Hello, I'm Donna Herrera Bell an advanced practice provider
at MD Anderson Cancer Center.
I'm here with my colleague, Carmella Wygant, a clinical
psychotherapist at MD Anderson.
And this is the Cancerwise podcast.
Carmella, thank you for joining me today.
Thank you for having me. The pleasure is mine.
Great. Well, we're here today to talk about some
of the side effects of cancer treatment, and
their impact on sexuality and
intimacy. And we want to explore some
of the most common side effects that patients can
experience in terms of their
sexuality and intimacy, and what we
can do to help with that.
And so, Carmella, first and foremost, I think
it's so important to normalize these conversations
with patients and to be able to provide
a space for them to have these conversations.
So, can you tell me a little bit about how you go about
normalizing these kinds of conversations?
Absolutely.
It is critical.
It is absolutely critical to normalize
their experience.
And I tell them, you're
having a natural response to an abnormal
situation.
And the other thing is educate, educate,
educate.
Absolutely.
It is so important for us
to get the word out to patients and
to providers that this is something that patients
will commonly experience.
And many times, because of,
you know, these subjects can be taboo, especially
from a cultural standpoint,
that they will not verbalize
these complaints. They'll talk about other complaints,
other physical complaints, but they won't bring forth these
complaints unless they're specifically
asked. And then, once they're specifically asked
about, you know, are you having pain with intercourse?
Are you having pain?
Are you having, just vaginal discomfort just sitting?
Then their, sort
of, their interest is piqued and that, sort of, it gives
them the OK to really
begin to share about what they're experiencing.
And, and for men as well, especially, you know,
I mostly deal with a younger population and our young
adults. And I have just been
floored with how significant
some of the symptoms that our young adults are
experiencing, and yet they've been experiencing them
for a significant amount of time, and yet they haven't
brought them to the attention of their providers.
And they trust their providers opinions.
They will follow their treatment recommendations,
but they, sort of, either are sometimes
a little embarrassed, or the other thing
that I feel is they don't know who to bring that
concern to.
Like, this is my lymphoma doctor.
So, I'm going to talk to them about my lymphoma stuff.
And this is my neurologist.
So, I'm going to talk to them about my neurology stuff.
But who do I talk to about the sexual
stuff? Who do I talk to about these other
very intimate side effects that
I'm experiencing? So, they don't know who to bring that to,
I think, sometimes.
Has that been your experience?
Not only is that my experience, you
know the literature. You know the research.
Between 70% and 90%
of our patients want the providers
to initiate the conversation.
So, we have to communicate.
And not just communicate the information, but communicate
to each other. ,
You know, I guess now we can talk a little bit about
specifics in terms of what specifically
patients can experience.
The number one thing that I hear from patients,
men and women is impact on libido.
Oh my gosh. Yeah.
Which, you know, I recently read a
definition for libido, which is sort of like the mental
energy, thinking. It's not just the, it's the
drive, but the desire and the mental energy
around sex.
And so, many of our patients report
to me an impact on libido
for them. Very different from, you know,
what they were prior to diagnosis, during treatment
and even after treatment.
Because we'll see patients, you know, before, during and
after treatment. One of their questions, especially after
treatment, is like, when am I going to get back to that
same drive? And one of the other questions that they
have is, how
do I share these changes with, if they're in
a, if they're partnered, if they're married or they have an
established relationship, like, how do I share these
changes in my libido with my partner?
Because I don't want my partner to think it's because
of them.
And so, I think that's, you know, there's a physical
aspect, but there's also the psychosocial, relational
aspect that just deeply impacts
their intimacy and their place of support
because their partner
that their intimate relationship with is who is supporting
them, many times, through this cancer journey.
And so, you know, that is a primary
relationship for many of them.
And so, the libido can really
be just so significant in terms of
a side effect that they can experience.
Men can experience issues with erectile
dysfunction.
They can experience issues
with ejaculation.
For women, they can experience vaginal
dryness.
Yes.
That can be very significant.
They can experience pain with intercourse.
And that pain can either be pain
with penetration.
So, the initiation of intercourse penetration, deep
pain during intercourse.
Some women can experience vaginal spasms
during intercourse or tightness that occurs.
Yes, yes, yes.
They can experience irritation or itching
of the vagina.
So, can be very significant.
GSM, genitourinary syndrome of
menopause, that M is menopause because of the low estrogen
state.
Right.
And so, they can also have other, they
can sometimes that can be associated with frequent UTIs
because of changes in the pH of the vagina.
And so, you know, definitely many, many physical
changes that can occur for men and women as secondary
to their treatment.
What are some of the things that patients report to you?
There are so many different ways I can go with
this, but I'm going to go back to what you said
about the loss of libido.
That is a very big and
significant loss.
And it's a loss.
And men and women feel it.
And I talk about we normalize,
we educate, we allow people to grieve because there's
a cluster of loss.
There is. It's very significant.
You know, going back to, you know, what we talk
to our patients about, is cancer
in itself, just the experience, is very
isolating. But then it really,
it isolates them in the bedroom.
Absolutely.
And, you know, it's an experience
that they're going through.
And, you know, their spouse, their loved
ones, their close family circuit is by their side,
is supporting them. But yet, they feel very alone.
And yet again, the impact
that cancer has on their, you know, the
sexual dimension some patients, you know, can
feel about, "Oh, you know, should I really be worried
about, you know, how I'm able to function sexually?" Like,
"Oh, this is just bonus. So, I, you know, I shouldn't
really be worried about this." I mean, that's just a part
of us being humans. And this is one of those ways that we
connect intimately with people that, you
know, that we have this kind of connection that we love,
that we're supported by.
And so, yes, I think there is great grief
and loss, and processing that, and
being able to speak to that.
And, you know, I find myself often having conversations
with patients and sometimes with couples about,
you know, other than intercourse,
how do you all connect?
Beautiful, beautiful.
How do you all connect intimately?
What does that look like for you?
And having those conversations, you know, having those sort
of conversations and just, sort of, sparking
that idea in their mind about let's
go home and have this conversation about,
you know, what other things like, are you OK if
there are other elements in the bedroom that could help
accomplish that?
My patients are fractured.
My patients are in shame.
They're in fear. They are isolated, and they don't want
anyone to see them.
They don't want to see themselves.
They say, I won't get out of the shower unless I know the
mirror is completely covered.
So, we do the grief work, of course, and then we look at
reconnecting.
One of the things that when I'm working with patients
who, you know, we've talked about and we've identified
they're experiencing some impact on their sexuality.
I think one of the first places as
a nurse practitioner that I go to looking
for culprits is their medication list.
Oh.
You know, we've talked a lot about grief, and we've talked
about, you know, the psychosocial impact of
cancer diagnosis and treatment has.
And so, for many patients, they can be very
commonly placed on an SSRI or some other
medications to treat depression or anxiety,
and very appropriately so.
What we know is that many of those medications
can most definitely impact libido.
Absolutely.
And so, and sometimes patients do need that for an
extended period of time.
But you know, looking at that medication list, and looking
to see, is there anything on that medication list that
could be contributing to
the issues they're having with libido?
For men, we've made great advances
in having discussions about fertility, you know, making
sure that men who are within reproductive age, and women,
know that cancer treatment can potentially impact their
ability to have children in the future.
I think we're much more aware, and those conversations are
happening much more frequently, which I think is amazing
and great. However, I think that sometimes,
and I've seen this in my own practice, men, especially,
can equate infertility with sexual dysfunction.
And so, they'll think, "Oh yeah, you know, I was told
that I was high risk for infertility in the future, and so
that's why I'm experiencing, you know, erectile
dysfunction. That's why I can't have an erection.
That's why I can't ejaculate." And so, I always make it a
point to talk to male patients and say, "I
know that you were told that you could potentially be
at high risk for infertility or that you're at risk for
infertility, but that does not mean that you
are not, you know, that you're not going to be able to
perform sexually. You should still be having erections.
You still should be able to ejaculate.
If you are unable to do any of those things.
That's not normal. That's not what we're talking about when
we say fertility.
And so, you need to let your provider know and we
can make a referral to urology."
Yes.
Or sometimes male patients can also benefit
from pelvic floor therapy.
Yes, yes, yes, yes.
Pelvic floor therapy has also become more popular for
women. But men can also benefit from pelvic floor
therapy.
Absolutely.
I think for women, depending on what
the, you know, what their complaints are,
some women may be candidates
for hormone replacement therapy.
Yes.
Some women will not be because of their cancer therapy.
But, sometimes the symptoms
that are related to changes in the vaginal tissue are
due to low estrogen.
And so, for some women, you know, hormone replacement will
help to address some of those symptoms.
And even so, for women who are not
candidates for hormone replacement, they may be candidates
for topical estrogen, even for some of our breast
cancer patients.
Absolutely. Sing it, sister.
Sing it.
I think, you know, those are conversations
that patients can have with their oncologist,
and that oncologists are very well-versed at having,
in terms of, you know, is, you know, what's my risk?
Like, these are the symptoms that I'm having that are
impacting my quality of life, like it's very significant.
Yeah.
And so, you know, am I a candidate?
These are the things that are available for me to be able
to address the symptoms that I'm having.
But, is this really safe for me because this is my cancer
history? This isn't the type of tumor that I received.
This is the type of continuing treatment that I'm having,
is, you know, am I candidate for this?
Yes or no? And you know, in the space
of topical estrogen, you know, is this safe?
Because I think for many women that's a big fear.
You know, we go back to that, you know, balancing
act of like, yes, I, you know, I want to enjoy,
you know, intercourse, and I want to be able to walk
without being uncomfortable because I have so much vaginal
dryness, but I also don't want to do something
that, you know, could potentially impact my risk of,
you know, my cancer coming back.
And those are real questions and real concerns
that women have. And so, having that conversation with
their oncologist of, in terms of like, what are
my options?
What I want to really also focus on
is the importance of educating regarding lubricants.
Coconut oil is very useful,
very helpful for women who are experiencing
vaginal dryness.
You know, and it's not just surrounding
intercourse. But vaginal dryness is just uncomfortable
in just daily life.
And so, women will, you know, report that.
"I'm just uncomfortable at my desk.
I'm uncomfortable, you know, I'm a teacher and I'm
uncomfortable when I'm standing, you know, in front of my
classroom." And so, coconut oil is definitely
something that can be used.
There's, you know, of course, a myriad of
other products that, you know, can be used.
Thanks, Carmella, for joining me today.
It was a great discussion.
And thank you for listening to the Cancerwise podcast
from MD Anderson.
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