Preserving and Rebuilding Sexuality in Women and Men with Cancer

Sexual life in cancer was again discussed at the annual San Francisco meeting of 2 international cancer societies (MASCC/ISOO). Experts considered common problems, treatment approaches and strategies for healthy sexuality after cancer, addressing men and women separately. This article presents their views and experiences.

Sexual Problems in Male Cancer Patients

Although not universal, sexual dysfunction may occur during and after cancer treatment through treatments or psychological factors. Problems include erectile difficulty, reduced libido, ejaculation problems, painful or delayed orgasm and premature ejaculation. They may bring reduced sexual satisfaction, concerns about sexual identity, avoidance of sexuality (often confused with loss of desire), and reduced overall relationship satisfaction. Restoring sexual and relationship well-being after a difficult illness is important for health professionals and supporters. Discussing this with professionals is crucial. Disease itself and treatments may cause problems, alongside cultural perceptions, anxiety or depression . Patients should therefore understand potential sexual effects of cancer and treatment—for example, erectile problems after radical prostatectomy. If treatment will cause low testosterone or permanent reproductive problems, these discussions should occur beforehand.

Maintaining sexual health requires communication between patient and doctor . A global study of sexual attitudes found that 12-14% asked family physicians questions. The most common reason for not asking was "not wanting to embarrass their doctors" in the responses.

In suitable patients, testosterone supplementation was also emphasized. Measuring patients’ testosterone levels is recommended. Low testosterone is not only a cause of reduced desire and inadequate erections, but may also be a risk factor for heart disease, osteoporosis and diabetes.

Experts also stated that indifference, judgment and intolerance in sexual health services are the biggest mistakes. Yet current medical training seems unlikely to provide doctors with a sufficient approach.

Sexual Health in Female Cancer Patients

After cancer treatment, during the menopausal transition, vasomotor symptoms such as hot flushes can be severe, particularly with hormonal treatments such as tamoxifen or aromatase inhibitors. Treatment may impair ovarian function in menstruating women. Women taking hormone therapy for menopause tend to stop when diagnosed with breast or gynecological cancer . Outside cancer, hot flushes are also treated hormonally, but women believe hormones cause or may cause cancer. Except for hormone-sensitive cancers, other women need not worry about this. Nonhormonal options also exist. Starting low-dose antidepressants (particularly venlafaxine), gabapentin, or using acupuncture improves adherence to other treatments.

Vaginal narrowing and dryness and reduced libido may follow treatment. After pelvic radiation treatment , vaginal narrowing may occur; vaginal dilators are a treatment option.

Many patients ask for vaginal dryness help, especially nonhormonal products. Although many US products exist, many are unsuitable for pH balance and osmolality, and inappropriate products should be avoided. For painful intercourse, pH-compatible products containing local anesthetics such as lidocaine may help.

Local vaginal estrogen may increase blood flow, secretions and lubrication and vaginal sensitivity. For this purpose, estrogen-containing Prasterone (vaginal dehydroepiandrosterone) received US Food and Drug Administration (FDA) approval. It improved symptoms in genitourinary syndrome of menopause without raising systemic hormone levels, but published data are lacking in breast cancer patients taking aromatase inhibitors. Many oncologists are nevertheless comfortable with local vaginal estrogen even in hormone receptor-positive patients taking aromatase inhibitors. When prescribing local hormones, physicians must consider absorption, which varies by substance. For vaginal-vulvar complaints, regional hormone treatment should be limited to the vulva, which is less vascular than the vagina.

According to Rowen, vaginal dryness and pain should always be treated before addressing libido loss. Once pain is relieved, off-label antidepressants such as bupropion and buspirone may be considered, having shown some effectiveness in improving desire.

Flibanserin increased sexual desire versus placebo in trials and was the first FDA-approved drug for low libido in premenopausal women. According to Rowen, "There is no reason to believe it would cause problems in our cancer patients, since it will not affect hormone-related diseases." It has not yet been approved for postmenopausal women, although evidence suggests efficacy.

Women Complain of Low Desire, Not a Lack of Satisfying Sex

In June 2019, bremelanotide, a melanocortin 4 receptor agonist, was FDA-approved for premenopausal women. Delivered by autoinjection, it improved sexual function and produced a satisfying increase in sexual events in trials.

"I think there is a problem with specifying satisfying sexual events, because women do not complain to me that they are not having satisfying sex. They complain of low desire; sexual desire is what matters most to women," she said. "The nice thing about bremelanotide compared with flibanserin is that it is a one-night drug."

Rowen noted that unfortunately no FDA-approved treatment yet exists for postmenopausal women, but the strongest evidence supports off-label testosterone.

According to Rowen, "Many oncologists and radiation oncologists know this matters, but often have no time to discuss it. This is where partnership with a colleague more familiar with the vagina and vulva, particularly a gynecologist, plays a major role."

She also said treatment planning must consider emotional and physical aspects of sexuality and how to redefine sex after cancer treatment. Rowen said, "Some of these women will not be able to have intercourse," she said. "Focusing on intercourse is generally a major problem, and there are other ways for people to be intimate."

In conclusion, the meeting found that discussing sexual health with cancer patients is vital, particularly providing information on how disease and treatment may affect sexuality, with appropriate communication essential.