Health and Wellness

Sex after breast cancer: Helping your patient cope

Any type of cancer has an immeasurable impact on the quality of life, including sexuality. Breast cancer’s impact on sexuality may be especially pronounced, because the disease and its treatments can directly alter body image, lower self-esteem, and cause physical impediments to sexual activity. One study found that sexual dysfunction may be one of the most common and distressing problems in breast cancer survivors.

Breast cancer can cause sexual dysfunction in men as well as women. As you’re probably aware, breast cancer occasionally occurs in men. Some men who develop it may feel embarrassed to have a “woman’s cancer”—and this can lead to or exacerbate sexual dysfunction.

A tough topic to broach
Sexuality influences how a person feels about herself and her body and how she relates to others. It encompasses more than just sexual behavior; it’s an ever-changing, lived experience that persists despite disease or treatment.

Unfortunately, nurses and other healthcare providers don’t always address patients’ sexuality concerns. Some may not even be aware these concerns exist. In a typical scenario, the nurse assumes that if a patient has such concerns, she’ll broach on her own. The patient, for her part, may be counting on the nurse to raise important issues; if she doesn’t, she may think sexuality isn’t important or assume she’s the only cancer patient who has sexual concerns.
To make matters worse, sexuality is a difficult topic for most people to broach. Nonetheless, only by acknowledging the importance of sexuality in your patients’ lives can you help them deal with sexual changes resulting from breast cancer or its treatment.

How breast cancer can lead to sexual dysfunction
Breast cancer itself and the treatments it may require can alter one’s physical appearance, damage a patient’s body image, and cause other physical and psychological problems that decrease sexual desire or make sexual activity painful and uncomfortable. In a study of female breast cancer survivors age 50 or younger, a substantial number experienced body-image and sexual problems within several months of diagnosis. Half experienced two or more body-image problems about one-third of the time; about 17% experienced at least one such problem much of the time. The researchers found that greater sexual problems were associated with being married, vaginal dryness (which can make intercourse painful), more body-image problems, a partner’s difficulty understanding one’s feelings, and poorer mental health. (See Risk factors for sexual dysfunction in the downloadable pdf available at the bottom of this page.)

Another study found that wo­men who’d had mastectomies with breast reconstruction were more likely to report that breast cancer negatively affected their sex lives, compared with those who’d had a lumpectomy or a mastectomy alone.


Early menopause symptoms
Research shows that about 53% to 89% of breast cancer survivors who receive multiagent adjuvant chemotherapy develop early menopausal symptoms, which in themselves can cause sexuality problems. (See Treating meno­pausal symptoms in the downloadable pdf available at the bottom of this page.)

Hot flashes are among the most commonly reported symptoms in women who’ve completed breast cancer treatment. These are significantly more frequent, more severe, longer-lasting, and more distressing in such women than in those who haven’t undergone cancer treatment. Cancer patients also are less likely to be taking hormone replacement therapy (HRT) and are more likely to have tried nonhormonal prescriptions previously, with less efficacy.

Communication breakdown
Even in the absence of breast cancer, many couples don’t communicate well about sexuality; instead, they simply expect sex to happen. When one partner has breast cancer, communication can suffer even more. The ill partner may be embarrassed about her change in sexual functioning and may hesitate to discuss it with her partner—or anyone else. The well partner may continue to be interested in sexual activity, yet be reluctant to talk to his partner for fear of upsetting her. In many cases, they simply stop having sexual intercourse, without any discussion.

When sexual intercourse stops, other forms of intimacy may wane. Couples may even stop hugging and kissing for fear they’ll arouse each other but not be able to proceed to intercourse.

Assessment and intervention
Being aware that illness can affect sexuality is crucial in helping patients deal with sexual dysfunction. To accurately assess sexual functioning and detect problems, you need to be knowledgeable about sexuality, including the physiologic changes that take place during sex.
Gather information in a way that helps your patient express her sexuality concerns. To make her more comfortable with the subject, address sexuality while she’s dressed and, preferably, alone. Be sure to use correct anatomic terms. To increase both her comfort level and your own, demonstrate knowledge and show that you’re comfortable with your own feelings about sexuality.

To elicit more information, ask open-ended questions, such as:

•    “What sexual changes have you noticed since your treatment?”
•    “Sexually, how have things changed for you since your treatment?”
•    “How are things going sexually?”

If your patient has had breast surgery, make sure to assess for body-image and self-esteem problems. To address these, help her explore the role her breasts play in her sexuality.
If your patient complains of reduced libido or vaginal dryness, explore her medication history. Be aware that breast cancer patients commonly receive aromatase inhibitors and selective estrogen-receptor downregulators—drugs that can cause vaginal dryness and decrease the libido.

When to seek drug therapy changes
In some cases, you might consider asking the physician to change the patient’s medication regimen to improve her sexual functioning. If she’s taking an antidepressant known to decrease the libido, perhaps she can switch to one less likely to have this effect.

Ordinarily, when a patient complains of vaginal dryness, a physician may prescribe estrogen to ease discomfort. But most breast cancer is hormone-related, and estrogen may promote tumor growth. So women who’ve had the disease usually aren’t allowed to take HRT. Nonetheless, some oncologists may permit the patient to use an estrogen vaginal ring or vaginal cream (drug forms containing low-dosage estrogen) to improve vaginal health. Black cohosh and soy, sometimes used to treat vaginal dryness and improve sexual arousal, also stimulate estrogen levels and should be avoided by women with breast cancer.

Other suggestions
Some women with cancer have found that although they may lack sexual desire initially, they can become aroused once sexual activity begins, and subsequently are able to enjoy it. Depending on your patient’s situation, consider suggesting the couple schedule sexual encounters instead of waiting for sexual desire to kick in. As fatigue is one of the most common and longest-lasting adverse effects of cancer treatment, scheduling encounters when the patient’s energy is highest can improve sexual function.

Similarly, if your patient has pain or other symptoms that medication can relieve, encourage her to plan accordingly. For example, advise her to take analgesics 30 minutes before having sex.

Depending on the specific sexual dysfunction, you might recommend experimenting with sexual positions. If appropriate, refer the patient or couple to such books as The Joy of Sex for ideas on alternate ways of pleasing each other sexually. The American Cancer Society (ACS) offers excellent resources on sexuality for both women and men with cancer, available by calling 1-800-ACS-2345 or visiting the ACS website (www.cancer.org).

As a nurse, you’re more likely than other healthcare providers to see the patient at regular follow-up visits or while hospitalized. Make the most of this advantage by assessing her sexual functioning at every visit. Once sexuality becomes a regular part of assessment, your patient will find it easier to bring up sexual concerns as they arise.

Mary K. Hughes is a Clinical Nurse Specialist in the Department of Psychiatry at the University of Texas MD Anderson Cancer Center in Houston.

Selected references
Fobair P, Stewart SL, Chang S, et al. Body image and sexual problems in young women with breast cancer. Psychooncology. 2005;15(7):553-649. www3.interscience.wiley.com/journal/112139159/abstract. Accessed August 18, 2008.

Huber C, Ramarace T, McCaffrey R. Sexuality and intimacy issues facing women with breast cancer. Oncol Nurs Forum. 2006; 33(6):1163-1167.

Wilmoth MC, Coleman EA, Smith SC, Davis C. Fatigue, weight gain, and altered sexuality in patients with breast cancer: exploration of a symptom cluster. Oncol Nurs Forum. 2004;31(6):1069-1075.

 

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