What Does It Take to Have a Better Sex Life after Cancer?

What is my biggest frustration in trying to help cancer survivors and their partners to overcome sexual problems related to cancer treatment? It is the expectation widely held by both patients and health professionals that one magic medical treatment will make everything better. How I wish that were true!

Sexual problems after cancer treatment often begin with damage to one of the physical systems needed for good sexual function: changes in hormone levels, damage to nerves in the pelvic area, loss of blood flow to the sex organs, scar tissue from surgery or radiation therapy, or loss of sensitive erotic tissue. Although physical damage can sometimes be repaired, regaining a satisfying sex life also means communicating with a partner about what feels good now, experimenting with new and different ways to give each other sexual pleasure, having the courage to risk a partner’s rejection despite changes in appearance or sexual function, and working with a partner to try new medical treatments for sexual problems that may interrupt the flow of lovemaking. Without making an effort to change communication and behavior, it is unlikely that sex will be satisfying again.

Here are some examples of treatments for post-cancer sexual problems that fall far short of the hype:

Pills that may improve erections like sildenafil (Viagra®) and its cousins. These medications are far less likely to be effective after pelvic radiation therapy or surgery for cancer than they are for men with other causes for erection problems. And in the general population of men, only a third to a half of men ever bother to refill their first prescription for one of these drugs.

Erectile dysfunction (ED) treatments like injections of drugs into the penis or use of a vacuum device are often more successful than the pills in creating firm, reliable erections. However, a large group of men are unwilling to try these options, and after a few months of use, dropout rates are quite high. Adding some couple sex therapy can often make these therapies less of a turnoff.

Although surgery to put in an inflatable penile prosthesis is the treatment for ED that has the highest rates of sexual satisfaction and continued sexual activity, very few men end up having this treatment (probably well under 5%). Issues include limited insurance coverage and fear of having a surgical procedure.

The “female Viagra” pill flibanserin (Addyi®) is expensive, needs to be taken daily, has unpleasant side effects, and is barely better than a placebo (sugar pill) in improving women’s sex lives. It is supposed to increase desire for sex. The drug manufacturer waged a major publicity campaign complaining that sexism was to blame for two failed attempts to get approval for flibanserin. Although the campaign was successful in getting the drug on the market, it was clear that lack of effectiveness and side effects were the major barriers to approval, not sexism. In fact, all the drugs approved to treat men’s sexual problems work by improving erections or lengthening the time to reach orgasm. There is no effective drug for men that increases sexual desire.

A pill that can reverse some menopausal changes in vaginal lubrication and stretchiness (ospemifene or Osphena®) actually has good research data showing effectiveness. However, it is not approved for women with a history of breast cancer (mainly due to lack of research studies), cannot be taken by women also using an aromatase inhibitor to treat breast cancer) and has to be taken daily. Sales have been disappointing.

Low dose vaginal estrogen can be used in a suppository or a ring (like the ring of a diaphragm without the rubber cup). Very little hormone escapes into the general blood stream, especially after the first couple of weeks since the lining of the vagina thickens and is less likely to tear during sex. However, many women find they still have some pain and dryness that interfere with sexual pleasure. Women with a history of breast cancer are often warned by oncologists not to risk even these low doses of hormones.

Fancy vibrators that come with other extras like phone apps, light therapy, or suction cups for the clitoris may indeed temporarily increase blood flow to a woman’s vaginal walls and vulva during sexual excitement. It is possible that using a vibrator several times weekly could prevent some of the loss of vaginal size and stretchiness that happens after menopause or pelvic radiation therapy. However, no research has been done to demonstrate this. No research studies suggest that using a vibrator “cures” sexual problems, although it typically is an easy way for women to learn to reach an orgasm.

Vaginal “exercisers” complete with phone apps have become popular lately. Most make claims that strengthening muscles of the pelvic floor will improve sexual problems. Again, there is no good research suggesting that women with stronger pelvic floor muscles have better sex lives, or that these home exercisers help women who have pain with sex or trouble reaching orgasm.

Laser or heat treatments of the vagina are often advertised as “vaginal rejuvenation.” The idea is that a probe is put inside the vagina and used to damage the lining. As the damage heals, the treatment supposedly causes new blood vessels to form and increases the amount of collagen in the vaginal walls. Collagen is a protein that helps keep tissues stretchy. Although there is some evidence that women who had menopause symptoms of vaginal dryness and pain feel better in the short-term after these treatments, the effects decrease after several months. The treatments are very expensive, are not covered by insurance companies because of the lack of evidence that they are effective, and recently the U. S. Food & Drug Administration issued a letter stating that none of the devices used for these treatments have been approved. A number of cases of long-term scar tissue or pain after such treatments have now been reported.

Some of the treatments described could be useful to cancer survivors and partners in regaining sexual pleasure. However, it is also essential to try new ways to make sex special and to cope with the sadness, shame, lack of sexual communication skills, and fear of rejection that are such common barriers to improving sexual satisfaction. Will2Love’s self-help programs for men and women have many suggestions on how to make such changes. Seeing a mental health professional with special training in treating sexual dysfunction can also be extremely valuable. 

 

For Further Reference:

Mulhall JP, McLaughlin TP, Harnett JP, Scott B, Burhani S, Russell D. Medication utilization behavior in patients receiving phosphodiesterase type 5 inhibitors for erectile dysfunction. J Sex Med. 2005 Nov;2(6):848-55.

Corona G, Rastrelli G, Burri A, Serra E Gianfrilli D, Mannucci E, Jannini EA, Maggi M. First-generation phosphodiesterase type 5 inhibitors dropout: a comprehensive review and meta-analysis. Andrology. 2016 Nov;4(6):1002-1009.

Polito M, d'Anzeo G, Conti A, Muzzonigro G. Erectile rehabilitation with intracavernous alprostadil after radical prostatectomy: refusal and dropout rates. BJU Int. 2012 Dec;110(11 Pt C):E954-7.

Schover LR, Fouladi RT, Warneke CL, Neese L, Klein EA, Zippe C, Kupelian PA. The use of treatments for erectile dysfunction among survivors of prostate carcinoma. Cancer. 2002 Dec 1;95(11):2397-407.

Kashanian JA, Golan R, Sun T, Patel NA, Lipsky MJ, Stahl PJ, Sedrakyan A. Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State. J Sex Med. 2018 Feb;15(2):245-250.

Barton GJ, Carlos EC, Lentz AC. Sexual Quality of Life and Satisfaction With Penile Prostheses. Sex Med Rev. 2019 Jan;7(1):178-188.

Ferreira CH, Dwyer PL, Davidson M, De Souza A, Ugarte JA, Frawley HC. Does pelvic floor muscle training improve female sexual function? A systematic review. Int Urogynecol J. 2015 Dec;26(12):1735-50.

Morin M, Carroll MS, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev. 2017 Jul;5(3):295-322.

Gordon C, Gonzales S, Krychman ML. Rethinking the techno vagina: a case series of patient complications following vaginal laser treatment for atrophy. Menopause. 2019 Apr;26(4):423-427.

This educational material is intended for informational purposes only and is not intended to replace, or substitute for, professional advice, counseling, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a condition. Never disregard professional advice or delay in seeking treatment because of something you have read in this educational material.

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