When you are first diagnosed with cancer, it’s natural to focus on getting well. You may not think about the impact on your self-esteem, body image, relationships and sex life until treatment is over. Increasingly, people are ‘living with cancer’, and this may involve ongoing treatment. You can find ways to live a fulfilling life while managing longer-term treatment for cancer.

Emotions and sexuality

It is normal to feel a range of emotions when dealing with cancer and its treatment. Some of the emotions you may feel include:

• Anger

  You may feel angry about having cancer and about the ways it has affected your life, including your sexuality or your ability to have children (fertility).

• Anxiety

  The thought of having sex again after treatment can cause anxiety. You may be unsure how you’ll perform, dread being touched, fear that intercourse will be painful, or feel self-conscious about being seen naked. If you’re single, you may feel anxious about getting involved in a new relationship. Worrying that you’re not satisfying your partner sexually, or that your partner no longer finds you sexually attractive, can also cause distress.

• Fear

  You may worry that others will avoid or reject you when they see how your body has changed. You may not be able to imagine yourself in a sexual situation again.

• Guilt

  Many people think they should just be grateful to have the cancer treated and feel guilty for thinking about their sexual needs.

• Self-consciousness

  If your body has changed physically after cancer treatment, you may feel self-conscious. Often people discover that their partner (or a potential partner) isn’t as concerned about these changes as they are. 

• Shame

  You may feel ashamed by changes that affect your sexuality, your appearance or the way your body functions. 

• Depression

  Symptoms of depression can include feeling sad, irritable or anxious, having trouble sleeping, losing interest in activities you previously enjoyed, poor appetite and a decreased interest in sex (low libido).

• Grief

  You may grieve for your former body and sex life if things have changed significantly.

These emotions can affect your self-esteem, sexuality and attitude towards intimacy. It can help to talk about how you’re feeling with someone you trust, such as your partner or a health professional, or with another person who has had cancer. You might also like to read Emotions and Cancer.

"Max felt he was not the same man after treatment. He would avoid talking and touching. Counselling gave us ways to help express what was really going on." – Amy

How cancer treatment affects sexuality

The most common cancer treatments are surgery, radiotherapy, chemotherapy and hormone therapy.

These treatments, as well as the cancer itself, can have temporary or permanent effects on your sexuality by changing:

• your feelings (they may cause fear, anger, anxiety, sadness, relief and joy)
• the body’s production of the hormones needed for sexual response
• the physical ability to give and receive sexual pleasure
• your body image, how you see yourself, and your level of self-esteem
• roles and relationships.

Even if you are aware of the potential impact, it is very hard to predict how cancer and its treatment will affect you. Some sexual problems are common, but these will not be an issue for everyone.

Common sexual problems for men and women include:

• tiredness and fatigue
• depression and anxiety
• loss of interest in sex
• painful intercourse
• changed body image, e.g. due to scarring, loss of a body part, hair loss from any part of the body, changes in weight
• loss of a body part, such as a reproductive organ
• incontinence
• fertility problems (temporary or permanent)
• strain on, or changes to, your relationship(s).

Some men also have:

• erection problems
• ejaculation difficulties.

Some women also have:

• vaginal dryness
• reduced vaginal size
• loss of sensation
• pelvic pain
• trouble reaching orgasm
• menopausal symptoms.

Surgery

Surgery aims to remove the cancer from your body. It can potentially affect your sex organs and body image.

After any surgery, you will have a period of recovery. This will vary depending on the type of surgery, but it is often around 4–8 weeks and even longer for some people. During this time, you may need to do some gentle exercise to build up your strength. Talk to your doctor about what level of activity is safe and when you can resume your usual activities, including sex.

Some forms of surgery for cancer can have longer-lasting impacts. The removal of a body part can affect body image. Sometimes bowel or bladder surgery involves the creation of a stoma, an opening on the abdomen that collects waste in a disposable plastic bag. Surgery in the pelvic or abdominal region can cause trouble holding urine or bowel movements ( incontinence). If the surgery removes part or all of a sex organ, sexual function can be directly affected. Nerve damage can also affect sexual function and pleasure.

Surgery for men

Surgery in the abdomen or pelvic region – Surgery for bowel, bladder or prostate cancer can damage the nerves used for getting and maintaining an erection ( erectile dysfunction). This may be temporary or longer-lasting.

It is sometimes possible to preserve the nerves that control erections, but this works best for younger men who had good quality erections before the surgery. Problems with erections are common for 1–3 years after nerve-sparing surgery, but aids such as penile injection therapy can improve the situation.

Removal of the prostate (prostatectomy)

Side effects vary but may include:

• erection problems
• feeling the same sensations of build-up before orgasm, but not ejaculating semen during climax ( dry orgasm)
• semen going backwards towards the bladder instead of forwards ( retrograde ejaculation)
• l eaking urine during orgasm
• loss of pleasure
• pain during orgasm.

Removal of the testicles (orchidectomy or inguinal orchiectomy)

If you have only one testicle removed, there should be no lasting effects on your ability to have sex or your fertility. Unless there are unrelated fertility issues, your remaining testicle will make enough testosterone and sperm for you to be able to father children. The scrotum’s appearance can be maintained with an artificial testicle ( prosthesis).

Having both testicles removed (bilateral orchidectomy) causes permanent infertility because you will no longer produce sperm, but you may be able to have sperm stored before the surgery for later use. Your body will also produce less testosterone, which may affect your sex drive, but this can be improved with testosterone replacement therapy.

Removal of the penis (penectomy)

Part or all of the penis may be removed to treat penile cancer. The part of the penis that remains may still get erect with arousal and may be long enough for penetration. A penile implant may be an option to help get and maintain an erection. It is sometimes possible to have a penis reconstructed after removal, but this is currently experimental and would require another major operation.

Removal of the anus (abdominoperineal resection)

Anal or bowel cancer sometimes requires the removal of the anus. This is a key erogenous zone for many men. For men who have sex with men, some sexual acts may no longer be possible, but you can find new ways to express intimacy.

Surgery for women

Breast surgery – Most breast cancers are treated with surgery. Women may have: part of the breast removed (breast conserving surgery or lumpectomy); the whole breast removed (mastectomy); or both breasts removed (bilateral mastectomy). Breast and nipple sensation usually remains the same after breast conserving surgery, but mastectomy can affect sexual arousal, particularly if you previously enjoyed being touched or kissed on the breast and nipple. You may also feel you have lost a part of your female identity or be worried about how your partner will react.

Lymph nodes are sometimes removed during surgery for breast cancer. This may cause the arm to swell (lymphoedema), making movement and daily activities such as dressing difficult. The swelling may also make you feel embarrassed or self-conscious.

Removal of the uterus (hysterectomy)

A hysterectomy may be used to treat gynaecological cancers, such as cancer of the cervix, ovary, uterus and endometrium (lining of the uterus). After a hysterectomy, you will be unable to become pregnant and will stop having periods ( menopause).

The surgery may shorten the top part of the vagina. The clitoris and the lining of the vagina will remain sensitive, so you will usually still be able to feel sexual pleasure and reach orgasm. For women who previously experienced uterine orgasms, however, removal of the uterus can have a significant impact on sexual satisfaction.

Removal of the ovaries (oophorectomy)

If both ovaries are removed (bilateral oophorectomy), and if you haven’t already been through menopause, you will experience early menopause. You will no longer have your monthly periods or be able to become pregnant ( menopause). The hormonal changes can result in vaginal dryness.

If only one ovary has been removed, the other should continue to release eggs and produce hormones. You will still have periods and may be able to become pregnant if you have an intact uterus. 

Removal of the vulva (vulvectomy)

The removal of some or all of the vulva will alter the appearance and sensation of your genital area and can mean major changes to your body image, self-esteem and sexual practices. If this is a concern for you, ask your doctor for a referral to a sexual therapist either before your surgery or during your recovery.

Even if the clitoris is removed, an orgasm may still be possible. Stimulation of other sensitive areas of your body, such as your breasts or inner thigh, can lead to a climax. However, it will take time for you and your partner to adjust to these changes.

Vaginal surgery

Vaginal cancer may be removed by surgery that takes out a small section of the vagina. Usually the remaining vaginal tissue can be conserved so you are still able to have intercourse. Some women need a larger operation that removes the whole vagina (a vaginectomy). A vaginal reconstruction may be an option, but the scar tissue from surgery can make intercourse painful and difficult.

Most people feel shocked and upset about having cancer in one of the most intimate and private areas of their body. Call Cancer Council 13 11 20 for support.

Radiotherapy

Radiotherapy (also called radiation therapy) uses x-rays to kill cancer cells or injure them so they cannot grow and multiply. It can be delivered by an external radiation beam or given internally (brachytherapy or radioisotope therapy). If you are having internal radiation, you may need to take some precautions, such as avoiding sexual contact or using barrier contraception (such as condoms), while the treatment is active. Your doctor will discuss any precautions with you.

During radiotherapy, your body uses a lot of energy dealing with the effects of radiation. Many people feel very tired during and after treatment. This fatigue may last several weeks or months. Your skin may also be very sensitive or painful to touch. You may not feel like having sex during this time, but physical affection such as hugs or holding hands can be very reassuring.

Depending on the area treated, you may also lose your appetite and lose weight. If you have hair in the area that is receiving radiotherapy – for example, your scalp, face or body – you may lose some or all of it during treatment. Usually it grows back and returns to normal after radiotherapy has finished.

Radiotherapy for men

Pelvic radiotherapy is commonly used to treat prostate, rectal and bladder cancer. It can damage the blood vessels and nerves that help produce erections, and this can cause temporary or permanent erectile dysfunction. It may also make the urethra inflamed, so ejaculating might be painful for some weeks.

Reduced sperm production is common after radiotherapy, and it may be temporary or permanent. If you might want to father a child in the future, ask about having sperm stored before treatment.

Radiotherapy for women

If you are having radiotherapy to the pelvic area for cancer of the rectum, bladder or cervix, the radiation oncologist will try to avoid the ovaries, especially if you have not yet been through menopause. In some cases, however, the radiation does affect the ovaries and stops them producing female hormones. This can cause symptoms of menopause such as a dry and itchy vagina, and your periods may become irregular or stop, a sign that your fertility is affected. Your periods may return after treatment is over, but some women will be permanently infertile.

Pelvic radiotherapy can cause short-term inflammation of the vagina and vulva. It may also cause bowel problems, such as diarrhoea, either temporarily or permanently. Scar tissue from radiotherapy can make the vagina shorter and narrower (vaginal stenosis). Sexual intercourse may be painful, but the use of vaginal dilators or vibrators can help.

Radiotherapy to the breast area can cause the skin to become red and sore and develop a sunburnt look. Small blood vessels in the skin can be damaged, causing red ‘spidery’ marks (telangiectasia), but this is becoming less common with new techniques.

Your skin may also have a slightly darker tone. It’s not unusual for the breast to feel firmer, and over months or years it may shrink slightly. Changes often can’t be noticed under clothing. If you’re unhappy with the changes, talk to your doctor about the options (e.g. an operation to reduce the size of your other breast).

"I didn’t really realise the radiation would affect my sexuality until it happened. I don’t think anyone can tell you what the pain, discomfort and exhaustion will do to you." – Donna

Chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cells. The drugs are called cytotoxics and they particularly affect fast-growing cells such as cancer cells. Other cells that grow quickly, such as the cells involved in hair growth, can also be damaged.

The side effects of chemotherapy vary depending on the individual and the drugs given. Common side effects include tiredness, nausea, vomiting, diarrhoea, constipation, hair loss and mouth ulcers – all of which may reduce your desire to have sex. Chemotherapy can also directly affect the levels of hormones linked to libido. If you have a partner, it may be helpful for them to understand why your libido has changed. Sex drive usually returns after treatment ends.

Chemotherapy for men

Chemotherapy drugs may lower the number of sperm produced and their ability to move (motility). This can cause temporary or permanently infertility. If you want to have children, talk to your doctor before treatment about arranging to store your sperm. The ability to have and keep an erection may also be affected, but this is usually temporary.

Chemotherapy for women

Chemotherapy can reduce the levels of hormones produced by the ovaries. This causes some women’s periods to become irregular, but they often return to normal after treatment. For other women, chemotherapy may bring on menopause. After menopause, a woman can’t conceive children with her own eggs. If this is a concern for you, speak to your doctor before treatment.

Chemotherapy for ovarian or colon cancer can be given as liquid directly into the abdominal cavity. This can cause the belly to swell a little, which may affect your body image, but the liquid will drain away after a short time.

Another common side effect in women having chemotherapy (especially if they are taking steroids or antibiotics to prevent infection) is thrush, which can cause vaginal itching or burning and a whitish discharge.

Protecting your partner

Whatever your preferred method of contraception, you should also use some sort of barrier during sexual activity for seven days after chemotherapy. This reduces the potential risk of your partner being exposed to the drugs, which may be excreted in your body fluids.

For intercourse, use condoms or female condoms. Partners can wear latex gloves if using their hands for penetration.

For oral sex with a woman, dental dams (latex squares) are sold in sex shops and some pharmacies.

Hormone therapy

Hormones that are naturally produced in the body can cause some cancers to grow. The aim of hormone therapy (also called endocrine therapy) is to reduce the amount of hormones the tumour receives. This can help reduce the size and slow down the spread of the cancer.

Hormone therapy for men

In men, testosterone helps prostate cancer grow. Slowing the body’s production and blocking the effects of testosterone may slow the growth of the cancer or even shrink it. Men receiving hormone therapy may experience side effects such as tiredness, erection problems, reduced sex drive, weight gain, hot flushes, breast tenderness, enlarged breasts, depression, and loss of bone density (osteoporosis).

Hormone therapy for women

In women, oestrogen helps some kinds of breast cancer to grow. Anti-oestrogen drugs (such as tamoxifen, goserelin and aromatase inhibitors) are used in hormone therapy to treat oestrogen- sensitive cancers. They can help slow or stop new breast cancers developing. Some women have no side effects, while others experience symptoms similar to menopause, including vaginal dryness or discharge, painful intercourse, hot flushes, weight gain, decrease in sex drive, night sweats, urinary problems and mood swings. Regular gynaecological check-ups after hormone therapy are recommended as there is a small risk of developing cancer of the uterus lining (endometrial cancer).

Other cancer therapies

Other treatments for cancer include immunotherapy and targeted therapies. Immunotherapy uses substances that encourage the body’s own natural defences (immune system) to fight disease. Targeted therapies attack specific weaknesses of cancer cells while minimising harm to healthy cells. Side effects for these treatments vary depending on the particular drug that is used, but can include swelling, weight gain, fatigue and pain, all of which may affect your desire for or ability to have sex. Your doctor will explain if you need to take any precautions during sex after having these therapies.

Palliative treatment

Palliative treatment aims to reduce symptoms without trying to cure the disease. It can be used at any stage of advanced cancer to improve quality of life. As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include surgery, radiotherapy, chemotherapy, targeted therapies or other medication.

Many people say that sexuality and intimacy remain important to them even when cancer is advanced. It is still okay to talk to your health care team about the impact of any treatment on your sex life or your ability to be intimate. If you have a partner, try to spend time together as a couple, rather than as ‘patient’ and ‘carer’, during palliative treatment. Intimacy can provide comfort and maintain connection during this time. Even if sexual intercourse is no longer possible or desired, you may find physical closeness through touching, massage or simply lying beside each other.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs. For more information see Understanding Palliative Care and Living with Advanced Cancer or phone Cancer Council 13 11 20.

Key points

• The main cancer treatments are surgery, radiotherapy, chemotherapy and hormone therapy (endocrine therapy).
• It is difficult to predict how treatment will affect you. Changes can be temporary, longer-lasting or permanent.
• It is natural to feel a range of emotions. These can include anger, anxiety, fear, guilt, self-consciousness, shame, depression and grief, which can all affect sexuality.
• Surgical removal of a body part can affect your sense of self and your body image.
• The side effects of cancer treatments can lower your libido.
• Radiotherapy to the pelvic area can affect sexual function and fertility by damaging blood vessels and nerves in, or near, the sexual organs.
• Chemotherapy can have a permanent effect on your hormones and your fertility.
• Side effects from hormone therapy can include tiredness, decreased libido, weight gain, hot flushes, loss of bone density, breast tenderness, increased breast tissue, and depression. Women may experience additional menopause-like symptoms.
• It is important for partners to be aware of the impact that treatments may have on sexuality and intimacy.
• Even when cancer is advanced, sexuality and intimacy remain important. Discuss any concerns you have with your medical team.
• Awareness, education and talking to a qualified counsellor can help you to find new ways to experience intimacy and sexuality.

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