Discussing Sexual Health Issues With Female Cancer Survivors

A Conversation With Don S. Dizon, MD, FACP

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Don S. Dizon, MD, FACP

I think we’ve fallen into the trap of assuming that if there’s an issue important to the patient, then the patient will bring it up. Unfortunately, that’s not always the case, and most of our data suggest that unless a provider opens that door, it will not be discussed.

—Don S. Dizon, MD, FACP

Advances in cancer treatment have led to increasing numbers of long-term survivors, bringing greater attention to the needs of this growing population. Female cancer patients often experience difficult adjustments related to sexual health and intimacy. To better understand the complexity of this important issue, The ASCO Post recently spoke with Don S. Dizon, MD, FACP, Assistant in Medicine at Harvard Medical School and the founder and Director of the Oncology Sexual Health Clinic, Massachusetts General Hospital, Boston.

Difficult Areas

How well are providers communicating with their female cancer patients about issues surrounding sexual health and intimacy?

Despite all our gains in cancer communications, sexual health and intimacy issues are still difficult areas for many clinicians to broach. Most of us are very comfortable talking with our patients about fertility issues, but for some reason putting a discussion about vaginal health in the context of sexual health continues to be problematic.

I think we’ve fallen into the trap of assuming that if there’s an issue important to the patient, then the patient will bring it up. Unfortunately, that’s not always the case, and most of our data suggest that unless a provider opens that door, it will not be discussed.

Women treated for cancer often experience difficult issues related to sexual health and intimacy, and they frequently cite this as a major area of concern, even among long-term survivors. So it’s an unmet need in the quality-of-life continuum in oncology.

Approaching the Issue

Sexual health is a subjective term. Is there a way to give physicians a better understanding of this issue so that we can bridge this communication gap?

One method that might make physicians more comfortable is letting them know that when they initiate a discussion on sexual health, they don’t need to open with penetrative intercourse. Not talking specifically about sex can remove one of the barriers in this discussion. Moreover, providers might not be prepared or knowledgeable enough about sexual issues to counsel their patients.

There is a lot more involved in sexual health and intimacy than sex itself. There’s a term in the literature that really hits home—the “coital imperative,” which is the idea that for sex to be real, there must be penetrative intercourse. But not every woman you are treating wants to have penetrative intercourse, or, for that matter, wants to discuss her treatment-related issues that make intercourse painful or unwanted.

So one way to approach this issue is by using terms you are comfortable with. For instance, for a surgeon who’s removing a woman’s breast, a body-image discussion might lead to a deeper discussion about sexual health. Or if a medical oncologist is talking about chemotherapy-induced premature amenorrhea, talking about vaginal health could open the door for a larger sexual health discussion. While talking about other more comfortable issues, we can say, “in addition, the vaginal atrophy you’re experiencing could lead to painful sensations that might interfere with intimacy.”

More important, people should not assume, either subconsciously or consciously that oncology sexual health is just about getting patients to a better place where intercourse is comfortable, because that’s not what we do. Sexual health is an important survivorship issue in women who have cancer and must be looked at in the context of the numerous physical and psychological challenges that cancer patients face.

Problematic Side Effects

What are some of the treatment-­induced side effects that affect a woman’s sexual health?

First, it’s important that sexual health issues be viewed in the overall context of women’s health issues, because issues related to cancer often overlap with normal changes related to the female aging process. Obviously, the effects of surgical procedures such as hysterectomy and oophorectomy can impact sexual health because of direct anatomic changes or hormonal imbalances. And, of course, women who undergo breast surgery have varying degrees of body image challenges.

However, among side effects–related sexual health issues, chemotherapy stands out as the biggest risk for future sexual dysfunction. The reasons are quite varied. Most cytotoxic agents result in fatigue and nausea, which can severely limit a woman’s interest in sex or intimacy beyond a certain level. The constitutional symptoms associated with chemotherapy include the body-image problem of hair loss, not only on the head but also in private regions of the body.

In a way, grappling with chemotherapy-induced fatigue and nausea would be akin to trying for intimacy while having a bad flu. Beyond that are the physiologic changes such as atrophy and toxicities to the vagina and pelvis. All of these issues dampen a woman’s libido.

An issue that comes up quite often for women is the psychological feeling that they’ve been de-feminized. Women who lose a breast, ovaries, or uterus to cancer often feel that parts of their bodies that make them a woman have been removed. Data also suggest that women who have had colorectal surgery requiring placement of an ostomy were at significant risk for sexual health issues and psychological distress, again due to body image.

Useful Resources

Are there guides to help physicians tackle the challenging discussions about mechanical difficulties that arise after cancer treatments?

There is a lot of sexual health information available that providers and patients should know about. Physicians can also incorporate sexual health questionnaires in their routine review of patients both during and after active treatment, to guide management and discussion.

Several models can help initiate these discussions, such as the PLISSIT, which stands for Permission, Limited Information, Specific Suggestions, and Intensive Therapy. Not surprisingly, there are also websites for providers that address the issue of sexual health. One that I’ve contributed to is the Living Beyond Breast Cancer website (, which offers an online brochure on sex and intimacy.

This is a multifaceted issue, so it’s important to break it down to its core components. First, we need to make sure that our patients know that this is an important issue not only to them, but also for us as their providers. It’s also important for providers not to expect to have all the answers about sexual health. And if pressed for answers, they should be comfortable in telling their patients that there are other resources outside the oncology office that can help them through this difficult period.

At the cancer center at Massachusetts General, I collaborate with great nurse practitioners who take these discussions as far as they can, discussing issues like vaginal estrogen, dilators, and lubricants. But once they reach a point where they don’t feel their suggestions are helpful, they send them to me. Approaching this issue with a clear understanding of your personal comfort level is essential.

Role of Community Oncologists

Are busy community oncologists equipped to handle these issues?

That’s a difficult question. Community oncologists are being tasked to do quite a lot, especially with the new Commission on Cancer guidelines that ask us to address distress, which is a broad area that includes sexual dysfunction. Sexual dysfunction was rated by a LIVESTRONG survey as one of the top three complaints among people treated for cancer. So I would hope that before initiating treatment, community oncologists would explain that certain common side effects such as nausea and fatigue might affect sexual health. Patients who are informed about the risks are more likely to seek out help proactively. It’s a complicated issue, but it is part of the continuum of quality care, and we need more awareness about it. ■

Disclosure: Dr. Dizon reported no potential conflicts of interest.