In this blog, Bridget Candy & Louise Jones, authors of a Cochrane review on women, cancer and sex after treatment, discuss why this matters, what might help, and what we need to know.
In a relationship? Not interested at the moment? Looking for someone? Gay or straight? Whoever we are, and at whatever stage in our personal lives, we need to feel comfortable with our bodies, accepted by ourselves and by others, and our attitudes to our sexuality and sexual lives are very important. Sex impacts on our zest for life, how we view ourselves and our relationships.
One in three of us will receive a diagnosis of cancer at some time in our lives. It often presents numerous challenges. Not only does our mortality come into sharper focus, but we may also begin to question our core values, our relationships and our sense of who we are. Dealing with the cancer often involves invasive, sometimes mutilating and often prolonged treatments and side effects. Many of us go on to survive cancer but there may be long term impacts on our bodies. It is no wonder that sexual matters can come into this maelstrom of changes. However, in illness sex is often side-lined, regarded as a luxury in the face of life threatening events, and rarely considered or mentioned by professionals in charge of our care. Our partners too may be confused and unsure how to help.
How we feel about our sexuality remains important
All cancers may affect our sex lives; some such as gynaecological or tumours elsewhere in the pelvic region may have a direct mechanical impact on how we function sexually. Breast cancer may particularly affect body image, and cancers affecting the head and neck can challenge how we look and feel attractive. Suffering from any cancer may lead to a loss of desire for sex, a fear in resuming a sexual relationship, and loss of sexual satisfaction. These effects may be short lived, although sometimes they may persist for years.
All cancers may affect our sex lives
Cancer treatments may further impact on our sexual functioning. They often involve radiation, surgery, chemotherapy, and hormonal treatment. Any or all of these may cause damage to nerves and blood vessels or cause scar tissue to develop, or a reduction in hormone levels as the ovaries are affected. Younger women face addressing potential loss of fertility and symptoms associated with an early menopause. Some gynaecological treatments lead to structural alterations in the pelvis, affecting pleasure from touch, or causing pain as the vagina has become too tight or dry. Cancer of the bowel may require temporary or permanent colostomy which may cause anxieties over feeling desirable, and potential for changes in body odour. Many other tumours require invasive surgery that leaves significant scarring.
When sick, people need to feel close to others, to feel loved and supported. Whether this involves sexual intercourse, or simply intimacy, how we feel about our sexuality and ourselves remains important, even in the face of the approach of death.
Talking about sexual problems is difficult
While sexual problems may be common there are difficulties in talking about them. We may feel uneasy talking about problems with our sexual partner, let alone a health professional like a doctor or nurse. We may feel too awkward to start such a discussion or fear embarrassment by exposing ourselves. Professionals too may be inhibited from initiating conversations that might help.
What help is there for sexual problems?
Let’s look at approaches that may help resolve sexual problems in women.
There are many types of complementary therapies which may provide simple and supportive environments in which to boost our self-esteem. Aromatherapy and massage may help us relearn how to relax by being touched and helping us to smell nice. Other approaches may help to manage symptoms like hot flushes.
Using hormonal treatments may be a way to get your sexual hormones back on track. These may make you feel better by increasing sexual desire and by dealing with menopausal symptoms.
Vaginal lubricants and moisturisers
Where vaginal dryness is a problem lubricants and moistuerisers applied directly may help.
Exercises and devices
Other approaches deal with the mechanics of our bodies. Physical exercises can help strengthen the muscles of the pelvic floor, keeping the pelvic organs in place and helping with any anxieties we have about bladder function. Vibrators and clitoral stimulators may help increase sexual desire and arousal.
Sex therapy is talking therapy where an experienced therapist works with an individual or couple. The focus is on sexual relationships, how we feel about ourselves and others. Sessions may focus on helping us to admit what we want and what we do not want, face the challenges of the future and make any changes we need. It may be particularly useful to have partners present so that they can learn more about our needs and express their own fears.
What do we know about how well these work for women following cancer treatment?
A Cochrane review
We undertook a Cochrane review of research papers that have been published internationally. This review included papers reporting the results of 11 clinical trials of interventions to help women after treatments for cancer. In total 1,509 women were involved. These women had breast or gynaecological cancer. Eight of the interventions tested involved a sex therapy. Two involved topical creams: one was a cream containing testosterone, the other a gel especially designed to suit the natural pH of the vagina. The other intervention tested was a set of exercises to strengthen the pelvic floor.
Did anything work?
It was difficult for us to draw any firm conclusions about what works and what doesn’t work from the research papers found. The studies of trials were mainly poorly designed; many of the trials were conducted with only small numbers of women and they measured benefit from the interventions in various different ways. Only a few of the trials considered whether there were any harmful effects of the interventions. Potential for harm is very important to measure, for instance for those having sex therapy, talking about personal sexual problems may cause emotional distress for some people.
In summarising our findings, our conclusions are short and to the point:
‘the studies do not provide clear information on the impact of interventions for sexual dysfunction following treatments for cancer in women. The sexual dysfunction interventions in this review are not representative of the range that is available for women, or of the wider range of cancers in which treatments are known to increase the risk of sexual problems. Further evaluations are needed’.
Where do we go from here?
Let’s start with what we know
- Many of us will get cancer sometime in our lives.
- Cancer and its treatments can have an impact on sexual functioning.
- There is limited reliable evidence of the benefit or potential harms of any of the approaches that may help tackle sexual problems in women following treatment for cancer.
Many things are missing from this limited evidence and for which further research could help.
- Much of the evidence we already have is potentially misleading as the clinical trials have weaknesses in how they were carried out.
- Trials have not evaluated all potential impacts of the approaches they were testing, including any potential side effects.
- The research has only been with women with gynaecological or breast cancer; women with other cancers should be included in future studies.
- Not all approaches that may help tackle sexual problems have been formally tested in clinical trials.
- No trials have been done that have tested a combination of these approaches.
What else can be done?
The most important step is that women with cancer, those close to them, professionals and researchers begin to recognise that sexual problems after treatments for cancer are common. It may then be possible for us to discuss what the problems are and think carefully about what approaches may be helpful, both for the women affected by cancer and their partners. Greater openness that these problems are common may support the testing of new interventions and encourage women and those close to them to take part in well designed and rigorous research.
What about men with cancer?
We are currently undertaking a review on interventions for sexual problems following treatments for cancer in men. Our findings will be ready this year. What is striking in comparison with our review on these interventions for women is that the number of trials for men is far greater.
Bridget Candy and Louise Jones have nothing to disclose.
This guest blog is one in a special series of blogs on #theproblemwithsex
More from #theproblemwithsex
Candy B, Jones L, Vickerstaff V, Tookman A, King M. Interventions for sexual dysfunction following treatments for cancer in women. Cochrane Database of In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More 2016, Issue 2. Art. No.: CD005540. DOI: 10.1002/14651858.CD005540.pub3.