By Jeannine Walston

“Sexuality is an important aspect of human life and relationships. Not to address it adds one more loss to cancer,” says Debbi Hampton, a 51-year-old breast cancer survivor from Tennessee, who speaks from experience.

After a modified radical mastectomy in 1994, Hampton says she focused on living and raising her 10-year-old daughter, who is now 19. She also adjusted to seeing herself without breasts. Crying after not finding a dress that fit her properly, Hampton decided to reclaim how she looked and felt before cancer, describing breast reconstruction as “a reunion with self.”

Four years later, a recurrence brought up more challenges with sexuality. Hampton didn’t want to lose her breasts again. The hormonal changes from her treatments also posed new problems. She found comfort in her breast cancer support group, where members talked openly about sexual concerns. After consulting with a gynecologist and a psychiatrist, who prescribed estradiol vaginal tablets and topical testosterone, Hampton says, “I got my sex life back!”

Impacts of Breast Cancer Treatments
Chemotherapy disrupts female sexuality more than other treatments, explains Patricia Ganz, MD, professor of health services and medicine and director of the Division of Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, Los Angeles.

“Chemotherapy can cause premature menopause. This may result in ovarian failure, diminished androgens such as testosterone, libido changes, and lubrication problems. Vaginal dryness occurs independent of age,” says Dr. Ganz.

Chemotherapy is most likely to trigger menopause for women who are close to its natural onset, but it can happen to younger women too. For women of childbearing age and their partners, fertility loss from premature menopause can be devastating.

Postmenopausal women diagnosed with breast cancer who stop taking hormone replacement therapy because of its association with cancer can experience dramatic hormonal changes. “This challenge affects a large number of healthy, aging women,” notes Dr. Ganz.

The Breast Cancer Prevention Trial, a study of 13,000 healthy, high-risk women, suggests that the hormonal agent Nolvadex® (tamoxifen), which works by blocking estrogen from binding to tumor receptors, increases vaginal discharge, hot flashes, and night sweats. Overall, however, Dr. Ganz describes the side effects of tamoxifen as “fairly limited.”

She does have concern for the side effects of aromatase inhibitors, which include Arimidex® (anastrozole), Femara® (letrozole), and Aromasin® (exemestane). This newer class of hormonal agents shuts down the production of female hormones estrogen and pro- gesterone in postmenopausal women. Unlike tamoxifen, there is little risk of developing uterine cancer and blood clotting with aromatase inhibitors. But women taking aromatase inhibitors for long periods of time may be at a higher risk of developing osteoporosis.

Radiation is another type of breast cancer treatment that can impact sexuality by possibly causing tiredness, nausea, skin changes, and hair loss. Some women report that these side effects are a detriment to sexual health.
Studies comparing breast-conserving surgery with mastectomy indicate both treatments may have similar effects on sexual health and functioning. Yet, breast-conserving surgery (see CURE, Fall 2003) may leave women with better body image, and therefore poses less impact on sexuality.

Predictors of Sexual Health
Dr. Ganz, who studied factors influencing sexual health in women three years after their breast cancer diagnosis, found vaginal dryness was the main predictor of sexual dysfunction, according to results published in the August 1999 issue of the Journal of Clinical Oncology. Other important factors included emotional well-being, body image, quality of the couple’s relationship, and sexual problems of the woman’s partner.

With or without cancer, “these predictors of sexual health are universal for women,” Dr. Ganz emphasizes. She explains there has been little research on men diagnosed with breast cancer and its potential sexual side effects.
Psychological distress because of cancer can also contribute to sexual dysfunction, leading to decreased sexual interest, challenges with arousal, and difficulty achieving orgasm. Fatigue, pain, and physical inactivity can also diminish sexual functioning.

Vaginal Products
For vaginal dryness, lubricants such as Astroglide® may be helpful during intercourse. Women who have dryness independent of sex may use an estrogen-free product such as Replens® (polycarbophil) a few times a week to increase moisture. Estring® (estradiol), which offers a slow local release of estrogen, has been effective for many women.

A testosterone supplement is another option, says Dr. Ganz. She notes women shouldn’t use the more traditional estrogen creams because they can be absorbed into the bloodstream and lead to increased levels of estrogen that are possibly associated with an increased breast cancer risk.

Women experiencing vaginal dryness should consider discussing it with their healthcare provider. “Someone from the healthcare team should be knowledgeable and sensitized to these issues. Patients need to make their needs known,” explains Dr. Ganz.

However, before using any products, Dr. Ganz recommends, “Psychological, relationship, and other issues such as fatigue should be addressed first.”

Behavioral Interventions
Ursula Ofman, PsyD, a sex therapist in New York City who works with cancer patients, believes women need to communicate sexual problems to their healthcare provider, other survivors, and especially their partner. Medical institutions should offer “proactive attention to educate women about common side effects from treatments,” she says.

“Women are often reluctant to address sexual difficulties, and they need to talk about them. Women and their partners should discuss it outside of the bedroom with space for reflection and without pressure to act sexually,” she adds.

In Dr. Ofman’s clinical experience, the best predictor of sexual function after cancer is sexual function before cancer. Research also reflects this tendency. “Women who have a good sex life before cancer adjust better after,” she explains.

A major challenge to sexual functioning can be avoidance. “Getting sexually started again can be extremely difficult for women and men alike,” notes Dr. Ofman. “Women and their partners need to develop comfort to explore sexually without expectation. Many couples learn sexual pleasure comes from new activities and routines.”

Dr. Ofman encourages partners to be compassionate and gently inquisitive. “A supportive partner who is interested without placing demands helps women gain acceptance for feeling desirable and capable again.”

Hampton’s husband, Steve, says, “The hardest part for me was that my wife might become disappointed in herself. I learned to place Debbi’s needs before my own and adjusted my expectations.”

The need for psychological counseling depends upon the relationship. “Many couples dealing with sexual challenges resulting from cancer don’t require sex therapy. It is more an issue of helping couples adjust to altered physical realities,” says Dr. Ofman. “Some couples who feel stuck often overcome their problems after a few sessions.”

For the Hamptons, the key was talking about sexual intimacy. “Without open communication, our relationship could have been destroyed,” says Steve Hampton. Instead, they both affirm personal growth from their sexual challenges.