Many people lose their interest in sex during cancer treatment. They are understandably concerned about survival, and other less pressing issues such as sex take second place for a while. This is normal. Pain, anxiety, depression, relationship problems, money and business worries can also act as a real turn off to arousal. So can tiredness resulting from the cancer or its treatment. If the partners have different levels of desire, this too may be more upsetting with the added complication of cancer. And it can create new inhibitions, for example stemming from the fear that cancer might in some way be catching -- which is quite wrong.
People respond in different ways to the adverse effects of treatment. Past sexual experiences and attitudes, past and current sexual life, a current partner's attitudes and much more can all affect what actually happens. But however bad the effects of treatment, people with loving partners who can communicate with each other and explore sexually pleasurable activities can still enjoy fulfilling sex, even if what goes on in the bedroom is rather different from before.
Let us look now at some specific problems from cancer and its treatments that get in the way of sexual performance and enjoyment.
Pain makes almost everybody feel less sexy. Pain on intercourse can occur after pelvic surgery or radiation to the area, or indirectly because medications have reduced a woman's natural lubrication. Just as erection problems or painful ejaculation can set off a circle of fear and failure in a man, so too can this sort of pain cause ongoing problems in a woman. She now expects painful sex, tenses up, gets or stays dry and then, of course, actually experiences pain. Getting rid of pain can be a valuable first step to improving your sex life.
Pain may also result from operations or therapy to other parts of the body. There is no need to suffer this in silence. Ask your doctor for effective pain relief as soon as possible; there are many ways in which pain can be successfully treated
Surgery Any form of surgery can effect our sex lives, even if it doesn't involve the sex organs directly. However, cancer treatment that affects the genitals directly causes quite marked differences.
Surgery's effects on women:
Hysterectomy (the removal of the uterus or womb) or removal of the ovaries is commonly performed for cancers of the womb, ovary and cervix. Once the womb is removed, the surgeon stitches up the top end of the vagina. This makes it a little shorter than it was before. Sometimes one or even both ovaries are removed as well. The slightly reduced vaginal length is usually no problem at all. But early on, while the surgery scars heal, a woman might prefer not to have penetrative sex, or for her partner to be very gentle and to try different positions.
This surgery does not affect a woman's ability to have an orgasm. Her clitoris and all the outer parts are exactly as they were before. Having said this, some women say that their experience of orgasm is different from how it was before the operation. This usually comes about in the woman whose main pleasure centred on the rhythmic contractions of her womb and cervix at orgasm. Some of my patients say that their orgasms are much better than before, so there's no way of telling until you get there yourself.
Surgery for cancer of the vulva, a much less common condition, sometimes involves removing the inner and outer lips, clitoris and local lymph glands. This alters not only the woman's perception of herself but also her genital sensations. Numbness can occur, though this sometimes goes after a few months. It can still be possible to have orgasms, as vaginal sensations are much the same, although it is less likely if the clitoris has been removed.
Early menopause: certain treatments for cancer may cause this. For example the ovaries may have to be removed by surgery, or radiotherapy or chemotherapy may cause them to stop working. This produces a `medical' as opposed to a `surgical' menopause. Unfortunately the symptoms (hot flushes, irritability, dry vagina and reduced desire) are likely to be much more dramatic in onset than natural menopause ones. In many cases, replacement hormones can return the body's systems to near normal. You'll need to talk all this through with your doctor.
Surgery's effects on men
After removal of the prostate or part of the bladder for cancer, a man may have `dry' ejaculations. In these situations semen goes into the bladder. When he next urinates his water is cloudy with the semen. Also, the sensations at ejaculation are different. The removal of tumours of the rectum at an operation called an abdomino-perineal resection may affect the nerves that control much of a man's sexual functioning. This can cause problems with erection and pleasure. Again there may be a dry orgasm. Modern surgical procedures are aimed at sparing the nerves in this part of the body but even so many men will still have erection problems.
Just a note of caution here. A large number of men say that they have erection difficulties after cancer surgery -- but the surgery alone may not be the only factor. Studies have found that many men complain of adverse sexual effects after operations that have nothing at all to do with their genitals. So clearly it makes sense not to blame your cancer operation for all your sexual difficulties; there may be psychological factors involved, which you are not consciously aware of.
Even if you have had an operation that has damaged your erection-producing nerves this need not be the end of your sexual activity. Some men find that they can recover full erections with time. Many couples don't realise that a half-erect penis can still be effective. There are also surgical methods, vacuum pumps and injections which can reduce erection problems. Ask your doctor if any of these might be suitable for you.
Such alterations in arousal and erection clearly call for new methods of lovemaking that give the man the best chance of having and keeping an erection. Some couples find that oral sex, for example, works where other methods fail.
Most men find radiotherapy to their pelvic area has little direct effect on their sexual function. Indirectly, though, the treatment might reduce desire because it is tiring. This sort of therapy may occasionally affect sexual function when used for cancers of the prostate, rectum and bladder. Adverse effects on erection are related to the dose used. The effects occur because of nerve damage or because blood vessels that supply the penis become scarred and are unable to let enough blood through to fill the penis. About one third of men treated in this way say that their erections are less strong than before. The changes are usually slow in onset, and can worsen over the first year or two following radiotherapy. Some men get an erection but then lose it. Others are unable to have one at all. Some feel a sharp pain as they ejaculate, caused by radiation irritating the urethra. This usually disappears within a few weeks after the treatment has ended.
Radiation to the surrounding area may affect the testicles. This tends to reduce testosterone production, so lowering sex drive in a few men.
In women, any radiation to the pelvic area for local cancer involving the rectum, bladder or cervix affects the ovaries and the production of female hormones. Sometimes this alteration reverses itself but usually the ovaries stop hormone production permanently. Clearly a woman past the menopause will have far fewer changes than one whose ovaries are still working. Your doctor may be able to give you hormone replacement therapy, which can make up for these changes. All this needs careful discussion with your doctors because you can't be sure that you won't ovulate and you may still need contraception.
The vagina can be affected by pelvic radiation. It becomes tender in the early stages and for a few weeks afterwards and, long term, this irritation can heal leaving scarring. This makes the vagina narrower and less flexible, which in turn alters the way both the woman and her partner experience penetrative sex. You may be advised to use graduated vaginal dilators, with lubricating jelly, to keep the vaginal walls open and supple, or to have regular intercourse to prevent or reduce vaginal shrinking.
Radiotherapy can also cause vaginal ulcers to produce a little bleeding. These can take weeks or even months to heal.
Provided that you are not affected by any of these vaginal side effects, and some women are not, then sex is perfectly safe during radiotherapy. You should continue with any contraceptive methods you were using before the treatment.
In women: chemotherapy can alter hormone production because some of these drugs harm the ovaries. Talk to your doctor about contraception, though, because menstrual cycles, while disrupted, may not fail altogether and you might get pregnant.
The symptoms of an early menopause can result from chemotherapy. These include hot flushes, irritability, sleep disturbances, vaginal dryness and perhaps a light spotting of blood after sex. Thrush is common in women having chemotherapy, especially if they are taking steroids or powerful antibiotics to prevent infection. Talk to your doctor about treatment for this.
Chemotherapy often reduces sexual desire. The nausea, vomiting, weakness, depression, tiredness and lack of energy hardly make for sexy feelings. Once chemotherapy is over, though, your sex drive will usually return in time. Unfortunately if the chemotherapy has caused hair loss, or weight loss, or a woman has gadgets (such as Hickman lines) involved in the chemotherapy itself, she may feel very unsexy at the time.
In men, chemotherapy is less disruptive. Some find that at the time of the therapy their sex drive falls, due to tiredness and possibly nausea. But sex drive usually returns soon after the end of the therapy. Some types of therapy reduce testosterone production but this usually returns to normal in time.
In both men and women chemotherapy drugs can affect fertility. If this is an issue in your relationship, discuss it with your doctor.
In women: Because tumours of the breast and womb lining are hormone-dependent, therapy involving hormones can be useful. Tamoxifen is an anti-oestrogen often given after surgery for breast cancer. It has far fewer side effects than chemotherapy. Some women complain of symptoms similar to those of the menopause -- soreness, dryness, vaginal discharge, shrinking of the vagina and a drop in sex drive -- while taking tamoxifen for breast cancer. However, the vast majority have no such side-effects.
In men: If the cancer in a man's prostate has spread beyond the gland itself it can be helpful to lower his testosterone production. In the past this was usually done by removing his testes or by giving female hormones, or both. Nowadays, an injection of a drug that stops the pituitary gland from producing male hormones is usually used instead. Tablets that block male hormones (anti-androgens) are often used together with the injection or on their own. These tablets have less effect on sexual function than other treatments and many men are able to maintain an erection while taking them. Unfortunately, though, it is often necessary to have both tablets and injection. Discuss this with your doctor if you are concerned.
Treatments to lower testosterone production have major effects on a man's sex life. He may feel much less like sex and when, or if, he does feel like it he can't obtain or maintain an erection. Not surprisingly a man whose testicles have been removed may feel `less of a man' -- but neither the operation nor hormone therapy `makes him a woman', as some fear. Men may notice that they produce less semen than before.
Talking about how cancer and the treatments affect your sex life can be difficult. Try to find a health professional who you think you could talk with about this, or who would be willing to suggest an expert to help you. Medical staff may not think to ask you about this but should be happy to refer you for counselling or specialist treatment.
Although this might sound like quite a catalogue of sexual ills, how much they affect any individual depends on many other factors. We shall see, later on, how people who are affected in such ways can still have a sex life that is acceptable to them.