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April 2017
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SEXUALITY AND TUMOURS

SEXUALITY AND TUMOURS

The diagnosis of a gynaecologic tumour can cause significant changes to a couple’s life and, consequently, to their sex life. For a woman, finding out she has breast or uterus cancer has a substantial psychological impact on her because it destabilises her female identity, just as having to face a genital tumour (testicular or prostate cancer) is an attack on a man’s virility. In both cases, the individuals find themselves having to face the inevitable mutilations that their bodies will have to undergo, which will also affect them aesthetically. As far as surgery is concerned, conservative procedures are preferred more and more, for example a quadrantectomy for breast cancer (the removal of just a quarter of the breast) or nerve sparing for both testicular and prostate cancer, since changing one’s body image can have various consequences.

When the diagnosis of a gynaecologic tumour ends up affecting the woman’s love life, it is important to reflect on how the couple’s sexual love life was before the diagnosis. If a couple did not have a satisfying sex life before the tumour was discovered, it will almost definitely be difficult to have a care-free sex love life after treatment. Vice versa, for couples who did have an intense sexual love life before treatment, it will be easy for them to get back to where they were and they may even have deeper feelings for their partner after having gone through a difficult time together.
However, these illnesses affect more than just sex between a couple; they also affect interpersonal relationships because the partner with the illness may feel guilty or inadequate or, as is the case for many people, they lose self-esteem, trust in the future and future plans. Therefore, relationship and psychological aspects are more important than the effects the illness has on physical sexual relations because the majority of people claim that the most important thing is to feel loved, wanted and accepted. This is also why, in many cases, sufferers oppress their sexual desires, which are conditioned by thoughts about surviving, anger and frustration, since they are afraid of not being accepted by their partners because their bodies bear the signs of operations.

EFFECTS OF CANCER AND TREATMENT ON SEXUALITY

Problems with desire or pain during sexual relations
Many sufferers undergoing treatment for cancer tend to lose interest in sex because their survival instinct dominates and this is accompanied by depressive thoughts, worries about work, financial situations, how to spend time with their children, and so on. All these factors affect the spheres of sexual desire and arousal and, if the partner is not able to interact properly with the sufferer, these spheres can be affected even more.

MEN: ERECTILE DIFFICULTIES

In normal conditions, when a man gets aroused his brain automatically emits nerve signals which go down the spinal cord and reach the anal area, prostate, urethra and, lastly, the penis. These signals free chemical substances which cause the corpus cavernosa to swell and the penile blood vessels to dilate and when blood reaches the penis’s blood vessels an erection occurs.  It must be mentioned however that these nerve impulses and chain reactions are uncontrollable processes.
The side effects of some anti-cancer treatments can cause nerve damage and reduced blood flow which, if accompanied by insecurity, stress, a fear of failing and thoughts about death, can make getting an erection difficult. Furthermore, after treatment in the prostate and/or pelvic areas, sperm may end up in the bladder and therefore be expelled when urinating. This is a phenomenon called retrograde ejaculation.

Advice for overcoming difficulties with erections
• Talk to your partner and a specialist (oncologist or sex/couple therapist) in order to find out exactly what the problem is;
• Find out what else gives you a feeling of power (since erection is a synonym of power);
• Learn how to ask your partner to be stimulated in a new way;
• Use your imagination, games and sense of humour so you do not concentrate on the erection and sex too much (use oral stimulation, self-stimulation, sex toys, and so on);
• Remember that sexual relations and orgasm are possible without an erection (the woman can lead and arouse you just the same).

Read this article too: erectile dysfunctions.

Medication and prostheses to deal with the side effects of hormone therapy
When curing prostate cancer and some cases of testicular cancer, treatment may be testosterone based. In fact, the growth of the tumour’s cells is linked to the presence of testosterone, a sexual hormone that is mainly produced in the testicles, thus, in order to prevent the growth of the tumour, the levels of this hormone must be lowered with specific drugs. Hormone therapy does have side effects though and they are similar to those of removing the testicles; for instance, sexual desire declines and it becomes difficult to get an erection. However, there are ways to work against these effects, such as using specific pharmaceuticals that induce an erection, like sildenafil (more commonly known as Viagra) and all its variants, which act on increasing the blood flow in the penis. Localised injections of alprostadil or papaverine or a penile prosthesis are alternative solutions to pharmaceuticals.

A scrotal prosthesis is nothing more than an artificial testicle which is inserted to make the scrotum look aesthetically pleasing, thus helping the patient to get his self-esteem back and body confidence back.
Negative pressure devices can also be used and these consist of a transparent cylinder which the penis is inserted into and, by blowing air into the cylinder, the pressure around the penis reduces, thus blood flow increases, resulting in an erection.
A penile prosthesis is made up of two components, one of which is inserted into the penis and consists of two inflatable cylinders, and the other which is a pump inserted into the scrotum which, when pumped, pushes a liquid into the two cylinders and this induces an erection. The implant is inserted under anaesthetic and is permanent.

Fertility and radiotherapy
About 50% of couples affected by testicular cancer also experience fertility problems right from the beginning of radiotherapy. Even though the most modern technology shields healthy testicles as best as possible, radiotherapy can temporarily compromise the production of sperm. A good way to remedy this problem however, is to preserve some sperm before starting radiotherapy (cryopreservation).

Cryopreservation is a process through which sperm is frozen so that it can be used at a later date for artificial insemination. This practice is highly recommended even if, at the time of treatment, the male/couple is not thinking about having children. However, it must be mentioned that the quality of the male’s sperm may already be insufficient before diagnosis due to the testicular cancer itself, therefore tests on the sperm’s shape and motility are carried out before cryopreservation with a spermogram.

Fertility and chemotherapy
Chemotherapy can also cause similar side effects to those of radiotherapy as far as the quantity and quality of the sperm are concerned. In fact, chemotherapy also attacks the healthy testicle which can compromise the quality of the sperm for an unknown amount of time, but, on average, it takes about 2 years for the damaged cells to regenerate and get back to the same quality that they had before treatment.

Hardly compromised fertility
Excluding cases of radical prostatectomy and other particular treatments for treating prostate cancer, the cases of permanent infertility are, today, becoming fewer and fewer. Modern surgical treatments always aim to conserve fertility as much as possible or at least guarantee recovery over time. Having said this, fertility problems may have existed before surgery or treatment, that is, the tumour itself may have caused a slight reduction in sperm production, which occurs in 20-50% of sufferers. This means that in adult males who were treated for testicular cancer from a young age, fertility will be around 85% compared to healthy males of the same age.
All in all, the possibility to remain fertile appears to be quite high and being able to do this basically depends on three elements: the number of sperm contained in the semen (sperm content), the type and dose of radio and/or chemotherapy and the age of the patient.

WOMEN: THE PHYSICAL AND PSYCOLOGICAL CONSEQUENCES OF A GYNAECOLOGIC TUMOUR

Ovarian tumour
For a woman, facing the diagnosis of an ovarian tumour is twice as hard because, on the one hand, she will be worried and scared about the disease itself but, on the other hand and more seriously and immediate, she has to face a tumour which could affect one of the most important sphere’s in the female universe: the reproductive system.
Treatment for ovarian cancer usually consists of an initial operation followed by chemotherapy and/or radiotherapy. The immediate consequence, in the majority of cases, is the loss of ovarian function and this translates into the precocious menopause, which is particularly hard to deal with for younger patients who are naturally fertile as they have to abandon dreams of motherhood which, of course, can cause a deep, emotional crisis resulting in depression, losing interest in everything, an identity crisis (not feeling like a woman anymore) and a fear of not being loved or being left alone. What is more, the female must deal with all the physical consequences of the treatment: hair loss, tiredness, fatigue and feeling bad in general.

Is motherhood still possible?
Apart from the cases that have already been mentioned about ovarian cancer, which requires a hysterectomy, or cases in which sufferers have had to have their ovaries removed or undergo irradiation, or in particular cases of adjuvant chemotherapy, motherhood after a gynaecologic tumour is still possible. If the menstrual cycle has not stopped, it is possible to get pregnant, and studies have shown that getting pregnant does not cause breast cancer to return.
However, as previously mentioned for men, women cannot choose to preserve their eggs for the future.

Before deciding to try for a baby, a series of precautions should be followed:
• speak to your partner and, if necessary, a psychologist too about what would happen if the cancer returned;
• wait until two years after chemotherapy;
• accept that it could take a long time because chemotherapy can affect fertility;
• do not worry if, after giving birth, you produce little milk because radiotherapy affects the mammary glands and accept that you may have to stop breast feeding to stop the breast that was operated on from inflaming.

Breast cancer
The diagnosis of breast cancer – just like for any gynaecological tumour – causes women to change what they think about themselves, their intimacy and their sexual love life. Breast cancer attacks female identity, the female’s sex life and her relationship, even if there are some women who can deal with this illness and all of its inevitable consequences with strength and courage. For others, however, the impact on sexuality is too much, especially for young women who find themselves having to give up the idea of motherhood because of the precocious menopause which is induced by chemotherapeutic treatments.
The type of surgery carried out on the breast(s) also has a big impact: there is a big difference between the conservative operation called a quadrantectomy (removal of a quarter of the breast), the removal of a sentinel lymph node (this is the first lymph node found on entering the breast) and, the worst case, a complete mastectomy (removal of the entire breast) along with a lymphadenectomy (removal of all the lymph nodes in the armpits).
A complete mastectomy has a series of negative consequences on the woman, starting from an aesthetic impact which inevitably leads on to a worsening of everything that has to do with eroticism and pleasure. 83% of women who have undergone this type of surgery report that there is a slight loss of sensation in the other breast and a feeling of shame when showing the scars to their partner which can prevent them from calmly accepting kisses or gentle caresses.

In order to be able to rediscover satisfying sexual and sensual intimacy, you should start by talking about it to your doctor or, better still, a sexologist, who can recommend treatment which can help on more than one level, such as:
• mood moderating drugs, which also help to control blushing;
• massages with St John’s Wort oil for vaginal dryness;
• vaginal biofeedback if the pelvic floor muscles are not tight and therefore there is little vaginal sensitivity or, on the other hand, are too tight and cause pain when having sex.
Furthermore, if the female’s main problem is feeling ashamed about her scars, she can always ask her partner to make love in semi-darkness or wear a bra, which has the double bonus of containing the prosthesis and hiding the scars. Wearing sexy underwear can also help because it makes the female feel more sensual and wanted without having to feel ashamed about the marks left over from surgery. It must be said though, that the majority of women who have to deal with their changed body worry about that and their partner more than they need to.

Reconstructive surgery
Today reconstructive surgery after a mastectomy or quadrantectomy is considered to be an integral part of treatment.

The benefits
The new breast is very similar to a natural breast.
The patient gets her self-esteem and femininity back.
The surgery does not affect any future treatment, whether it is radiotherapy, chemotherapy or pharmacological, nor does it affect any screening tests.

The limits
It is not always possible to make the breast perfect (it is sometimes smaller than before) and sometimes the healthy breast has to be operated on to balance them out.
There is less sensitivity.
It is not always possible to breast feed from the operated breast.
Very rarely the reconstructed breast becomes hard.
The prosthesis needs to be changed every 10-15 years.

Sexuality problems
During and after treatment, a series of psychosexual problems appear in both male and female oncology patients; for instance, a drop in desire, changes to physical reactions and problems with communication with the partner. Women affected by gynaecologic tumours are particularly vulnerable and research has shown that ovarian cancer is one of the main reasons behind a reduction in the frequency of sexual relations, a drop in the libido and problems related to the perception of one’s body.  What is more, a drop in the libido, or even a complete lack of sexual desire, together with a negative response to foreplay or orgasm and a poor idea about one’s body image can even lead on to some women becoming completely abstinent from sex.
Many women who feel their female attributes are impaired are not able to think of themselves as attractive and desirable therefore, before being able to rediscover their body and get back their self-esteem, they need to accept the changes that have happened to them so that, eventually, they can once again consider their body to be a source of pleasure.

Dyspareunia
Surgery and therapy for cancer of the female reproductive system can cause vaginal dryness and pain during sexual relations and this usually results in a drop in the libido because the female is scared of the pain she might feel when having sex. More specifically, the pain felt can happen following surgery or radiotherapy on the pelvic area, or it can be an indirect consequence of pharmacological treatment which reduces vaginal lubrication. Unfortunately, this can cause a vicious circle in females regarding dyspareunia (pain during sex), as can the erection problems mentioned previously for men which make them afraid of failing (performance anxiety).
In the face of a situation like this, an insensitive partner could think the other person has just lost interest, is rejecting him/her and is being insensitive but, in reality, this is just the result of a physical impairment.

PSYCHOLOGICAL SUPPORT

The first objective of psychological support is to slowly reconstruct a new equilibrium between the couple by working on being open towards each other and on what many women feel at this stage: guilty. The same goes for men who have had to deal with testicular or prostate cancer and, in fact, many men feel angry and guilty and they blame themselves which, if not confronted, can result in serious anxiety problems and depression which have strong repercussions on their social life and especially on their love life. This is exactly why counselling and psychological support is recommended. It is a special form of individual or group treatment that lasts for a short amount of time (six months) and which aims to solve specific problems, help individuals to make decisions, deal with crises, improve relationships and develop better personal awareness. The main objective, however, is to provide patients with more resources in order to be satisfied with themselves and live a better social and love life.
The person who provides support is a psycho-oncologist, who can be a psychologist or psychiatrist who helps both patients and relatives to deal with cancer. Together with the patient, the psycho-oncologist evaluates all of the negative feelings related to the illness (low self-esteem, stress, fear, sadness) and helps the patient to obtain a better quality of life and chooses, with him/her, the best strategies to deal with difficulties resulting from the illness and treatment.
Depending on the situation, patients can choose from couple therapy or self-help group therapy.

SEXUALITY AND TUMOURS

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