blood to the penis.
Brachytherapy (internal radiation therapy using radioactive implants) is being used more often to treat prostate cancer. With brachytherapy alone, ejaculation and erectile function are better preserved than when external radiation and/or hormone therapy are added. Radiation damage to nerves and blood vessels may occur with brachytherapy, and higher doses of radiation may cause more damage.
- Changes in orgasm quality or lack of orgasm.
- Pain during orgasm (dysorgasmia).
- Incontinence during orgasm (climaturia).
Problems related to orgasm after prostate cancer treatment can be managed, but at this time, there is no treatment that will return orgasm to the way it was before surgery. Pain during orgasm may occur in the penis, abdomen, or rectum. Pain can be treated with alpha-blockers, drugs that relax muscle tissue in blood vessels and in the prostate gland. Incontinence or leakage of urine from the bladder during orgasm can be managed by limiting fluid intake and emptying the bladder before sexual activity or by using condoms, if the leakage is minor.
The penis may be 1 to 2 centimeters shorter after a radical prostatectomy. This shortening of the penis may be related to nerve injury or structural changes that can occur right after surgery or months after surgery.
Testicular cancer and its treatment can affect sexual well-being. Most study results suggest that problems with sexual function are usually short-term. Function improves later to about the same level as seen in men who do not have testicular cancer.
Other Pelvic Tumors
Men who have surgery to remove the bladder, colon, and/or rectum may improve recovery of erectile function if nerve-sparing surgical techniques are used. The sexual side effects of radiation therapy for pelvic tumors are similar to those after prostate cancer treatment.
Women who have surgery to remove the uterus, ovaries, bladder, or other organs in the abdomen or pelvis may experience pain and loss of sexual function depending on the amount of tissue/organ removed. With counseling and other medical treatments, these patients may regain normal sensation in the vagina and genital areas and be able to have pain-free intercourse and reach orgasm.
Chemotherapy is associated with a loss of desire and decreased frequency of intercourse for both men and women. The common side effects of chemotherapy such as nausea, vomiting, diarrhea, constipation, mucositis, weight loss or gain, and loss of hair can affect an individual's sexual self-image and make him or her feel unattractive.
For women, chemotherapy may cause vaginal dryness, pain with intercourse, and decreased ability to reach orgasm. In older women, chemotherapy may increase the risk of ovarian cancer. Chemotherapy may also cause a sudden loss of estrogen production from the ovaries. The loss of estrogen can cause shrinking, thinning, and loss of elasticity of the vagina, vaginal dryness, hot flashes, urinary tract infections, mood swings, fatigue, and irritability. Young women who have breast cancer and have had surgeries such as removal of one or both ovaries, may experience symptoms related to loss of estrogen. These women experience high rates of sexual problems since there is a concern that estrogen replacement therapy, which may decrease these symptoms, could cause the breast cancer to return. For women with other types of cancer, however, estrogen replacement therapy can usually resolve many sexual problems. Also, women who have graft-versus-host disease (a reaction of donated bone marrow or peripheral stem cells against a person's tissue) following bone marrow transplantation may develop scar tissue and narrowing of the vagina that can interfere with intercourse.
For men, sexual problems such as loss of desire and erectile dysfunction are more common after a bone marrow transplant because of graft-versus-host disease or nerve damage. Occasionally chemotherapy may interfere with testosterone production in the testicles. Testosterone replacement may be necessary to regain sexual function.
Radiation Therapy-Related Factors
Like chemotherapy, radiation therapy can cause side effects such as fatigue, nausea and vomiting, diarrhea, and other symptoms that can decrease feelings of sexuality. In women, radiation therapy to the pelvis can cause changes in the lining of the vagina. These changes eventually cause a narrowing of the vagina and formation of scar tissue that results in pain with intercourse, infertility and other long term sexual problems. Women should discuss concerns about these side effects with their doctor and ask about the use of a vaginal dilator.
For men, radiation therapy can cause problems with getting and keeping an erection. The exact cause of sexual problems after radiation therapy is unknown. Possible causes are nerve injury, a blockage of blood supply to the penis, or decreased levels of testosterone. Sexual changes occur very slowly over a period of six months to one year after radiation therapy. Men who had problems with erectile dysfunction before getting cancer have a greater risk of developing sexual problems after cancer diagnosis and treatment. Other risk factors that can contribute to a greater risk of sexual problems in men are cigarette smoking, history of heart disease, high blood pressure, and diabetes.
Hormone Therapy-Related Factors
Hormone therapy for prostate cancer can decrease normal hormone levels and cause a decrease in sexual desire, erectile dysfunction, and problems reaching orgasm. Younger men do not always experience the same degree of sexual dysfunction. Some treatment centers are experimenting with delayed or intermittent hormone therapy to prevent sexual problems. It is not yet known if these modified treatments affect the long-term survival of younger men.
Women older than 45 years who are treated with adjuvant tamoxifen therapy may have slightly more hot flashes, night sweats, and vaginal discharge. Studies show that patients who take tamoxifen do not have less sexual activity, but may have slightly less sexual desire and more problems reaching orgasm.
In a large study of women with breast cancer who were treated with adjuvant hormone therapy, patients who took exemestane, a type of aromatase inhibitor, had fewer hot flashes and less vaginal discharge than those who took tamoxifen. However, patients who took exemestane had more vaginal dryness, bone pain, and sleep disorders than patients who took tamoxifen.
Patients recovering from cancer often have anxiety or guilt that previous sexual activities may have caused their cancer. Some patients believe that sexual activity may cause the cancer to return or pass the cancer to their partner. Discussing their feelings and concerns with a health care professional is important for patients. Misbeliefs can be corrected and patients can be reassured that cancer is not passed on through sexual contact.
Loss of sexual desire and a decrease in sexual pleasure are common symptoms of depression. Depression is more common in patients with cancer than in the general healthy population. It is important that patients discuss their feelings with their doctor. Getting treatment for depression may be helpful in relieving sexual problems. (Refer to the PDQ summary on Depression for more information.)
Cancer treatments may cause physical changes that affect how an individual sees his or her physical appearance. This view can make a man or woman feel sexually unattractive. It is important that patients discuss these feelings and concerns with a health care professional. Patients can learn how to deal effectively with these problems.
The stress of being diagnosed with cancer and undergoing treatment for cancer can make existing problems in relationships even worse. The sexual relationship can also be affected. Patients who do not have a committed relationship may stop dating because they fear being rejected by a potential new partner who learns about their history of cancer. One of the most important factors in adjusting after cancer treatment is the patient's feeling about his or her sexuality before being diagnosed with cancer. If patients had positive feelings about sexuality, they may be more likely to resume sexual activity after treatment for cancer.
Childhood Cancer Survivors
Being treated for cancer as a child may lead to sexual problems in adulthood. Childhood cancer survivors who were diagnosed at age 21 years or younger with different types of cancer were surveyed in their late teens, twenties, or thirties. About one-half of the women and one-third of the men in the study reported trouble with sexual function, including problems becoming aroused or lack of interest in sex. Childhood cancer survivors who had emotional and health problems were more likely to have problems with sexual function.
Although women in the study reported more sexual problems, men reported more feelings of distress. While this study did not directly link a cancer diagnosis or cancer treatment with sexual problems, it found that childhood cancer survivors, especially men, had more problems with sexual function than the same age group with no history of cancer.
Assessment of Sexual Function in People with Cancer
Sexual function is an important factor that adds to quality of life. Patients should discuss their problems and concerns about sexual function with their doctor. Some doctors may not have the appropriate training to discuss sexual problems. Patients should ask for other information resources or for a referral to a health care professional who is comfortable with discussing sexuality issues.
General Factors Affecting Sexual Functioning
When a possible sexual problem is identified, the health care professional will do a detailed interview either with the patient alone or with the patient and his or her partner. The patient may be asked any of the following questions about his or her current and past sexual functioning:
- How often do you feel a spontaneous desire to have sex?
- Do you enjoy sex?
- Do you have enough energy for sexual activity?
- Do you become sexually aroused (for men, are you able to get and keep an erection, or for women, does your vagina expand and become lubricated)?
- Are you able to reach orgasm during sex? What types of stimulation can trigger an orgasm (for example, self-touch, use of a vibrator, shower massage, partner caressing, oral stimulation, or intercourse)?
- Do you have any pain during sex? Where do you feel the pain? What does the pain feel like? What kinds of sexual activity trigger the pain? Does this cause pain every time? How long does the pain last?
- When did your sexual problems begin? Was it around the same time that you were diagnosed with cancer or received treatment for cancer?
- Are you taking any medications? Did you start taking any new medications or did the doctor change the dose of any medications around the time that these sexual problems began?
- What was your sexual functioning like before you were diagnosed with cancer? Did you have any sexual problems before you were diagnosed with cancer?
Psychosocial Aspects of Sexuality
Patients may also be asked about the significance of sexuality and relationships whether or not they have a partner. Patients who have a partner may be asked about the length and stability of the relationship before being diagnosed with cancer. They may also be asked about their partner's response to the diagnosis of cancer and if they have any concerns about how their partner may be affected by their treatment. It is important that patients and their partners discuss their sexual problems and concerns and fears about their relationship with a health care professional with whom they feel comfortable.
Medical Aspects of Sexuality
Patients may be asked about current and past medical history since many medical illnesses can affect sexual function. Lifestyle risk factors such as smoking and high alcohol intake can also affect sexual function as well as prescribed and over-the-counter medications. Patients may be asked to fill out questionnaires to help identify sexual problems and may undergo a variety of physical examinations, blood tests, ultrasound studies, measurement of nighttime erections, and hormone tests.
Effects of Medicines on Sexual Function
The side effects of medicines can add to the sexual side effects of surgery, radiation therapy, and chemotherapy. Cancer patients may receive drug therapy that can affect nerves, blood vessels, and hormones that control normal sexual function. Mental alertness and moods may also be affected. These side effects may occur in cancer patients who take opioids for pain and drugs to treat depression, for example.
Treatment of Sexual Problems in People With Cancer
Many patients are fearful or anxious about their first sexual experience after cancer treatment. Fear and anxiety can cause patients to avoid intimacy, touch, and sexual activity. The partner may also feel fearful or anxious about initiating any activity that might be thought of as pressuring to be intimate or that might cause physical discomfort. Patients and their partners should discuss concerns with their doctor or other qualified health professional. Honest communication of feelings, concerns, and preferences is important.
In general, a wide variety of treatment modalities are available for patients with sexual dysfunction after cancer. Patients can learn to adapt to changes in sexual function through reading books, pamphlets, and internet resources or listening to and watching videos and CD-ROMs. Health professionals who specialize in sexual dysfunction can provide patients with these resources as well as information on national organizations that may provide support. Some patients may need medical intervention such as hormone replacement, medications, medical devices, or surgery. Penile rehabilitation may be helpful for men who have had surgery for prostate cancer. Patients who have more serious problems may need sexual counseling on an individual basis, with his or her partner, or in a group. Further testing and research is needed to compare the effectiveness of various treatment programs that combine medical and psychological approaches for people who have had cancer.
Radiation therapy and chemotherapy treatments may cause temporary or permanent infertility. These side effects are related to a number of factors including the patient's sex, age at time of treatment, the specific type and dose of radiation therapy and/or chemotherapy, the use of single therapy or many therapies, and length of time since treatment.
When cancer or its treatment may cause infertility or sexual dysfunction, every effort should be made to inform and educate the patient about this possibility. When the patient is a child, this can be difficult. The child may be too young to understand issues involving infertility or sexuality, or parents may choose to shield the child from these issues.
For patients receiving chemotherapy, age is an important factor and recovery improves the longer the patient is off chemotherapy. Chemotherapy drugs that have been shown to affect fertility include: busulfan, melphalan, cyclophosphamide, cisplatin, chlorambucil, mustine, carmustine, lomustine, vinblastine, cytarabine, and procarbazine. In women older than 40 years, adjuvant endocrine therapy increases the risk that chemotherapy will cause permanent loss of menstrual periods.
For men and women receiving radiation therapy to the abdomen or pelvis, the amount of radiation directly to the testes or ovaries is an important factor. In women older than 40 years, infertility may occur at lower doses of radiation. Fertility may be preserved by the use of modern radiation therapy techniques and the use of lead shields to protect the testes. Women may undergo surgery to protect the ovaries by moving them out of the field of radiation.
Patients who are concerned about the effects of cancer treatment on their ability to have children should discuss this with their doctor before treatment. The doctor can recommend a counselor or fertility specialist who can discuss available options and help patients and their partners through the decision-making process. Options may include freezing sperm, eggs, or ovarian tissue before cancer treatment.