The gravity of cancer treatment can make concerns like sex life appear less important. Nevertheless, the treatment of sexual side effects of cancer therapy is imperative to maintain the patient’s well-being.

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Sexual response is multifactorial and depends on physical, psychological, and behavioral variables. The most common sexual problems among male cancer patients are loss of sexual interest and erectile dysfunction. Among women, vaginal dryness, dyspareunia, and vaginal atrophy or contraction are all concerns.

Sexual problems, unlike other physiologic adverse effects of cancer treatment, do not usually remit after treatment. Instead, sexual adverse effects of cancer therapy can persist or get worse.

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Sex as a lifelong concern

1. Data published by the National Cancer Institute in 2014 revealed some form of sexual dysfunction occurring in 40% to 100% of individuals diagnosed with cancer.
2. Sexual dysfunction, which is a term that is less expansive than sexuality, refers to either dysfunction in one of the four phases of the sexual response cycle, or dyspareunia. 
3. The WHO defines sexuality as a central component of being human throughout life. It encompasses gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. 
4. Sexual health, therefore, is not just the absence of pathology; it refers to all the biopsychosocial aspects of sexual well-being, according to the experts. Although cancer and its treatments are known to adversely affect sexual health, it’s difficult to quantify the impact in all its aspects. 

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Causative treatments

The National Cancer Institute lists some of the cancer treatments in men that can lead to sexual problems.

1. Chemotherapy can lower testosterone levels and libido during treatment.
2. External-beam radiation therapy to the pelvis at the level of the anus, bladder, penis, or prostate, and brachytherapy (ie, internal radiation therapy), can damage nerves and blood vessels, leading to erectile dysfunction. 
3. Androgen-directed therapy can decrease testosterone levels and reduce sex drive, which may lead to erectile dysfunction. In cases of penile, rectal, prostate, testicular, and other pelvic cancers, surgery can damage nerves, thus contributing to erectile dysfunction. (Nerve-sparing surgery can sometimes serve as a preventive measure.)

In women, sexual adverse effects can occur, as discussed in an article in Breast Care (Basel).

1. In breast cancer survivors, cancer treatment affects all phases of sexual response, with vaginal atrophy being very troublesome and resulting dyspareunia common—especially among those treated with aromatase inhibitors (AIs).
2. Treatments that block the production of estrogen can lead to vaginal dryness, dyspareunia, lack of libido, and related problems.
3. Women receiving radiation for cervical or anal cancer experience vaginal atrophy or contraction.

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Management of sexual health complaints

When treating patients with sexual health issues secondary to cancer treatment, it may be a good idea to put them in touch with a sexual health expert or counselor. You can also recommend that they join a support group. 

The CDC notes that most men can continue to be sexually active during cancer treatment, although there may be periods of increased infection or bleeding during which temporary abstinence may be required. Additionally, a barrier form of birth control such as condom may be necessary to prevent pregnancy, depending on the type of  chemotherapy.

Medical interventions for male sexual dysfunction secondary to cancer treatment include surgery (eg, penile implant) or drugs. The use of PDE5 inhibitors (PDE5i) may also help with erectile dysfunction secondary to certain cancer treatments, such as with prostate cancer following radical prostatectomy and radiotherapy.

A systematic review published in Frontiers in Surgery discussed the role of PDE5i.

“Chronic dosing of PDE5i was proposed as a measure to accelerate recovery of return to spontaneous erections after nsRP [nerve-sparing radical prostatectomy],” the authors wrote.

“Nightly and long-term administration of sildenafil did indeed show to increase the return of spontaneous erections.”

The authors added, “The other PDE5i [tadalafil] did not show significant increase in faster return to spontaneous erections after surgery. But, follow-up periods used may have been short. In the available trials, follow-up was never longer than 12 months; although neuronal recovery after nsRP has been shown to take up to as long as 4 years. Therefore, hard conclusion about the true effects on daily PDE5i on return to spontaneous erections after nsRP cannot be made yet.”

Other erectile-dysfunction treatments mentioned by the authors include intraurethral alprostadil and intracavernosal injection, as well as penile vibratory stimulation.

In breast cancer survivors, note the authors of the article in Breast Care (Basel), vaginal lubricants and moisturisers may be used, although little research has been done on the topic. Estrogen treatment should be used only after consultation with the patient’s oncologist and a thorough review of risks. The engagement of multidisciplinary teams can also reduce female sexual dysfunction and relationship issues.

In an exclusive email interview, Jeffrey A. Bubis, DO, noted that “women with the most severe complaints (which are less frequent due to lower incidence of the disease) are those who receive radiation for cervical or anal cancer. This frequently leads to vaginal atrophy and contraction requiring dilation.”  

The multifactorial nature of sexual health, says the CDC, means that related problems, including fatigue, hair loss, pain, sadness, insomnia, or anhedonia, should be treated in a bid to improve sex life. 

The CDC recommends that cancer patients discuss their feelings about sex with their spouse or partner. 

“Sexual health and intimacy are important parts of a person’s well-being. They are closely linked to how you see yourself and relate to others. After cancer treatment, it can be challenging to face sexual health concerns, even if you’ve been with your partner for years.”

— CDC

Talking about sexual concerns openly and honestly, the CDC says, may prevent frustration and confusion. Overall, sexual side effects secondary to cancer therapy are difficult to treat in both men and women, according to Dr. Bubis.

“You can treat the men by stopping hormonal therapy, but that has been associated with inferior outcomes. You can give pelvic therapy to women. While some of these changes are reversible, not all are, and things are never the same,” he said.

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This story is contributed by Naveed Saleh and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members