Sex & Intimacy when Living with Cancer

Transcription

1 Sex & Intimacy when Living with Cancer Jeffrey Albaugh, PhD, APRN, CUCNS NorthShore University Healthcare William D. & Pamela Hutel Ross Sexual Health Clinic

2 Sexual Dysfunction The persistent impairment of a couple s normal or usual patterns of sexual interest and/or response AFUD concensus conference, 1998 (Basson, et al, 2000)

3 Masters and Johnson, 1966 Female Sexual Response

4 Alternative Cycle of Female Sexual Response Emotional Intimacy Emotional & Physical Satisfaction Motivates the sexually neutral woman To find/ be responsive to Sexual Stimuli Arousal & Sexual Desire Psychological and biological factors govern arousability Adapted from Basson, R. (2001) Obster Gyne, 98, Sexual Arousal

5 Classifications/Categories for FSD Sexual Desire Disorders Hypoactive Sexual Desire Disorder (HSDD decrease Libido) Sexual Aversion Disorder (302.79) Sexual Arousal Disorder Orgasmic Disorder (302.71) Sexual Pain Disorder Dyspareunia (625.0)- persistent pain in pelvic area during or after sexual intercourse Vaginismus (625.1)- persistent difficulty in allowing vaginal penetration -Basson,R et al, (2000). Journal of Urology, 163: / 1998 AFUD Consensus Panel.

6 Male Sexual Dysfunction Desire disorder- decreased libido Ejaculation Disorders: Retarded (delayed) or Rapid Ejaculation-Ejaculation that occurs to early during sexual relations Peyronie s Disease- Curvature Orgasmic disorder- Inability to reach orgasm. Decreased Sensation to penis Erectile Dysfunction- The consistent or recurrent inability to attain and/or maintain a penile erection sufficient for sexual performance. WHO-ISIR. 1st International Consultation on ED, 1999

7 Sexual Dysfunction and Cancer Sexual dysfunction rates can occur in up to 90% of patients after cancer treatment Desire disorders and lack of pleasure from sex may be underlying reasons for sexual dysfunction Pelvic or genital surgery such as prostatectomy, colorectal surgery, cystectomy, etc or radiation to the pelvic area may cause desire disorders, ED in men, sensory changes, vaginal expansion or lack of lubrication in women. Hormonal changes may cause lack of libido, vaginal lubrication, pain and pleasure in women, and Ed in men Anderson, B.L. (1990). How cancer affects sexual functioning. Oncology, 4, Berglund, G. Efect f endocrine treatment on sexuality in premenopausal brest cancer patietns: A prospective randomized study. Journal of Clinical Oncology, 19, Schover, L.R. et al. ( 2002). Defining sexual outcomes after treatment for localized prostate cancer. Cancer, 95, Bacon, C.G. et al. (2003). Sexual function in en older than 50 years of age: Results from the health professionals followup study. Annulas of Internal Medicine, 39, Jensen, P.T. et al. (2003). Longitudinal study of sexual function & vaginal changes after radiotherapy for cervical cancer. Int J of Radiation Oncology Biol Phys, 56,

8 Sexuality and Cancer Surgery-gynecological, testicular, prostate surgery, pelvic surgery including colorectal surgery- cause desire, arousal, orgasmic, erectile, and pain disorders Radiation to the pelvis-same types of disorders as above Chemotherapy-alkylating agents, antimetabolitesamenorrhea, premature menopause, ED, azospermia or olgiospermia, & decreased libido Medications-antidepressants, antiemetics, antihistamines, antihypertensives, narcotics, sedatives, steroids, and tranquilizers Treatment side effects: Fatigue, Feeling Bad, Pain, Stress Psychological issues Krebs, L. (2005). Sexual and reproductive dysfunction. In C. Yarbro et al. Cancer Nursing: Principles and Practice, 6 th Edition. Sudbury, MA: Jones & Bartlett

9 Radical Prostatectomy Outcomes for Sexual Function and Incontinence Prostate Cancer Outcomes Study (Reports from Survey within Multiple States across the US). n = 1288 Erectile dysfunction 78% at 24 months after treatment and 72% 60 months after treatment. Sildenafil most common treatment reported» Penson et al. (2008). 5 year urinary and sexual outcomes after radical prostatectomy The Journal of Urology, 179, S40-44.

10 How does Prostate Cancer Treatment Impact Sexual Function? The most common side effect of prostate removal, prostate radiation, or hormone ablation is erectile dysfunction Ejaculation does not typically occur after prostate removal or radiation The penis may seem to have gone up into the body after these procedures These factors can impact how a many feels about himself and his intimate relationship with his partner

11 Sexual Function and Breast Cancer Sexual dysfunction is common in breast cancer patients -77% of women with breast cancer (n = 83) had sexual dysfunction. [Raggio GA, Butryn ML, Arigo D, Mikorski R, Palmer SC. (2014). Prevalence and correlates of sexual morbidity in longterm breast cancer survivors. Psychol Health, 29(6): ] -64 % of Dutch women 45 or younger (n = 345) reported sexual dysfunction [Kedde H, van de Wiel HB, Weijmar Schultz WC, Wijsen C.(2013). Sexual dysfunction in young women with breast cancer. Support Care Cancer. Jan;21(1): ] Related to hormone manipulation, self image changes & impact of chemotherapy

12 Sexuality and Colorectal Cancer Sexual dysfunction occurred in about 60% of women after treatment for colorectal cancer The most common problems were vaginal dryness and dyspareunia (pain during penetrative sex) & this can impact QOL. Panjari et al. (2012) Sexual function, Incontinence and well being JSM, 9, Di Fabio et al. (2008)Long term outcome after colorectal cancer Tumori, 94, Hendren et al. (2005), Prevalence of male and female Ann Surg, 242, Erectile dysfunction occurred in 54% of rectal cancer patients and 25% of colon cancer patients and ejaculation dysfunction occurred in 68% of rectal and 47% of colon cancer patients in large European international study (n = 1359). Den Oudsten et al. (2012). Higher prevalence of sexual dysfunction in colon Eur J of Cancer, 48, After treatment for colorectal cancer, 65.5 % of men had modereate to severe ED (Using IIEF) and 42.3% of women had sexual dysfunction (using FSFI) -Milbury et al. (2013). The association between psychosocial Support Care Cancer, 21,

13 Therapies Counseling/Behavioral Therapy Pelvic Floor Physical Therapy Hormonal Estrogens Testosterone DHEA Vacuum Devices Pharmacological Agents Surgery Herbs American Urological Association. (2005, June 2007). Management of Erectile Dysfunction. 3rd Edition. Retrieved October 15, 2012, 2012, from

14 Pelvic Floor Physical Therapy for Pain, Arousal and Orgasmic Disorders Pelvic Floor evaluation and management Vaginal Dilators Pelvic floor physical therapy for arousal and orgasmic disorders (Pelvic floor weakness ; dysfunction Herman, H. (2005). Physical therapy for female sexual dysfunction. In Women s Sexual Function and Dysfunction (Eds) Irwin Goldstein et al. London: Taylor Francis Pelvic floor physical therapy for pain: 85 sexual pain subjects- Manual PT treated w/ pelvic stabilization & direct PFM massage for 4-16 visits Dyspareunia/vaginismus= 80-90% resolution of symptoms Rosenbaum, T. (2005). JSMT, 31, » Other studies that support pelvic floor PT-Bergeron et al (2002), JSMT, 28, ; Oyama et al. (2004). Urology, 64, ; Danielsson et al. (2006). Acta Obst Gyne Scand, 85, ; Nappi et al. (2003). JSMT, 29,

15 Oral Agents INTERVENTION: MEDICAL TREATMENTS - Oral Therapies PDE Type 5 inhibitors primary drug class - oral erectile dysfunction therapy Sildenafil (Viagra) mg Vardenafil (LeVitra) 5-20 mg; Staxyn 10 mg disentegrating tablet Tadalafil (Cialis) 5-20 mg on demand and 2.5-5mg Daily Avanafil (Stendra) mg Drugs are potent, selective inhibitors of type 5 phosphodiesterase - improve erectile function by inhibiting breakdown of cyclic GMP - smooth muscle relaxation enhanced

16 Sexual Dysfunction INTERVENTION: Vacuum constriction device (VCD) FDA approved for over the counter distribution - efficacy rates of 80%-90% reported Apply negative pressure to flaccid penis, drawing venous blood into the penis, retained by elastic constriction band at penile base

17 FSD: Eros Therapy Clinical Study: Conclusions The benefit of increasing blood flow using the Eros Therapy: Greater sensation (90%) Increased deep vaginal lubrication (80%) Enhanced ability to achieve orgasm (55%) Improved overall sexual satisfaction (80%) The Eros Therapy is both Safe and Effective. -Billups, K., Berman, L., Berman, J., Metz, M., Glennon, M., and Goldstein, I., (2001) A New Non Pharmacological Vacuum Therapy for Female Sexual Dysfunction. Journal of Sex & Marital Therapy.

18 Treatment of ED: Injections Intracavernosal Injection Therapy (PGE1 & Trimix): alprostadil sterile powder and alprostadil alfadex, both synthetic formulations of prostaglandin E1 Trimix (off-label/non-fda approved)-pge1, phentolamine, & papavarine Dosage: alprostadil-5-40 mcg w/ PGE; Doses vary w/ trimix Onset: 5-20 mins; duration: 30 mins-4hours Contraindicated: drug hypersensitivity, risk for priapism (e.g. sickle cell disease, hypercoagulable states) & women/children Adverse Reactions: prolonged erections or priapism, penile pain, and fibrosis with chronic use, ecchymosis, hematoma

19 Vulvar Pain Inflammation sometime related to lack of estrogen and testosterone Hart s Line to hymen ring endodermandrogen dependent Treated with transdermal % estrodial % testosterone in methylcellulose base {off-label; expect 50% improvement by 12 weeks}

20 Local Estrogen and Breast Cancer Preliminary study results indicate that low-dose local vaginal estrogen therapy have low absorption rates and therefore may been appropriate for use in breast cancer patients as they do not cause a systemic increase in estrogen [Dew et al (2003), Biglia et al (2007), Del Pup et al (2010), Ponzone et al(2005)] If inadequate relief from non-hormonal treatments, informed discussion with their provider about the unknown risks of starting on estrogen therapy & start at a low-dose and gradually increase the dosage until they experience symptom relief.

21 Treatment for Vaginal Atrophy and Lack of Lubrication during Sex Clinical guidelines for atrophic vaginitis concluded that local estrogen replacement is the first choice to improve vaginal mucosal thickness, decrease vaginal ph and diminish vulvovaginal atrophy. Johnston, S.L. et al. (2004). SOGC Joint Committee-Clinical Practice Gynaecology and Urogynaecology. The detection and management of vaginal atrophy, Journal of Obstetrical Gynecologic Cancer, 26, pp Vaginal rings, creams and tablets work equally well for local estrogen replacement-follow prescribing information Suckling, J., Lethaby, A., and Kennedy, R. (2006). Local oestrogen for vaginal atrophy in postmenopausal women, Cochrane Database Syst Rev 18, CD Variety of Non-hormonal Moisturizers and Lubricants Available

22 Non-hormonal Moisturizers or Soothing Creams Neogyn Vulvar Soothing Cream- non-medicated cosmetic cream formulated with Cutaneous Lysate to sooth/comfort vulva; free of parabens, propyline glycol, color additives, fragrances, analgesics that can dull sensation. Applied BID for about 6-8 weeks. Vitamin E vaginal suppositories Replens, Luvena KY Liquibeads moisturizer NeuEve Natural Feminine Suppositoryvaginal moisturizer and odor eliminator. Contains palm oil, beeswax, tapioca starch, inulin, frutos-oligosaccharides, soy lecithin, orange oil, tocopherois (vitamin E) and proprietary blend

23 Resources for Patients gyourdiagnosis/afterdiagnosis/afterdiagnosis-how-will-cancer-affect-my-sex-life ortivecare/sexuality/patient/page2 (for women)

24 Key Points Sexual dysfunction is common with many disease processes including cancer Sexual & intimacy issues can be addressed successfully Communication can be critical in dealing with changes in sex & intimacy It is possible to have enjoyable sex and intimacy with the help of expert providers You can make a difference in your patients lives by acknowledging sexual issues and pointing patients towards help with sexual issues