Sexuality & Fertility Issues in
Cancer Patients
Carolyn Vachani, MSN, RN, AOCN
9/12/2006
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Scope of Sexuality Issues
• 40-100% of cancer patients experience some form
of sexual dysfunction
• Issues do not always resolve after therapy
• Almost all cancer treatments have the potential to
alter sexual function (surgery, chemotherapy,
radiation, hormones)
• Represents major quality of life (QOL) issue
• With intervention, up to 70% of patients can have
improved functioning
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To Optimize QOL, Nurses Can:
• Learn evidence-based information on how
diagnosis/treatment affects sexual function
• Conduct assessments before/during therapy
• Inform patients of possible changes
• Educate clients & partners
• Provide guidance & suggestions for adapting to
changes
• Know resources & refer when needed
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Survey of Physician/Patient Communications
If you wanted to talk to your doctor about a sexual
problem, how concerned would you be that --- might
happen?
Your doctor would be uncomfortable
talking about the problem because it was
sexual in nature
45%
Your doctor would dismiss your concerns
and say it was just in your head
51%
There would be no medical treatment for
your problem
20%
46%
0%
Very Concerned
23%
10 20 30 40
%
%
%
%
Somewhat concerned
30%
50
%
60
%
70
%
80
%
Marwick, C Survey says patients expect little physician help on sex. JAMA 1999;281:2173-2174.
Nurses’ Beliefs
• Someone else will do it
• Patients never ask about it, so they must
not care
• I don’t know how to help or have time
• I don’t agree with their lifestyle
• They should be happy to be alive
• They are too old, sick, young, etc.
• I will offend them by asking
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Johnson’s Behavioral Model
• All of the patterned, repetitive, purposeful ways of behaving
that characterize each person's life make up an organized
and integrated whole, a “system”
• Categorizes all human behavior into seven subsystems:
Attachment, Achievement, Aggressive, Dependence, Sexual,
Ingestive, and Eliminative
• Disturbance in one subsystem affects the other subsystems
• Can be applied to sexual dysfunction
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PLISSIT Model for Communication
• Permission (Assessment)
• Limited Information (Education)
• Specific Suggestion (Counseling)
• Intensive Therapy (Referral)
• Developed in 1976 by Robinson & Annon based
on the four levels of intervention
• Applied to sexuality by Estes in 2002
• 70% can be managed by first 3 levels
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Sexual Dysfunction in Men
• Chemo/hormonal therapy: Erectile dysfunction, decreased
libido, ejaculatory dysfunction, gynecomastia, penile/ testicular atrophy,
and infertility
• Radiation/ brachytherapy: Urinary issues, impotence, bowel
dysfunction, penile/ testicular atrophy
• Surgery: Urinary issues, impotence, body image, pain, retrograde
ejaculation
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Sexual Dysfunction in Women
• Chemo/Hormone therapy: Irregular menses, early
menopause, hot flashes, insomnia, irritability, depression, vaginal
dryness, painful intercourse, infertility, and decreased libido
• Radiation/ brachytherapy: Pelvic fibrosis, vaginal
atrophy/stenosis, scarring, decreased lubrication, urinary effects,
erythema, edema, ulceration, decreased elasticity, shortening,
and increased irritation of vagina
• Surgery: Body image, bowel changes, ROM issues,
menopause, pain, changes in vaginal size/sensitivity, loss of
nipple
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General Nursing Interventions
• Ask the question!
• Educational resources
– ACS booklets for men & women
• Suggestions for energy conservation,
alternatives to intercourse, position changes,
resting
• Set the right mood with relaxation, candles,
music, wine
• Sense of humor
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General Nursing Interventions
• Suggest open communication with partner
• Use of pillows to alleviate pain with positioning,
use of pain meds
• Kegel exercises to relax pelvic muscles
• Treat depression
• Neutropenic pts - no intercourse / tampons
• Referral to therapist – relationship & sexual issues
– Look for AASECT (American Association of Sex
Educators, Counselors, Therapists) credentials
and/or a marriage and family therapist who has
experience with people with cancer
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Ostomy Surgery: Interventions
• Address issues of Body Image
• Concerns about odor
– Tight appliance
– Avoid foods that cause flatulence or urinary odor (asparagus)
• Appliance cover, lingerie
• Ostomy accessories (search for “ostomates”)
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Interventions for Male Issues
• Surgical Nerve-Sparing Techniques
– Results depend on surgeon skill, pt age (better if <50yo,
worse if >70yo), comorbidities
– Both nerve bundles spared: 50-90% success
– One bundle spared: 25-50% success
– No nerves spared: >84% with impotence
– More likely to have initial impotence, but regain function
within 6 mos – 3 yrs
– Early intervention with meds to prevent atrophy
– Without prostate, can have orgasm / normal sensation, but no
ejaculate/semen “dry orgasm”
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Interventions for Female Issues
• Vaginal lubricants
– Use before/during sexual activity
– Water soluble, water- or silicone-based
– Petroleum-based can damage condoms and encourage
vaginal infection
• Vaginal Moisturizer
– Replens: 3x a week, for a minimum of 3 months
– Vaginal tissue regains moisture & elasticity
– Use with lubricants, can also use Replens before intercourse
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Interventions for Female Issues
• Vaginal Estrogens
– Creams: use 2-3x week
– Causes elevated systemic estrogen (highest in first 3-4 mos),
not good for breast cancer pts
– E-string: silicone ring, slow release of local estrogen over three
months
– Vagifem: tablet inserted at night, QD for 2 weeks, then
biweekly
– Risk is thought to be low for breast cancer pts. With ring &
tablets, but long term studies not done yet
– Don’t confuse with Femring (a hormone replacement therapy)!
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Radiation-Induced Vaginal Stenosis
• Radiation for cervical and endometrial cancers, or to the pelvic
region: risk for fibrosis / stenosis
• Risk increases with brachytherapy
• Decreased blood supply leads to dry, tender, less elastic tissue
that may close off vagina
• Women who are sexually active should be encouraged to remain
active
• Vaginal dilator with or without estrogen cream used 3 times a
week for life (can substitute with intercourse). Start when
radiation starts.
• Educate on use and cleaning of dilator, give written instructions –
also important for exam comfort (not just sexual activity), can start
small and increase size of dilator
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Other Interventions for Women
• Eros device to increase blood flow
to clitoris, use 3-4x a week.
Increases sensitivity & lubrication
with gentle vacuum
• Sensua & Viagel – creams
containing L-arginine (dilates blood
vessels) & menthol applied to
clitoris to increase blood flow
• Viagra being tested in women
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Resources
• www.eyesontheprize.org (online community for gynecologic
cancers)
• Support groups (Gilda’s Club, Wellness Community)
• www.oncolink.org
• www.ustoo.org (prostate cancer website)
• www.fertilehope.org
• www.resolve.org (fertility)
• ACS Sexuality booklets
(available on ACS website)
Pregnancy & Treatment
• ~4% (50,000) of people diagnosed with cancer are under age 35
• Discuss importance of birth control use - for both sexes - during
hormones, chemo, xrt
• Condoms for 48 hrs after chemo (excreted in semen)
• IUD, sponge, diaphragm – risk of infection if neutropenic, foams
can irritate vaginal tissue
• Should not conceive after treatment for ~1 yr for women, ~2 yrs
for men
• Data on risk for fetus exposed to chemo is limited and related to
trimester (1st is greatest risk)
• Drug choice, does it enter fetal circulation?
• Delay radiation until after birth or use shielding
• Use non-radiation tests (US, MRI), choose safe anesthesia
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Risk of Infertility: Radiation
• Small dose can = big damage
• Temporary or permanent, can take up to 4 yrs to resume fertility:
monitor FSH & sperm counts if desire pregnancy
• Permanent sperm damage at 4 Gy, but Leydig cells need higher
dose (20-30 Gy), so sexual characteristics can be unaffected
• Oocytes related to pre-treatment pool size
• >40 yrs old: 5-6 Gy; <40 yrs old: 20 Gy for permanent ovarian
failure
• <35 yrs old more likely to resume menstruation, but can still
have premature menopause
• TBI causes sterility in 80% men, 90% women
• Cranial XRT affecting pituitary - may require supplemental
hormones (testosterone, FSH)
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Radiation Risk to Future Pregnancy
• Pelvic/ Uterine radiation
• XRT in childhood results in changes in uterine musculature
& blood flow, decrease in size (40% of normal size)
• Spontaneous abortion: 38% vs. 12% (in the general public)
• Preterm labor: 62% vs. 9%
• Low birth weight: 62% vs. 6%
• No increase in birth defects seen after XRT or chemo in
men or women
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Risk of Infertility: Chemo
• Drug(s), dose, duration, and age of patient
• Higher dose, longer duration, and older age pose highest risk
• Alkalating agents most likely to cause infertility (don’t require cell
proliferation to cause damage)
• Stem cell / BMT (without TBI): infertility extremely likely in
women, 50% of men
• Women can regain menses and still have premature menopause
(42% by age 31 vs. 5% of normal population)
• Resumption of menses is no guarantee of fertility
• Men can develop low/no sperm count with no damage to Leydig
cells
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Chemotherapy (dose to cause effect)
Known Effect on Sperm Count
Chlorambucil (1.4 g/m2)
Cyclophosphamide (19 g/m2)
Procarbazine (4 g/m2)
Melphalan (140 mg/m2)
Cisplatin (500 mg/m2)
Prolonged or permanent
azoospermia in 90% of men;
platinum agents 50%
BCNU (1 g/m2)
CCNU (500 mg/m2)
Azoospermia in adulthood if treated
before puberty
Busulfan (600 mg/M2)
Ifosfamide (42 g/m2)
BCNU (300 mg/m2)
Nitrogen mustard
Actinomycin D
Azoospermia likely, and are often
given with other highly sterilizing
agents, adding to the effect
Risk for Infertility: Surgery
•
•
•
•
•
•
Orchiectomy (bilateral)
Penectomy
Prostate or bladder surgery damage
Prostatectomy
Hysterectomy
Oopherectomy (bilateral)
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Options for fertility preservation in men
• Sperm banking – only after puberty
– $700-1500 for 1-3 donations/ 1-5 yrs storage
– Although many men have poor quality sperm at diagnosis,
new techniques can use it anyway (even just 1-2 samples)
– No sex for 5 days prior, 24-48 hours between samples;
Testicular aspirate if no semen
• Intracytoplasmic sperm injection (ICSI)
– Newer technique for fertilization, very successful
• GnRH agonist/antagonists
– “Turn off” gonads (only tested in mice, no births)
• Cryopreservation of testicular tissue, then
transplant or grow in vivo (+ births in mice)
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Options for Fertility Preservation in Women
• Embryo freezing – cycle 12-14 days, 10-25% chance of
pregnancy per embryo stored, cost $8-12,000, then cost of
storage, thaw & implanting
• Ovarian transposition (oophoropexy) – move
ovaries from XRT field, can be laparoscopic, cost ?, been done
for 30yrs, 16-90% success rate
• Egg cryopreservation – cycle 12-14 days, 2% chance
of live birth per thawed egg, cost ~$8,000, then cost of storage,
thaw, fertilizing & implanting
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Options for Fertility Preservation in Women
• GnRH agonist/antagonist : theory is to stop
proliferation
– Suppress ovarian function via hypothalamic-pituitary
access (some studies use birth control pills for same effect)
– Experimental, studies +/-, large randomized study by
SWOG ongoing
• Ovarian tissue freezing: 60% follicles lost to
freezing, have been 2 live births*
– 5 laparoscopic biopsies can yield 3500 follicles
– Transplant: auto* (orthotopic/heterotopic), xeno (mice), In
Vitro Maturation (success in mice, cows)
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Options for Fertility Preservation in Women
• Radical trachelectomy: for cervical cancer,
experimental?
– Remove cervix, leave uterus intact, permanent cerclage
(stitch closed uterus)
– Started in 1987, >100 live births, 53% chance of
pregnancy over 5 years
– High risk births (premature rupture of membranes) –
about ½ premature delivery, all need c-section
– Recurrence rates equivalent to radical hysterectomy
– Only for early stage disease (IA & IB)
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Assessing Ovarian Function in Survivors
• FSH & Estradiol
– Check on 3rd day of menses
– FSH >12mIU or E2 > 75pg/ml =severely impaired fertility
(or poor ovarian reserve)
– Levels effected by tamoxifen
• Anti-Mullerian hormone (AMH)
– Produced by early follicles, good predictor of reserve
• Antral follicle count
– Via ultrasound on 3rd day menses, not affected by
tamoxifen
– Count # developing follicles, is proportionate to # remaining
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Financial Assistance
• 11 states require insurance companies to cover infertility dx
& tx (unless self-insured) (NJ, NY & MD)
• www.resolve.org (has info for all states)
• Check on extent of benefits, talk to HR representatives
• Sharing Hope program thru Fertile Hope – sperm bank for
$150 (1yr storage) (must meet requirements)
• www.fertilehope.org – has many financial assistance
links/tips
• Rates vary greatly!! Shop around
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Local Sites for Sperm Banking
• 3 National organizations (by mail)
– www.cryolab.com
– www.reprot.com
– www.xytextissues.com
•
•
•
•
•
Women’s Institute; 815 Locust / Plymouth Meeting
Penn Fertility 3701 Market
Fairfax Cryobank 3401 Market (http://www.fairfaxcryobank.com/)
Drexel Fertility Bala Cynwyd / Center City
Reproductive Science Institute Jenkintown
(http://www.rsiinfertility.com/)
• Women’s Health Group of PA Bryn Mawr
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Local Sites for Women
• Women’s Institute: 815 Locust / Plymouth Meeting
(http://www.womensinstitute.org/)
• Penn Fertility: 3701 Market
(http://www.pennhealth.com/fertility)
• Drexel Fertility: Bala Cynwyd / Center City
(http://www.drexelfertility.medem.com)
• Women’s Health Group of PA: Bryn Mawr
(http://www.mainlinefertility.com)
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References
• Devita, VT, Hellman, S & Rosenberg, SA. Cancer: Principles & Practice
of Oncology (7th edition). Lippincott Williams & Wilkins, Philadelphia,
PA 2005.
• Itano, JK & Taika, KN. Core Curriculum for Oncology Nursing (4th
edition). Oncology Nursing Society 2005.
• Krebs, L. & Marrs, JA. What Should I Say? Talking With Patients About
Sexuality Issues. Clinical Journal of Oncology Nursing. 10 (3)313-315,
2006.
• Lee SJ, Schover LR, Partridge AH, et al: American Society of Clinical
Oncology recommendations on fertility preservation in cancer patients.
Journal of Clinical Oncology 24:2917-31, 2006
• Nieman CL, Kazer R, Brannigan RE, et al: Cancer survivors and
infertility: a review of a new problem and novel answers. Journal of
Supportive Oncology 4:171-8, 2006
• Simon B, Lee SJ, Partridge AH, et al: Preserving fertility after cancer.
CA: A Cancer Journal for Clinicians 55:211-28; quiz 263-4, 2005
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