Breast Cancer Sexuality, Sensuality and Intimacy: Part I
Michael L Krychman MD Executive Director of the Southern California Center for Sexual Health and Survivorship Medicine. Newport Beach CA
Associate Clinical Attending University of Southern California
Diane Parks, MS, CNM, WHNP, Certified Sexuality Counselor, Charlotte, NC
This is part one of a two part series on Breast Cancer Sexuality and Intimacy. Part One addresses etiological issues related to surgical, radiation and chemotherapeutic causes of female sexual complaints for the breast cancer patient. Part two will focus on the practical and clinical treatment paradigms to assist the health care professional in their management of sexual complaints.
Sexual health concerns are distressing complications for patients and their partners during the diagnostic, treatment, and recovery phases of their cancer. Healthy sexual functioning is a vital step toward reestablishing their sense of normalcy and well-being.(1) Several physiological and psychological factors that are specific to oncology patients, such as extensive surgical procedures, pelvic, breast or extremity radiation, chemical or surgically induced menopausal symptoms, premorbid sexual dysfunction, and negative self-concept or poor self image, all can impact overall sexual functioning. (2, 3) For those women who have partners, sexual dysfunction may threaten the integrity and stability of their relationships, limiting this source of social support (1, 4, 5). Single women and those in same sex relationships also may face specific sexual concerns. These special populations are often neglected or ignored in clinical practice.
SURGERY
Surgical excision alters structural anatomy and may compromise the neurovascular integrity to organ systems critical to sexual responsiveness, thereby affecting sexual self image, or how one views oneself as a sexual being. Several scientific reviews have examined the impact of breast surgery on sexual functioning and concluded that conservative operative procedures and/or reconstruction played only minor roles in overall sexual functioning (6, 7). Patients who have undergone breast conservation surgery may be more likely to engage in breast caressing than women who have undergone mastectomy. Women who have undergone total mastectomy often have issues relating to altered body image and may develop a negative sexual self perception. Recent data demonstrated that those women who undergo immediate reconstruction are more likely to be satisfied with the cosmetic and esthetic result achieved and least likely to feel loss with respect to sexual attractiveness. (8)
Up to 10% of women with breast cancer may carry the BRCA gene mutations and choose to undergo a risk-reducing bilateral salpingo-oophorectomy if they are found to be at an increased risk for the development of ovarian cancer (9). They are troubled by abrupt menopausal syndrome including deprivation of estrogen which may lead to symptoms including vaginal dryness, painful intercourse (10) and debilitating hot flashes and flushes.
RADIATION
Radiation therapy often causes skin damage and changes, as well as fatigue. Many radiation-induced symptoms contribute to general malaise and may impact the sexual response cycle, most commonly, sexual interest or libido. Psychologically, patients and/or their partners fear the myth of being “radioactive.” Skin thickening and discoloration to the irradiated and affected breast can impact self-esteem and sexual functioning. Scars with breast skin and axillary region fibrosis may limit range of motion and contribute to lymphedema. Asymmetrical breast tissue, changes in skin coloration are also of concern for many women and many who have enjoyed breast caressing feel troubled by this change in a once erotic area.
CHEMOTHERAPY
Chemotherapy may produce ovarian failure (11) inducing menopausal symptoms, such as dyspareunia, vaginal atrophy, decreased vaginal lubrication and hot flashes. The vaginal lining may become thin, with diminished pliability and elasticity, leading to painful intercourse or coital dyspareunia. Distressing hot flashes are troublesome for the young cancer survivor. Menopausal Syndrome and its associated effects may impact general health and mood which can lead to sleep disturbances, irritability, and ultimately, affect the sexual response cycle.
HORMONAL THERAPY
Selective estrogen receptor modulators (SERMS) and aromatase inhibitors (AI) can exacerbate menopausal symptoms. Tamoxifen ® is a SERM often prescribed to block estrogen receptors in the breast and has been inconsistently linked to reports of vaginal dryness, excessive vaginal discharge, vaginal soreness, delayed orgasm, and changes in libido (12, 7, 13, 14) Aromatase inhibitors, on the other hand, (Anastrozole, Letrozole, and Exemestane) are rapidly becoming the mainstay of treatment for various stages of breast cancer and these medications halt the conversion of testosterone to estrogen, thus diminishing circulating estrogens. Many more women complain of vaginal dryness, dyspareunia and loss of sexual desire with AI treatment than with tamoxifen alone (15)
PSYCHOLOGICAL CONCERNS
The literature supports that many women adapt well after they learn of their diagnosis. However, there is a significant subset of women who report continued anxiety, depression, and concerns regarding body image, the fear of recurrence, post-traumatic stress disorder, and sexual problems even after they are treated. (16) Sometimes women may link prior negative sexual experiences, past sexual behavior (promiscuity, extra marital affairs and/ or sexually transmitted diseases) to the cancer diagnosis.
The dynamics of relationships can be strained and changed with a cancer diagnosis and therapy. The survivors’ level of relationship distress, depression and age may be
seen as the most significant variables affecting arousal, orgasm, lubrication, satisfaction
and sexual pain rather than hormonal levels. (17) Women may be absent from their roles as caregivers and/or wage earners which directly impacts their partners and can create both marital and financial tension. Worries regarding partner abandonment, and sexual rejection may interrupt existing or hinder the development of intimate relationships. Single women who are breast cancer survivors may also face different concerns including, negotiating new relationships, time to disclose medical illnesses or fertility issues. Other forms of psychological distress include fear of recurrence, early death, disfigurement, as well as financial, employment and insurance concerns.
Although there are many etiological issues that precipitate sexual health concerns for women with breast cancer there are simple interventions which the health care provider can easily suggest and implement. Such interventions will have a significant impact on sexual health issues and will undoubtedly affect sexuality, intimacy and sensuality. Simply discussing and addressing sexual problems and validating their existence will give patients hope. The treatment of sexual health concerns will directly impact quality of life.
Part II will address a practical, clinical and pharmacological treatment paradigm for addressing sexual health problems.
REFERENCES
1 Schover LR. Sexuality and Fertility after Cancer. New York: John Wiley and Sons, 1997.
2 Devita VT, Rosenberg SA, Hellman S, eds. Cancer: Principles and Practices of Oncology, 6th Ed. Philadelphia, PA: Lippincott Williams& Wilkins, 2000 3032-49.
3 Anderson BL. Surviving cancer: the importance of sexual self-concept. Med Pediatr Oncol 1999;33:15-23.
4 Van de Wiel, Weijmer, Wouda, Bouma. Sexual functioning of partners of gynecologic oncology patients. Sex Marital Ther 1990;1(4):479-94.
5 Auchincloss SS. Sexual dysfunction in cancer patients: issues in evaluation and treatment. In Holland JC, Rowland JH, eds. Handbook of Psycho-oncology, Psychological Care of the Patient with Cancer. New York: Oxford University Press, 1990:383-413.
6 Schover LR. Sexuality and body image in younger women with breast cancer. J Natl. Cancer Inst Monogr 1994;16:177-82.
7 Schover LR, Yetman RJ, Tuason LJ, et al. Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustment, body image, and sexuality. Cancer 1995;75(1):54-64.
8 Fernandez-Delgado J., Lopez-Pedraza MJ., Andradas-Aragones E et al. Satisfaction with and psychological impact of imediate and deferred breast reconstruction Annals of Oncology 19: 1430-1434. 2008.
9 Van Oostrom I, Meiijers-Heijboer H, Lodder LN, et al. Long-term psychological impact of carrying a BRCA1/2 mutation and prophylactic surgery: a 5-year follow-up study. J Clin Oncol 2003;21:3867-74.
10 Robson M, Hensley M Barakat R et al Quality of Life in Women at Risk for Ovarian Cancer who have undergone Risk Reducing Oophorectomy. Gynecologic Oncology 89; 281-287, 2003.
11 Kornblith AB, Ligibel J. Psychosocial and sexual functioning of survivors of breast cancer. Semin Oncol 2003;30;799-813.
12 Kaplan HS. A neglected issue: the sexual side effects of current treatments for breast cancer. J SexMarital Ther 1992;18(1):3-19.
13 Ganz PA, Rowland JH, Desmond K et al. Life After Breast Cancer: Inderstanding women’s Health realted Quality of Life and Sexual Functioning. J clin Oncol 16 (2) 501-14, 1998.
14 Meyerowitz BE, Desmond KA, Rowland JH, et al. Sexuality following breast cancer. J Sex Marital Ther 1999;25(3):237-50.
15 Fallowfield L Cella D, Cuzick J, francis S., Locker G Howell A. Quality of life of postmenopausal Women in the Arimidex, tamoxifen alone or in combination (ATAC) Adjunct Breast Cancer Trial. J clinc Oncology 2004; 22;4261-4271.
16 Kornblith AB, Ligibel J. Psychosocial and sexual functioning of survivors of breast cancer. Semin Oncol 2003;30;799-813.
17 Speer JJ, Hillenberg B Sugrue et al Study of Sexual Functioning Determinants in Breast Cancer Survivors, The Breast Journal 11;6: 440-447. 2005
Treatment of Sexuality Dysfunction after Breast Cancer Treatment: Part II
Michael L Krychman MD Executive Director of the Southern California Center for Sexual Health and Survivorship Medicine. Newport Beach CA
Associate Clinical Attending University of Southern California
Diane Parks, MS, CNM, WHNP, Certified Sexuality Counselor, Charlotte, NC
Sexual difficulties are common problems for the breast cancer survivor because of the multifaceted etiological factors, which were described in detail in part one. Sexual complaints often develop because of the emotional impact of the diagnosis and are compounded by treatments such as surgery, radiation therapy, and chemotherapy, hormonal medications, each of which can have sexuality-altering side effects. (1) Sexual dysfunction includes a broad spectrum of concerns such as sexual disinterest, loss of libido, changes in sexual arousal and orgasmic problems, and dyspareunia (painful intercourse) caused by vaginal dryness/ atrophy and vaginal spasms/vaginismus. (2) Ideally, the treatment paradigm is multifaceted (1) and therapeutic strategies to address sexual concerns can be classified into a) educational efforts, b) psychotherapeutic and c) non pharmacological methods and d) pharmacological therapies. (3)
OVERALL GENERAL HEALTH.
Often in the acute crisis of cancer care, chronic medical illnesses such as hypertension or thyroid dysfuction are left unaddressed. Identifying and treating simultaneous chronic medical conditions can be helpful in restoring sexual functioning. Maintenance of a well-balanced diet (limiting fat and alcohol), engaging in mild to moderate aerobic exercise frequently throughout the week, as well as discontinuation of tobacco or illicit drugs and minimizing alcohol consumption can contribute to overall wellness, and help re-invigorate sexual response. (1) Maintaining a good sleep balance and decreasing stress is also important to overall health and maintenance.
EDUCATIONAL EFFORTS.
Several researchers have suggested that both patients and healthcare providers benefit from clear, precise, knowledgeable information about sexual difficulties while stressing the common occurrence of this problem. Education is key to managing menopausal syndrome and some of the symptoms may be manageable without medication but with lifestyle changes including the avoidance of spicy foods and caffeine, decreasing alcohol consumption, lowering ambient thermostats, and dressing in layers. (1) Education about sexual anatomy, sexual responsivity and the natural changes a couple experiences with time may also be very helpful for the couple who is struggling with a change in their sexual and intimate lives.
PSYCHOTHERAPEUTIC METHODS.
Marital or sexual counseling can be beneficial for stress, time management as well as to enhance and develop effective communication techniques. Sometimes structured sexual exercises such as sensate focus, erotic massage and communication techniques can be paramount in the comprehensive management for sexual complaints. The integration of treatment to include genitor- pelvic floor physical therapy can be very effective to address dyspareunia from vaginismus or radiation damage (2) and this therapy will frequently include relaxation techniques, biofeedback therapy, kegel exercises, and dilator therapy. Frequent visits to the sexual medicine specialist will help maintain your progress with the dilators. Sexual health resources to enhance body image (wigs, special lingerie, attachable nipples etc) should be widely available to help the cancer patient /survivor reclaim her sexual self-esteem. (4)
NONPHARMACOLOGICAL METHODS.
Over the counter, nonhormonal vaginal moisturizers and water-based vaginal lubricants are often helpful to address both vulvar and vaginal dryness and mucosal irritation. Women should to avoid placing over the counter products that contain potentially irritative additives such as: warming agents, bactericides, microbicides, perfumes, coloration, and flavors into sensitive dry areas such as the vagina as they can further irritate an already sensitive vaginal area.
There are a variety of neutriceutical products including a botanical feminine arousal oil, Zestra®, which for some patients have augmented the genital arousal responses. The author has used this product often with women who have breast cancer and complain of changes with respect to orgasmic intensity and latency. Commercially available vibrators/self stimulators can also be helpful for women who benefit from extra stimulation to erotic areas of the vagina and clitoris. (1) The Eros Clitoral Therapy Device is a small clitoral vacuum pump used to increase sensation, lubrication, ability and intensity of orgasm and improve overall sexual satisfaction. This device has been approved by the U. S. Food and Drug Administration and can be purchased discretely from Web-based companies (2)
PHARMACOLOGIC THERAPIES.
Breast cancer is often hormonally sensitive and tumor cells possess estrogen and progesterone receptors; therefore, treatment of menopausal sequelae with systemic replacement hormones is almost always contraindicated and remains a hotly debated topic. Many advocate a tempered approach with individualization in the use of minimally absorbed local vaginal estrogen products. These products remain contraindicated in breast cancer patients however many health care providers are using them sparingly in clinical practice and for those who have failed conservative non hormonal regimes and are still suffering from debilitating vaginal complaints. (4) Local treatments with minimally absorbed vaginal estrogen preparations have gained attractiveness within the oncology community because of their minimal systemic absorption and efficacy in the treatment of vaginal dryness and pain with intercourse. Several small reports noted increased estradiol levels in women on aromatase inhibitors on vaginal estrogen tablets. (5) Long-term safety data is lacking and use of estrogens for the treatment of vaginal atrophy in breast cancer women remains controversial and contraindicated. The amount of escape in to the systemic circulation remains problematic and has the potential to interfere with aromatase inhibition. Recent data on DHEA vaginal ovules intravaginally may be promising for the breast cancer patient; although still in stage 3 clinical trials, and not studied in those women with a history of malignancy, the emerging data demonstrates efficacy with atrophy reversal and no changes in systemic hormonal levels. This product remains experimental and is not FDA approved as of the article being drafted. ( 6)
Recent studies on the use androgen replacement for sexual dysfunction in breast cancer patients has shown inconsistent benefits (7,8) and few studies are available to confirm benefits of androgen therapy in cancer patients. There are concerns regarding possible aromatization of androgens to estrogen in women with breast cancer (2) and future studies are warranted to examine the safety and efficacy of androgens in this population.
The nonhormonal medication like, Bupropion has been shown to increase sexual arousal, orgasm intensity and overall sexual satisfaction. (3) Many women are taking antidepressants as a non-hormonal alternative to control hot flushes and other menopausal symptoms and are experiencing undesired sexual side effects of these antidepressants. Bupropion has been shown to increase sexual desire and frequency of activity in patients with antidepressant-induced sexual dysfunction. (2)
Phosphodiesterase Inhibitors for the treatment of female arousal disorder has been gaining popularity in recent years. The data is inconsistent regarding benefits and there are no large, long-term studies confirming safety in breast cancer survivors or those at risk for the disease. (2) However , phosphodiesterase inhibitors remain a new, exciting area of interest for the treatment of SSRI induced sexual dysfunction.
Summary. Sexual dysfunction, during or following cancer therapy, is a very complex disorder and can compound an already stressful life event. Care and consultation between the survivor, her family, the oncological team and general medical practitioner should be aimed at discussing individualized treatment plans that minimize risk and maximize sexual wellness. (1)
REFERENCES
1 Krychman M, MD and Kellog S PhD. Coping with Sexual Issues with Breast Cancer. May 2009
2 Derko, C MD, Elliott, S MD, Lam, W MD. Management of sexual dysfunction in postmenopausal breast cancer patients taking adjuvant aromatase inhibitor therapy. Current Oncology. 2007; 14 (Supplement 1); S20-S40
3 Thors, C PhD, Broeckel A PhD, Jacobsen, P PhD. Sexual Functioning in Breast Cancer Survivors. Cancer Control. 2001; 8: 442-448.
4 North American Menopause Society: the role of local estrogen for treatment of vaginal atrophy in postmentopausal women: 2007 position statement on the North American Menopause Society, Menopause 14:355-369.2007.
5 Kendal A, Dowsett M, Folkerd E, Smith I Caution: Vaginal estradiol appears to be contraindicated in postmenopausal women on adjunct aromatase inhibitors Ann Onco 2006; 17: 584-587
6Labrie F, Archer D, Bouchard C, Fortier M, Cusan L, Gomez JL, Girard G, Baron M, Ayotte N, Moreau M, Dubé R, Côté I, Labrie C, Lavoie L, Berger L, Gilbert L, Martel C, Balser J. Intravaginal dehydroepiandrosterone (Prasterone), a physiological and highly efficient treatment of vaginal atrophy. Menopause. 2009 Sep-Oct;16(5):907-22.
7 Barton DL Wender DB, Sloan JA et al, Randomzied clinical trial to evaluate transdermal testosterone in female cancer survivors with decreased libido. North Central Cancer Treatment Group Protocol N02C3. J Nat Cancer Instit 99: 672-678, 2007.
8 Krychman ML, Stelling CJ, Carter J, Hudis CA.A case series of androgen use in breast cancer survivors with sexual dysfunction.J Sex Med. 2007 Nov;4(6):1769-74.