Erika Limoncin1, Daniele Mollaioli1, Giacomo Ciocca1, Giovanni Luca Gravina1 and Emmanuele A. Jannini2
(1)
Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
(2)
Chair of Endocrinology and Medical Sexology, Department of Systems Medicine, Tor Vergata University of Rome, Via Montpellier 1, 00131 Rome, Italy
Emmanuele A. Jannini
Email: eajannini@gmail.com
11.1 Introduction
The diagnosis of any type of tumor always involves hurt and grief at the loss of everlasting health – a fact that we all take for granted. A tumor is an intimation of mortality. Therefore, a common consequence of a cancer diagnosis is a negative impact on psychological well-being and consequently on sexual health. Frequently, consequences can be observed in the form of depressive symptoms, anxiety, agitation, anger, misbelief about the cancer’s origin, and stress related to personal relationships, as well as various sexual disturbances. In particular, sexual problems are frequent in those with a diagnosis of a urogenital cancer. In addition, the side effects of cancer treatment have an important bearing on male and female sexuality. Among these treatments, chemotherapy takes a central role in worsening the psychological equilibrium and overall well-being. The most frequent symptoms related to chemotherapy are nausea, vomiting, diarrhoea, constipation, mucositis, weight changes, and an altered sense of taste and smell. Hence, the patient is conscious of taking a drug, which, on the one hand, is crucial to overcoming the illness, and, on the other hand, it destroys the integrity of body and mind. In this context, a common consequence of chemotherapy is loss of sexual desire, since sexuality is symbolic of life, while cancer calls to mind a death experience.
The negative impact of chemotherapy on sexuality is a result of the decline in three fundamental aspects: the physical factors that indirectly influence sexuality; the direct impact on sexual function and fertility; and the psychorelational aspects.
11.2 Physical Factors Indirectly Influencing Sexuality
In cancer treatment, chemotherapy induces many physical side effects that can strongly impact sexual function and wellness. Among these, nausea and vomiting are the most distressing side effects. Nausea and vomiting associated with chemotherapy can be acute, delayed, or anticipatory. Acute emesis can occur within 12–24 h posttreatment; delayed emesis occurs more than 24 h posttreatment and can persist for up to 1 week, and anticipatory emesis occurs before administration of chemotherapy [1].
Other common side effects of chemotherapy treatment are diarrhoea and constipation. Chemotherapy-induced diarrhoea (CID) seems to be caused by changes in epithelial surface area available for digestion and absorption, while chemotherapy-induced constipation (CIC) is recognized as being a mixture of reduced frequency of bowel action and increased stool consistency. Regardless of the pattern and the severity of chemotherapy, the presence of bowel symptoms can lead to a progressive loss of sexual interest due to the chronic state of discomfort that prevents the person from relaxing and focusing on the sexual encounter [2].
Chemotherapy-induced hair loss (alopecia) is another common side effect of adjuvant and metastatic chemotherapy regimens. Because hair is an integral part of human identity and body image, especially in women, it seems reasonable to think that loss of hair might have negative repercussions on a variety of aspects of quality of life (QOL), including sexual aspects.
Oral mucositis (aphthosis) is a common morbid condition after chemotherapy. Being very painful, it will strongly diminish talking (with lesser communication), kissing, and active oral sex.
Chemotherapy with neurotoxic agents such as taxanes, platinum compounds, and vinca alkaloids can induce peripheral neuropathy, with a range of complaints: intolerable symmetric numbness, pain and burning sensations, and tingling in distal limbs. They not only disrupt the common daily functions but also intimate contact possibilities when erogenous zones are affected or the hands that used to stroke or massage are involved.
Many patients receiving adjuvant chemotherapy for cancer treatment have a tendency toward progressive weight gain, typically between 2.5 and 6 kg, but in some cases to over 10 kg [3]. Some data indicate that chemotherapy induces changes in body composition and metabolic functioning that may have a role in weight gain, as well as a role in the fatigue that occurs during treatment. Weight gain not only affects a woman’s self-concept and sexuality but also has health risks, including heart disease and diabetes, further reducing the sexual and the general quality of life, as also increasing the risk of malignancy recurrence [3].
Many non-central nervous system (CNS) cancer patients with chemotherapy suffer from cognitive decline. This “Chemobrain” phenomenon with impairment of memory, concentration, executive function, and the speed of information-processing is especially described in breast cancer patients. This is another set of elements that increases fatigue and disturbs the opportunities for relaxed intimacy and sexuality.
11.3 Direct Impact on Sexual Function and Fertility
The cytotoxic agents of chemotherapy have a remarkable impact on female sexual function with a reduction of the ability to produce vaginal lubrication and a loss of orgasmic capacity, in addition to possible coital pain. Many adjuvant chemotherapeutic drugs have a direct effect on sexuality due to disturbance of the gonadal hormone production [4]. Another side effect after surgery in women with gynaecological cancer, and especially with cervical cancer, is the peripheral neuropathy that affects the control of pelvic organs. In this regard, for major preservation of sexual function, neoadjuvant chemotherapy (NACT) followed by radical hysterectomy (RH) has been demonstrated as a valid alternative to the standard treatment [5]. Therefore, an adequate assessment of the main side effects of chemotherapy as peripheral neuropathy related to sexual problems are necessary for improving the quality of life [6]. A recent study pointed out specific sexuality-related and psychological problems in women after breast cancer and related chemotherapy treatment. The authors discussed the relationship between sexuality and quality of life and they concluded that the multidisciplinary approach to breast cancer patients after the surgery is an important challenge for physicians [2].
Chemotherapy can induce premature menopause. The loss of estrogen from the ovaries leads the woman to a series of psychophysical consequences, such as vaginal atrophy, loss of tissue elasticity, decreased vaginal lubrication, and increased frequency of urinary tract infections, which may negatively impact sexuality [7]. In men, chemotherapy usually does not affect erection or ejaculation. High dose as given in blood/lymph cancer can damage the gonadal hormones, diminishing desire. Sometimes it causes permanent infertility.
The power of chemotherapy lies in damaging fast-dividing cells. Not only cancer cells are fast-dividing, but also and especially the gonadal reproduction cells. Chemotherapy can cause damage to the chromosomes of the gonads in the ovaries and of sperm cells.
During chemotherapy and shortly after chemotherapy the woman should not become pregnant. For the man it takes a much longer period before his sperm is safe again, as the life of a sperm cell takes >70 days before being mature and ready for ejaculation.
Chemotherapeutics are also toxic for the partner. Depending on the drug, it takes between 2 and 7 days before the agents have completely disappeared from the semen, the vaginal fluid, the saliva, and the excreta. So safety procedures need to be discussed with the couple and observed.
11.4 Psychorelational Factors
The psychorelational factors consequent to chemotherapy that have substantial negative effects on sexuality are: dysfunctional beliefs about the cancer and its therapy, psychological difficulties (guilt, depression), [8] reactions to the modification in body image, and stress with interpersonal relationships.
Dysfunctional beliefs about cancer are a frequent factor appearing after a cancer diagnosis, and after its treatment. Generally, a person is led into thinking that her/his uncorrected lifestyle (i.e., past sexual activity, an extramarital affair, sexually transmitted disease, abortion) is somehow the cause of this illness. In addition, some people, in particular those with malignancy of the pelvic or genital areas, believe that sexual life may promote the relapse of the cancer. The role of a physician, together with a psychologist, is to explain to the person that his or her past sexual life did not contribute to the actual situation.
The dysfunctional beliefs are inevitably a source of intrapsychic and relational stress. From an intrapsychic point of view, the person is more subjected to a development of a psychological disease, such as depression. On the other hand, from the relational point of view, misbeliefs about cancer, together with depression, may lead to relational problems. Hence, it appears clear that depression, misbeliefs, and relational problems due to cancer treatment can negatively impact sexuality and the quality of sexual intimacy, leading to a loss of desire, hypo-lubrication, pain during sex, and erectile dysfunction.
Another very important factor related to the impact of chemotherapy on sexuality regards the modifications in body image that are subsequent to chemotherapy. In particular, a consequence that may make a female less attractive and sexually seductive is the loss of hair, including pubic hair, together with weight changes (loss or gain). In fact, a study investigating physical, emotional, and sexual functioning of a group of women undergoing a surgery for breast cancer compared with a group of women undergoing both surgery and subsequent chemotherapy demonstrated the worst psychosexual well-being of the group of women undergoing both surgery and chemotherapy [9].
In addition, the impossibility of pregnancy, especially during the treatment period, may produce, in younger females, a profound wound in terms of self-esteem, and, above all, female identity.
Conclusions
Cancer diagnosis, together with cancer treatments, significantly worsens the male and female psychological well-being, self-esteem, and sexual quality of life (Table 11.1). Genuine expertise in sexual medicine with mental health professional skills should always be offered to the patient undergoing cancer chemotherapy as a functional and integral part of the oncology team. Patients, in fact, may benefit from brief psychosexual interventions, including education, counseling, and support, in combination with symptom management (Table 11.1). It has been demonstrated that patients receiving careful counseling or behavioral therapy increases their compliance to chemotherapy treatment [10].
Table 11.1
A decalogue on coaching patients undergoing cancer therapy about sexuality and fertility
|
1. |
Setting |
Create privacy and confidentiality, be aware of cultural differences, be nonjudgmental and respectful, and avoid jargon. |
|
2. |
Education on the impact of serious systemic diseases on sexuality |
The patient should be aware that any important disease might affect sexuality. This is an adaptive mechanism. But it is a good prognostic sign to resume sexual activity. |
|
3. |
Education on the impact of cancer on sexuality |
The patient should be aware that the disease process (weight loss, muscle loss, anemia, pain, fatigue, incontinence, neurological impairment, ascites, loss of sensation, depression…) might affect sexual life, so that he/she can face it in the best way. |
|
4. |
Education on the impact of cancer treatments on sexuality |
The patients must know a therapy’s impact on sexual performance beforehand. However, he/she should also be informed that there is a great variability in this. |
|
5. |
Education on the impact of cancer treatments on fertility |
In patients with both good and bad prognosis, preservations of gametes before chemotherapy, radiotherapy, and surgery should be discussed in counseling. |
|
6. |
Suggestions on improving intimate communication |
Sex should be regarded as part of an intimate relationship, particularly important when facing cancer. |
|
7. |
Suggestions on resuming sex comfortably and how to mitigate sexual handicap |
This is of particular importance in patients whose treatment has caused or will cause mutilation. In some cases, the importance of nonpenetrative sex should be stressed. |
|
8. |
Self-help strategies to overcome specific sexual problems |
A minority of patients may need specialized, intensive psychological treatment. |
|
9. |
Use of pro-sexual drugs as antidotes to anticancer therapy’s side effects |
The use, when indicated, of hormones, PDE5 inhibitors, prostaglandins, even prostheses should be encouraged. |
|
10. |
Follow-up |
For most patients, discussion of their quality of life and sexual issues after treatment is particularly important. |
Modified from [6, 10]
Although broad attention has been paid to the general quality of life, sexuality has been often seen as an optional factor. From a survivor perspective, the reactivation of sexual functioning may contribute to ameliorating the global well-being. For this reason, the oncology team should also analyze, with sexual counseling, the quality of sexual life of persons affected by cancer in order to better comprehend their needs and to help them overcome any possible sexual difficulties.
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