Addressing Unanswered Questions About Sexuality
Barbara Rabinowitz, RN, MSW, PhD
Monmouth Medical Center
Last Modified: November 1, 2001
Innovations in Oncology Nursing, Vol. 10, No. 23, 1994
Reprinted with permission of the publisher
It takes more than a little courage to come forward with complaints that the medical community does not yet see as standard. If those complaints are sexual in nature, it is surely even more difficult to continue to address the subject and ask the medical community to listen and respond. But for some time, brave women have come forward, one by one, complaining of changes in their sexuality that they insisted could not be explained by the loss of their breast. Indeed, both women with mastectomy and those with lumpectomy brought froth these complaints.
Women receiving chemotherapy are aware of many transitional side effect they may suffer (e.g. nausea and vomiting, hair loss, fatigue). However, there are also sexual side effects often not discussed and sometimes irreversible. Preliminary research suggest that some chemotherapeutic agents interfere with the production of sex hormones. If the women with whom I've talked are a good barometer, discussion of sexual matters, if any, is limited to the shutdown of ovarian function and premature menopause as it relates to estrogen depletion, resulting in traditional menopausal symptoms (including a negative impact on the arousal phase of a woman's sexual response cycle). Rarely discussed with women is the fact that functioning ovaries also produce another hormone essential for normal sexual functioning. Often referred to as the male hormone, a small but vital amount of testosterone is also synthesized by the ovaries. Research by Kapland Owett suggest that a virtual lack of testosterone can be a dramatic side effect of chemotherapy . This decrease brings with it a loss of sexual desire and decrease in the ability to experience orgasm.
In a non random sample generating 63 quesionnaires returned to Linda Bloom, a San Francisco, California psychotherapist and herself a breast cancer survivor, all but one of the women reported a drop in the enjoyment level of their sexual experiences, with 52 women convinced that their sexual symptoms were long-term side-effects of chemotherapy (L. Bloom, unpublished data, 1994).
This information will come as no surprise to those women who have been speaking out about the decrease in sexual interest and sexual pleasure they have felt following chemotherapy. Many women relate that they have been told that these sexuality changes they experience are all psychological. Certainly for many, there is some psychological impact of the breast cancer on their relationships that may need to be addressed. That in no way obviates the need to address the very real organic impact that chemotherapy may have on sexual functioning. Kaplan puts forth very clearly the combination of depleted estrogen and testosterone may negatively affect all three phases of the sexual response cycle: desire, arousal, and orgasm .
There is little information in the literature about this impact of androgen (testosterone) depletion on sexual functioning for women with breast cancer, and even less on how to remedy it. Although Kaplan notes that in some instances, women are being offered small nonvirilizing doses of testosterone, she quickly adds that this has not been well studied and that some specialists are "reluctant to risk testosterone administration," fearing the unknown.
There is still much to learn. What percentage of women experience permanent androgen depletion and under what circumstances? What can we learn about long-term safety of "testosterone replacement therapy"? Are there other medications that can effectively restore desire and capacity for orgasm? In what ways can we assess the interface between the psychological determinants of sexual difficulties for these women? In addition to finding answers to questions such as these, it is essential that health care professionals inform women about all potential risks and benefits of available treatment alternatives, including the side effects.
As many women have said to me in one way or another, "It's great to know that I'm not alone, to have it validated that something really is happening to my body. But I wait for more." They, as we do, look to the horizon, to await answers to the above questions and more -- answers that will help each woman reach out and feel sexually alive again.
2. Kaplan HS, "A neglected issue: the sexual side effects of current treatments for breast cancer." J. Sex Marital Ther. 1992; 18:3-19.