How treatment can affect sexuality

Surgery for women

Surgery to treat cancer can affect a woman's sex organs, both in appearance and function. This can impact negatively on her body image.

Breast surgery

Most breast cancers are treated with surgery.

• Breast conservation surgery - part of the breast removed.

• Mastectomy - whole breast removed.

Breast surgery may make a woman feel like she has lost part of her female identity. A woman may feel less attractive or worry that her partner will reject her because of her changed appearance.

Mastectomy can damage the nerves that influence nipple feeling. This means you may no longer feel sexual when your breast is fondled, even if you have a breast reconstruction. Breast and nipple feeling usually remains the same after breast conserving surgery.

Hysterectomy

Hysterectomy means removal of the uterus.

It may be used to treat gynaecological cancers such as cancer of the cervix, ovary, endometrium and uterus.

After the uterus is removed, the top part of the vagina is stitched up. This shortens the vagina. The length of your vagina doesn't affect your ability to feel sexual pleasure and you don't need the uterus to have an orgasm. However, you may notice some difference because the muscles that normally contract during an orgasm have been removed. The clitoris and the lining of the vagina remain sensitive.

Oophorectomy

The removal of an ovary is called an oophorectomy.

• Removing one ovary - the other ovary should continue to produce eggs.

• Removing both ovaries - monthly periods cease and you will go through menopause. You will not be able to become pregnant and you may have menopausal symptoms such as hot flushes, vaginal dryness, tiredness, mood swings and difficulty sleeping. These symptoms may occur more quickly than natural menopause because your body hasn't had time to get used to the reduced amount of hormones.

Vaginal surgery

Some women need a small operation to remove cancer from the vagina. Remaining tissue can be stretched so you can still have intercourse. If the whole vagina is removed, this is called a vaginectomy. A vaginal reconstruction is an option, but scar tissue can make intercourse painful.

Vulvar surgery

There are different types of surgery for cancer of the vulva, including local excisions, vulvectomy (some or all of outer sex organs), and pelvic exenteration, which removes the vulva and other affected organs. Surgery will change the appearance of the sex organs and can affect sensation, especially if the clitoris has been removed. However, orgasms are still often possible.

Radiotherapy for women

Radiotherapy to the pelvic area

Radiotherapy for cancer of the rectum, bladder or cervix can stop the ovaries producing female hormones. This can cause menopausal-like symptoms, such as irregular menstruation and a dry vagina. Scar tissue may form, which will shorten and narrow the vagina. Penetration may be painful but your ability to reach orgasm won't be affected. After treatment, your periods may return but some women lose their fertility permanently.

Radiotherapy to the breast

Radiotherapy to the breast can make the skin red and sore. The breast may also change in size or shape. The change is permanent, but it is usually only slight and not noticeable under clothing. Some women may notice that their breast feels a little firmer but it usually softens over time.

More information

Understanding Radiotherapy

Chemotherapy for women

Chemotherapy can reduce the amount of hormones produced by the ovaries or can affect the eggs. This may cause some women's periods to become irregular but they usually normalise after treatment. For other women, chemotherapy brings on temporary or permanent menopause. Thrush is common, causing vaginal itching, burning and discharge. Chemotherapy can also cause exhaustion, which can impact on sexual desire.

More information

Understanding Chemotherapy

Immunosuppression

Some women who are receiving chemotherapy or who have had a transplant can be immunosuppressed or immunocompromised. This means they are more prone to infections such as chickenpox, the flu and sexually transmitted infections. They may also experience severe fatigue and vaginal dryness, which can reduce their enjoyment of sex. Immunosuppressed women should avoid having sex if their partner has an infection that could be passed to them. Barrier contraception should be used to minimise the risk of spread of infections. Women should also be screened regularly for cervical cancer. They should see a gynaecologist for specific advice about managing this and other sexuality issues.

Hormone therapy

Hormones that are naturally produced in the body, such as oestrogen, can make some cancers grow. Hormone therapy reduces the amount of oestrogen in the body or stops cancer cells from getting oestrogen.

There are different types of hormonal therapies:

• Anti-oestrogens - work by stopping cancer cells from getting oestrogen. Tamoxifen is the most common anti-oestrogen. It can help slow the growth of, or stop, new breast cancers, lower the chance of the cancer returning and reduce the risk of developing heart disease or osteoporosis.

• Aromatase inhibitors - work by stopping oestrogen from being produced. They are usually used in women who have been through menopause. Three common drugs are Arimidex, Aromasin and Femara. Side effects include osteoporosis, vaginal dryness, hot flushes and weight gain.

Hormone therapy may cause you to become temporarily or permanently infertile. However, many women go on to have a baby when their menstrual cycles have been re-established after treatment.

Surgery for men

Prostate surgery

Many men with early prostate cancer have the prostate removed with surgery (radical prostatectomy). Afterwards, most men experience problems getting and keeping an erection (erectile dysfunction or impotence). The ability to have an erection usually improves, often over several years, but the problem can be ongoing for some men.

The prostate and seminal vesicles are removed during a radical prostatectomy, which means you will not ejaculate semen when you climax. This is a dry orgasm.

Infertility is likely to occur. Although sperm may be produced, it cannot be ejaculated, as the vas deferens is blocked during surgery. Radiotherapy can also affect the quality of semen.

Nerve-sparing surgery

Nerve-sparing surgery involves the removal of the prostate and the preservation of the erection nerves. These nerves can only be saved if the cancer has not spread along them. This surgery works best with men who had good quality erections before the operation.

Orchidectomy

An orchidectomy is the removal of one or both testicles (testes).

One testicle removed - there are no lasting effects on your fertility or your ability to have an erection or intercourse because the remaining testicle makes enough testosterone and sperm.

Both testicles removed - causes some permanent side effects. The lower testosterone levels may affect your sex drive and you will be infertile.

Appearance of the scrotum - if you're concerned about the appearance of the scrotum, it can be maintained with an artificial testis, called a prosthesis. Ask your doctor about this.

Bowel or rectal surgery

Surgery to the bowel may sometimes cause nerve damage that makes it difficult to get an erection. Erection performance may improve over time but it is sometimes affected permanently. Some men with bowel cancer need a stoma.

Cystectomy

In a radical cystectomy (full removal of the bladder), the prostate gland is taken out too. This can affect sexual function if the nerves in the pelvic area are damaged.

Removal of the penis

This operation is only done for cancer of the penis, which is very rare.

Depending on the location of the tumour, part, or all of, the penis may be removed. The remaining part of the penis may still get erect with arousal and may be long enough for penetration. A man can still reach orgasm with sexual stimulation, and will ejaculate through the opening at the end of the remaining penis.

Reconstructive surgery is still experimental, but it is sometimes possible to have a penis reconstructed. A penile implant is another option.

Radiotherapy for men

Radiotherapy can cause the following problems:

• Tiredness - During radiotherapy your body uses a lot of energy dealing with the effects of radiation, so many men feel tired during and after treatment. This fatigue may last for several weeks or months. You may not feel like having sex during this time.

• Painful ejaculation - Radiotherapy to the pelvic area may make ejaculating painful as the urethra (the tube that carries urine from the bladder out through the penis to the outside of the body) has become inflamed. The pain usually disappears a few weeks after the treatment ends.

• Erection difficulties - Problems with having an erection are common after radiotherapy. The nerves and blood vessels needed to have an erection become scarred and are unable to let enough blood through to fill the penis. This problem may not develop until 12 months after treatment.

• Reduced sperm production - This is common after radiotherapy and may be temporary or permanent. If you want to father a child, consider having sperm stored before your treatment starts.

More information

Understanding Radiotherapy

Chemotherapy for men

Chemotherapy can cause a number of side effects relating to sexuality:

• Fertility concerns - The drugs may lower the number of sperm produced and reduce their ability to move. This can cause infertility, which may be temporary or permanent. If you want to have children, you can store your sperm for later use before treatment starts.

• Erection difficulties - The ability to have and keep an erection may also be affected but this is usually temporary.

• Tiredness - Chemotherapy may make you feel too tired or sick to want sex. Once chemotherapy is over, your sex drive usually returns.

More information

Understanding Chemotherapy

Hormone therapy for men

This treatment blocks the body's natural hormones, such as testosterone, that help some cancers grow. Blocking the production of testosterone using hormone therapy may slow the growth of the cancer or even shrink it. Hormone therapy is often given for several months before radiotherapy to reduce the size of the cancer.

Hormone treatments to lower testosterone levels may cause side effects, but these can be treated.

Side effects include:

• tiredness

• erection problems

• reduced sex drive

• weight gain

• hot flushes

• breast tenderness

• depression

• loss of bone strength (osteoporosis).

Stoma for men and women

A stoma (or ostomy) is formed when any portion of the small or large intestine is brought out onto the abdomen so that waste can be removed from the body. Stomas may be temporary or permanent.

In women, if the rectum is removed, the nerves that control a woman's genital sensations are not usually damaged but there may be a different feeling in the vagina during penetration. Sex may be uncomfortable, as the rectum no longer cushions the vagina.

In men, creating a stoma usually involves removing all or part of one or more organs in the pelvic area. This may affect the nerves controlling erections.

More information

• Speak to a stomal therapy nurse, available at most large hospitals.

• Contact the Ileostomy Association of NSW on (02) 9568 2799.

• Contact the Colostomy Association of NSW Inc. on (02) 9565 4315.

Effects on men who enjoy anal penetration

If you enjoy anal penetration or stimulation, surgically closing the anus may be a problem. Intercourse via the stoma can cause damage and sexually transmitted diseases can still be passed via the stoma.

Fertility and contraception

Some, but not all, cancer treatments can cause infertility (inability to conceive a baby), which can be temporary or permanent. If fertility is important to you, you should talk to your doctor before treatment about your risk of infertility and ways your fertility might be preserved. You may be able to store eggs or sperm for use in the future.

When people learn that they may be permanently infertile they often feel a great sense of loss. You may be devastated that you won't have your own children or additional children, and you may worry about the impact of this on your relationship. Even if your family is complete,
you may experience distress. As well as talking to your partner, discussing your situation with a counsellor, radiation oncologist, urologist
or gynaecological oncology nurse can be beneficial.

Although chemotherapy and radiotherapy reduce fertility, it is still possible for women having treatment, or the partners of men having treatment, to become pregnant. Your doctor may suggest you wait two years before trying to conceive. This gives the body time to recover and allows the eggs and sperm to become healthy again. During treatment and for the waiting period afterwards, some form of contraception must be used.

Ask your doctor about your contraceptive options and talk to your doctor immediately if you become pregnant. If you have a stoma, the effect of the contraceptive pill may change depending on the type of surgery and stoma you have. Talk to your surgeon, stomal therapy nurse or gastroenterologist about the most suitable contraception for you.