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SEXUAL DYSFUNCTION

Sexual dysfunction is a frequently overlooked yet significant issue among people with cancer, resulting from the disease itself or its treatment modalities. It is best conceptualized through a biopsychosocial framework, which recognizes that biological, psychological, and social factors collectively shape a person’s sexual health and experiences.

Abrupt hormone changes due to chemotherapy or hormonal therapy, surgery, or radiation may have caused sexual health problems. This includes partial or complete loss of one or both breasts, premature menopause due to cancer treatment, physical challenges of alopecia, and lymphedema. These changes alter a woman’s relationship with herself and can negatively impact a woman’s perception of her physical appearance and sexuality.

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  • What is sex?

    • The act of having sexual intercourse. This can also include other ways you express intimacy.

  • What is sexuality?

    • The way you express yourself as a sexual being.

  • What is intimacy?

    • How connected you are with another person – can be physical, emotional, or mental.

 

You are not alone!

 

General prevalence of  sexual health related concerns:

  • Up to 66% of women with cancer report sexual dysfunction

  • Rates of sexual dysfunction are as high as 90% among gynecologic cancer survivors

  • 75–90% of breast cancer survivors (BCS) experience sexual dysfunction

  • 77% of female lung cancer survivors report sexual health symptoms

  • 75% of colorectal cancer survivors report sexual health symptoms

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You may feel embarrassed or ashamed to ask about sexual health issues after surviving cancer. However, sexual health concerns are just like any other side effects from cancer deserve attention. You should feel empowered to bring up these issues to your primary care providers. If a doctor or clinician does not seem comfortable or experienced with these concerns, there are professionals who can help. Ask for a referral to urologist or gynaecologist, other professionals who treat sexual difficulties. 

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What to ask your healthcare provider?​

  • How can sexual side effects be relieved or managed, if they do occur?

  • Can sexual side effects occur after treatment ends?

  • Is it safe for me to have sex during cancer treatment?  Would you recommend that I talk with a counsellor or sex therapist?

  • How might my treatment affect my sexual function, desire, or intimacy?

  • Are there treatments or resources available to help with sexual health concerns?

  • Would you recommend that I speak with a counsellor, sex therapist, or another specialist?

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Physical symptoms to report:​​

  • Little or no interest in sex

  • Reduced vaginal lubrication (dry vagina)

  • Decrease genital sensation (feeling touch)

  • Reaching orgasm

  • Pain during sex activity

  • Or any other concerns​​

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​​​​​​​​​Psychological and/or emotional symptoms to report:​​​

  • Body image concerns

  • Anxiety

  • Depression 

  • Poor self-esteem​

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Risk factors:

  • Individuals who received radiation, chemotherapy, and endocrine therapy

  • Individuals who underwent mastectomy

  • Higher baseline body mass index (BMI)

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Why does sexual dysfunction happen:

  • Physical impacts of treatment: Treatments like chemotherapy or radiotherapy can disrupt sex hormones, causing symptoms such as vaginal dryness. Hormonal therapies may also inhibit hormones essential for sexual function 

  • Surgical effects of treatment: Procedures such as mastectomy or lumpectomy might impact a woman's body image and lead to sexual dysfunction. Additionally, the risk of nerve damage from these surgeries can result in decreased sensation  

  • Psychological impacts of treatment: The emotional stress from treatment and uncertainties about the future can decrease sexual desire and function. The trauma experienced during treatment can also affect self-image and physical functioning, making a woman feel less desirable and self-conscious, particularly during sexual activities.​​

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Use vaginal moisturizers (gel or cream) 3–5 times per week at bedtime

Use vaginal lubricants during sexual activity (water-, silicone-, or oil-based)

Consider hyaluronic acid vaginal products 3–5 times per week at bedtime

Vitamin D (1000 IU) and/or Vitamin E (30–200 IU) vaginal suppositories used nightly

Avoid products that may irritate the vulvar or vaginal area

Discuss prescription options with your healthcare provider, such as low-dose vaginal estrogen, vaginal DHEA (6.5 mg nightly), vaginal testosterone (150–300 μg daily), or ospemifene (60 mg once daily)

Vaginal dryness, irritation, itching, or burning

TREATMENT INTERVENTIONS

Pain during sexual activity (dyspareunia)

Use vaginal moisturizers and lubricants regularly

Pelvic floor physiotherapy and exercises may help reduce pain

Vaginal dilators and vibratory stimulation devices may improve comfort and flexibility when used several times per week

Treat any underlying vaginal or vulvar conditions contributing to pain

Prescription options may include vaginal estrogen, vaginal DHEA (6.5 mg nightly), vaginal testosterone, or ospemifene (60 mg daily)

Ask about referral to a gynecologist or pelvic floor specialist

Low sexual desire

(libido)

Individual, couple, or psychosexual counselling

Sex therapy, cognitive behavioural therapy (CBT), or mindfulness-based programs

Sexual aids, self-stimulation exercises, and strategies to enhance intimacy

Prescription options may include flibanserin (100 mg at bedtime), bremelanotide (1.75 mg injection before sexual activity), bupropion (150–300 mg/day), or testosterone therapy under specialist supervision

Referral to a sexual health specialist may be helpful

Difficulty reaching orgasm

Directed self-stimulation exercises

Vibratory stimulation devices

Cognitive behavioural therapy (CBT)

Address pain, dryness, or other symptoms that may interfere with sexual pleasure

Referral to a sexual health specialist for additional support

Emotional or relationship concerns affecting intimacy

Supportive counselling

Cognitive behavioural therapy (CBT)

Mindfulness-based programs

Couples counselling or psychosexual therapy

Referral to a psychologist, psychiatrist, sex therapist, or couples counsellor when appropriate

ONCOMENOPAUSE

OncoMenopause is an emerging field of medicine focused on the intersection of cancer survivorship, menopause, and midlife women’s health.

What is Onco-Menopause?

Onco-menopause refers to menopause that occurs as a result of cancer treatment or cancer-related surgery. It can affect people who have had cancer treatments such as:

  • Chemotherapy

  • Hormone (endocrine) therapy (e.g., tamoxifen, aromatase inhibitors)

  • Radiation therapy involving the pelvis

  • Surgical removal of the ovaries (e.g., risk-reducing bilateral salpingo-oophorectomy [RRBSO]

 

Unlike natural menopause, which usually happens gradually, onco-menopause often occurs suddenly and symptoms can be more severe.

 

Why Does It Happen?

Many cancer treatments reduce or stop the ovaries' production of estrogen and other hormones. These hormones help regulate body temperature, sleep, mood, sexual health, bone strength, and overall wellbeing. When hormone levels drop quickly, menopausal symptoms can develop.

 

Common Symptoms of Onco-Menopause

  • Vasomotor Symptoms

    • Hot flushes (hot flashes)

    • Night sweats

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  • Sleep and Energy Problems

    • Difficulty falling or staying asleep

    • Fatigue (persistent tiredness)

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  • Mood and Cognitive Changes

    • Anxiety

    • Low mood or depression

    • Irritability

    • Difficulty concentrating or "brain fog"

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  • Genitourinary Symptoms

    • Vaginal dryness

    • Vaginal irritation or discomfort

    • Pain during sex

    • Urinary urgency or recurrent urinary tract infections

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  • Sexual Health Concerns

    • Reduced libido (sex drive)

    • Difficulties with intimacy or sexual function

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  • Long-Term Health Effects

    • Bone loss (osteoporosis)Increased risk of fractures

    • Possible effects on heart health

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Treatment: Vasomotor Symptoms 

Vasomotor symptoms (VMS), including hot flushes and night sweats, are among the most common and bothersome symptoms experienced by cancer survivors. They result from a sudden decline in estrogen levels caused by cancer treatments such as chemotherapy, endocrine therapy, pelvic radiation, or surgical removal of the ovaries. Compared with natural menopause, onco-menopause often occurs abruptly, leading to more severe symptoms that can negatively affect sleep, mood, daily functioning, and overall quality of life.

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Management of vasomotor symptoms should be individualized and often involves a combination of lifestyle measures, medications, and supportive care.

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Lifestyle and Behavioral Strategies

Simple lifestyle modifications may help reduce symptom severity and improve coping:

  • Keep the environment cool and use fans when needed.

  • Wear lightweight clothing and dress in layers.

  • Avoid potential triggers such as:

    • Spicy foods

    • Hot drinks

    • Alcohol

    • Smoking

  • Maintain a healthy weight.

  • Engage in regular physical activity.

  • Practice relaxation techniques, mindfulness, or yoga.

  • Consider Cognitive Behavioral Therapy (CBT), which has been shown to reduce the impact of hot flushes and improve sleep and wellbeing.

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Non-Hormonal Pharmacological Treatments

For many cancer survivors, particularly those with hormone-sensitive cancers, non-hormonal medications are considered first-line treatment options.

Commonly used medications include:

  • SSRIs

    • Escitalopram

    • Citalopram

  • SNRIs

    • Venlafaxine

    • Desvenlafaxine

  • Other agents

    • Gabapentin

    • Pregabalin

    • Oxybutynin

    • Clonidine (less commonly used)

Important: Patients taking tamoxifen should generally avoid paroxetine and fluoxetine, as these medications may reduce tamoxifen's effectiveness.

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Hormone Therapy

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms. However, its use in cancer survivors requires careful consideration.

  • May be considered for selected patients after specialist assessment.

  • Generally avoided in patients with a history of hormone receptor-positive breast cancer.

  • Decisions should involve shared decision-making between the patient, oncology team, and menopause specialist.

 

Complementary Therapies

Some patients may find additional benefit from:

  • Acupuncture

  • Hypnosis

  • Mindfulness-based interventions

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However, evidence for these therapies varies, and herbal supplements should be used with caution because their safety and effectiveness in cancer survivors are often uncertain.

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