Sexuality and breast cancer☆

Most men know that prostate cancer treatment comes with a high risk of impotence. But few women are told that being treated for breast cancer may cause them to develop their own form of sexual dysfunction.

Many oncologists are unlikely to mention it unless asked. And most of the popular patients' guides to breast cancer gloss over the subject. When they do, most of these books discuss the emotional issues involved with living with a deformed or missing breast, the result of surgery, or with the temporary loss of hair, the consequence of chemotherapy.

Certainly, those are issues that may impact on a woman's sexuality. But they are no means the only issues, or even the most potentially damaging ones that women who have undergone breast cancer treatment face.

Besides the emotional issues that breast cancer surgery poses, there are physiological changes—the result of chemotherapy or hormonal therapy—that can render a woman uninterested, unresponsive, or both.

“It affects 100 percent of women who have been treated for breast cancer,” said Dr. Irwin Goldstein, who heads the Institute for Sexual Medicine at Boston University School of Medicine. “There is no possibility of having the same sexual function you had before the treatment. Much of the therapy in breast cancer is completely adverse to sexuality. It's a very controversial and emotional issue.”

Randi Rosenberg of New York City, who was diagnosed 5 years ago at the ripe young age of 32, noted that she was not at all in the mood for sex during her treatments, as she had a new scar in her breast, a bald head, and was always nauseous from chemotherapy.

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“I had a strong sense of my attractiveness and sexuality and now I had all these physical issues,” she said. “All these things take their toll.”

But she said she had no idea that for a long time after her treatments had ended she still would have no interest in sex.

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“It became an issue in my relationship,” said Rosenberg, the president of the Young Survival Coalition, an advocacy group for younger women diagnosed with breast cancer. “We'd go months and months without having any sexual relations. No relationship can withstand that for a long period of time.”

Eventually, she and her husband divorced.

The chemotherapy regimen that is recommended for most breast cancer patients—even many with early-stage tumors—can put a younger woman into what is known as “chemical menopause.”

The changes seen are similar to those experienced during natural menopause, but “symptoms can be more severe than those associated with the more gradual lowering of estrogen levels that occurs with normal aging,” said an October 2000 study by breast cancer specialists at the Dana-Farber Cancer Institute, published in the New England Journal of Medicine.

Being propelled into menopause overnight surely can wreak havoc with one's sex life. Not only is desire down, but the lack of estrogen can cause the vaginal tissues to become dry, making intercourse painful.

Although she didn't go into menopause, Rosenberg said she experienced both consequences, probably the combination of chemotherapy and tamoxifen, a drug that blocks estrogen receptors in the breast.

“My libido was very low,” she said. “The chemo probably knocked my estrogen down. And the tamoxifen made it worse. It happens to many of our young women. I really had a hard time recovering my sexuality. When you are not having sex and your libido doesn't register, your muscles can atrophy. When I did have an inkling of desire, it was so painful, it made the experience unpleasant. It was difficult to achieve any lubrication. Even with gels and what have you, it is very challenging.”

Fortunately, Rosenberg said her sexuality has recently received a jumpstart—with a new relationship and the stopping of her tamoxifen pills. “Sex is not an issue at all now,” she said.

But for many, the problems remain.

“Changes in the urogenital epithelium can be most bothersome and can markedly impair the quality of life,” concluded the Dana-Farber study, by Dr. Harold Burstein and Dr. Eric Winer.

Breast cancer treatment affects not only hormone levels, but may also interfere with such things as blood flow, nerves, and the emotions, Goldstein noted.

“The basic things that are needed for the physiological sexual response are interfered with by surgery, chemo and radiation” he said.

He said oncologists must pay more attention to these quality of life issues. “Sexual health is everybody's right,” he said.

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These issues also may affect patients who have been treated for other cancers that are not hormonally dependant, he said. For that reason, studies are needed to look at how hormone replacement therapies might be able to help such patients, he said. One day, studies might seek to find out how such therapies might be able to be given to patients with hormone-dependant cancers, he added.

But giving estrogen to breast cancer patients with estrogen-dependent cancers is risky, although the use of estrogen rings and vaginal estrogen creams is generally deemed less so.

“The oncologists are all fearful,” he said. “But I see these patients every week in my clinic. They're happy to be alive, but they're dead sexually. They ask, ‘Is there anything to help me?' We've got to do studies to find out how we can help these women.”