Presentation 10 Feb 2, 2019

Transcription

1 Addressing Sexual Relationship Concerns for the Patient Treated for Cancer 2019 BREAST HEALTH: A TEAM APPROACH 2/2/2019 SARAH JAX, MA, APRN, AOCNP MINNESOTA ONCOLOGY - PLYMOUTH Objectives Discuss causes of sexual dysfunction in patients treated for cancer Identify strategies for evaluating sexual health concerns of patients Identify hormonal and non-hormonal therapies and resources for patients with sexual health concerns AllinaHealthSystem 1

2 Common issue with our patients % of cancer survivors complain of sexual dysfunction 50-75% of women with breast cancer report persistent problems with sexual functioning Physical sexual side effects can be temporary or long-term The emotional impact of cancer on sexuality is real Female sexuality Masters and Johnson (male and female sexual response cycle) Excitement, plateau, orgasm and resolution Basson model (female sexual response cycle) Emphasis on psycho emotional processes (intimacy) Libido (innate desire) occurs at a number of places in the sexual response cycle Rewards /satisfaction (physical, emotional intimacy, lack of negative feelings) motivation SEPARATION OF SEXUALITY FROM INTIMACY Basson Model Basson R. Women's sexual dysfunction: Revised and expanded definitions. CMAJ. 2005;172: AllinaHealthSystem 2

3 Sexual health and survivorship Menopausal status before treatment Some issues may already be present before starting treatment Treatment effects Surgery Direct effect on anatomy (body image and self-esteem concerns) Changes in hormones (eg. oopherectomy) Medical therapy (chemo and endocrine therapy) Side effects of chemotherapy limit sexual interest or arousal Vaginal dryness Radiation therapy Acute erythema, discoloration, breast edema, arm mobility Barriers to discussion Patient perspective Fear of dismissal Fear of discomfort of provider Assumption - lack of treatment options available Provider perspective Assumption that patient will bring up if concern present Time constraint Assumptions about patients (age, overall prognosis, current partner) AllinaHealthSystem 3

4 Evaluating sexual health Sexual activity Intimacy Intimacy by itself is valued by patient Other ways to be intimate (not just penetrative intercourse) Questionnaires Can aid in evaluation of sexual health (recall 7 days 4 weeks), but tend to be long and not suited for clinical setting Female Sexual Function Index Body Image Scale Personal Assessment of Intimacy in Relationships Evaluating sexual health Sexual history Taking history early on shows importance of topic to provider and signals to patient that it s ok to discuss I always ask patients about any concerns they may have about intimacy (sexuality) Ask both during AND after treatment Approach with few assumptions Open-ended questions Privacy is essential PLISSIT model BETTER model Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS. PLISSIT model Permission Invites patient to enter into a discussion about sexual health I d like to review how you re doing as it relates to both sexuality and intimacy. Is that okay? Limited Information Normalizes that issues related to sexual health are common A common complaint is pain during intercourse. Is this something that is happening with you? Specific Suggestions Offer advice that can be actionable and easy to incorporate if possible If you have trouble with vaginal dryness, it may help to use a lubricant before and during sex. Intensive Therapy If one is not comfortable with issues brought up or does not know what to advise, offer expert consult locally or other resources It sounds like you might benefit from seeing an expert in sexual health. Can I suggest a referral? Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS. AllinaHealthSystem 4

5 BETTER model Bringing up the topic Providers are encouraged to raise the issue of sexuality with patients Explaining that sex is a part of quality of life The helps to normalize the discussion and may help patients to feel less embarrassed or alone in having a problem. Telling patients that resources will be found to address their concerns Timing the intervention This step suggests to patients that even if the nurse does not have the immediate solution to the problem or question, there are others that can help. Patients may not be ready to deal with sexual issues at the time a problem is identified; however, patients can ask for information at any time in the future. Educating patients about sexual side effects of treatment Educating patients about potential side effects from treatments does not mean that they will occur. However, informing patients about sexual side effects is as important as informing them about any other side effects. Recording It is not necessary to describe in detail what was discussed; however, a brief notation that a discussion about sexuality or sexual side effects occurred is important. Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS. Sexual dysfunction diagnoses** Female orgasmic disorder Female sexual interest/arousal disorder Genito-pelvic pain/penetration disorder Includes vaginismus (pain with penetration of vagina from smooth muscle spasms) and dyspareunia (pain with intercourse) ** Lifelong vs. acquired; generalized vs. situational ** Symptoms should be present 6 months ** Result in distress or inability to respond sexually or achieve pleasure Management of Sexual Dysfunction BODY IMAGE Look at oneself. Think of how strong her body is. Exercise Eat healthy Support groups Find clothing one feels comfortable in and makes her feel good Find sexy clothing she feels comfortable having her partner see her in Seek professional counseling - there may be underlying depression or anxiety AllinaHealthSystem 5

6 Management of Sexual Dysfunction DESIRE Complex: involves the brain, emotions and previous experiences Focusing on desire may not be the first step Motivation increases with sexual satisfaction as well as non-sexual rewards (satisfying a partner, feeling wanted, intimacy) Set small goals and build on them Try sensate exercises to regain physical intimacy Progression of touch between partners Management of Sexual Dysfunction AROUSAL Influenced by emotional and psychological factors Process: blood flow to the genitals in response to physical and mental stimulation which creates lubrication, swelling Arousal will increase comfort during penetration Use sexual stimulation devices AKA toys Try massage/foreplay Management of Sexual Dysfunction DYSPAREUNIA (painful sex) Can easily become a memory and deter future sexual activity Menopause: lack of hormones causes dry vagina/vulva; vestibule is dry and thin Treat by focusing on arousal, lubrication, positioning, hormones(?), toys, pelvic floor PT Lidocaine? AllinaHealthSystem 6

7 Treatment of Dyspareunia Nonendocrine therapies **FIRST LINE OF THERAPY** Lubricants and Moisturizers Sexual enhancement devices Counseling Endocrine therapies Vaginal estrogen (eg. Vagifem, Estrace) DHEA Compounded product, or Intrarosa (prasterone) intravaginal steroid for moderate to severe pain related to vulvovaginal atrophy FDA approved Nov ** Hasn t been evaluated in survivors of cancer **NOT RECOMMENDED AT THIS TIME** Ospemifene (Osphena) oral tablet estrogen agonist/antagonist No apparent estrogenic effects elsewhere in body (endometrium and breast) Hasn t been evaluated in survivors of cancer **NOT RECOMMENDED AT THIS TIME** Lubricants and Moisturizers Lubricants: generally short-acting products designed to make vaginal penetration more comfortable; use with sexual intercourse Water based may need to reapply Silicone based (Überlube, Pink Silicone, etc.) best for post-menopausal women; may interact with silicone toys (do spot check) Oil based coconut/grape seed (use refined, organic) Moisturizers: help balance ph, hold water in place on vaginal wall; use twice weekly in vagina Oils Silicone lubricants Replens performed head-to-head with estrogen; not recommended for sensitive skin RepHresh not recommended for sensitive skin Luvena may work for women with recurrent infection; not recommended for sensitive skin HYALO GYN - hyaluronic acid derivative component applied intravaginally every 3 days ***AVOID products with polyethylene glycol, propanediol, polypropylene glycol and glycogen Sexual enhancement devices Vibrators Dilators Positioning devices Cuffs/bumpers Smitten Kitten 3010 Lyndale Ave S Minneapolis, MN AllinaHealthSystem 7

8 Books and Written Resources American Cancer Society Sexuality for the Woman with Cancer The Lovin Ain t Over for Women with Cancer Ralph and Barbara Alterowitz Becoming Orgasmic Julia Heiman Woman Cancer Sex Anne Katz When Sex Hurts Goldstein, Pukall, Goldstein The Elusive Orgasm Vivienne Cass, PhD Sexy Ever After: Intimacy Post-Cancer (ebook) Patty Brisben & Keri Peterson, M.D. Sexy After Cancer ~ Meeting Your Inner Aphrodite on the Breast Cancer Journey- Barbara Musser And in Health: A Guide for Couples Facing Cancer Together Dan Shapiro, MD Websites AASECT.org American Cancer Society Sexuality for the Woman with Cancer Breastcancer.org Sex and Intimacy Susan G. Komen National Cancer Institute Body changes and intimacy Livestrong.com Dating and Sex after Cancer Sexualityresources.com A Woman s Touch sexuality resource center drannekatz.com Referrals Minnesota Oncology Sexual Health program - Multiple locations Park Nicollet Sexual Medicine Clinic medical and counseling services, University of Minnesota Center for Sexual Health promotes sexual health of individuals, couples, and families of all backgrounds and ages by providing assessment and treatment. Medical and counseling services, Sky Hill - sex therapy clinic Edina, Lauren Fogel, PsyD, LP psychologist, relationship problems, sexual health concerns, LGBT concerns Allina Nicollet Mall Clinic, Lori Anafarta, MA, LMFT, CST sex therapy & counseling for individuals, couples Forest Lake area, Jan Swanson, Psy.D., LP, ABPP individual/couples counseling; sex therapy, AllinaHealthSystem 8

9 References Basson, R. (2005) Women's sexual dysfunction: Revised and expanded definitions. CMAJ, 172, Dizon, D. S., Suzin, D., & McIlvenna, S. (2014). Sexual Health as a Survivorship Issue for Female Cancer Survivors. The Oncologist, 19(2), Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS. Minnesota Oncology (2016). Vaginal and Vulvar Lubricants and Moisturizers handout. Contact info Sarah Jax, MA, APRN, AOCNP Nurse practitioner, Survivorship program coordinator & APP lead Minnesota Oncology Plymouth Sarah.Jax@USOncology.com (office) (cell) AllinaHealthSystem 9