Things You're Too Embarrassed to Ask a Doctor Season 1, Episode 7: Sex and Cancer Part 1 with Dr. Stacy Lindau

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You are listening to Things You're Too Embarrassed to Ask a Doctor, a production of UChicago Medicine. Each week, we'll feature one physician and ask them your most searched questions in their areas of expertise. For more information on our episodes, visit us at www.UChicagoMedicine.org/podcast. Have something you're too afraid to ask your doctor? Tweet us @tytepodcast. I'm your host Kat Carlton.

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Hello, and welcome back to Things You're Too Embarrassed to Ask a Doctor. Today is a very special episode. It's part 1 of a two-part show. Our guest is Dr. Stacy Tessler Lindau.

I'm a gynecologist, and I'm a specialist in helping women preserve and recover their sexual function after cancer and in the setting of other health conditions.

On today's episode, we'll focus specifically on how cancer can affect people's sexual function.

People always ask me, is sex good for your health? Safe sex, pleasurable sex, satisfying sex, I think, is good for your health.

Next time, we'll delve into questions about sex related to aging populations. But enough small talk. Let's get to our first most searched question relating to sex and cancer. That question is, do I need to stop having sex with cancer?

It's interesting you phrased the question that way. I remember an early study we did talking to lung cancer patients and their partners about sex. And we studied that population because lung cancer, especially at that time, was really a terminal diagnosis. And people diagnosed with lung cancer, when we started that work, maybe could expect four to six months of life.

And we wondered whether people near the end of their life with cancer cared about their sexual function. We found, in fact, that people did care about their sexual function, both the person with cancer and their partner. And one of the interesting quotes I remember from the interviews with people was, "I feel like I'm having sex with cancer," which was a disconnect for people. Because cancer is something they wish they didn't have in their body, and sex was something they wanted.

I thought that was such an interesting finding and struggle for people in that setting. So should people, in general-- is it OK to have sex when you have cancer, which is what I think you're asking? Sex is OK to have if you desire it. I think having sex when you don't feel up to it, when you don't feel ready for it, when you don't feel safe, in general, is not a good time to have sex.

But I can't think of very many situations in the setting of cancer treatment where having sex would be bad. Let me give a couple exceptions. Your platelets are really low. Having sex could trigger bleeding. And so if your platelets are really low, you need to talk to your doctor about whether it's OK.

Similarly, with white blood cell count. If your immune system is really struggling to recover because of your cancer treatment, that might be a time period where you would abstain from sex. But in general, a person with cancer, or recovering from cancer, or a cancer survivor, sex, if you desire it, probably has more benefits than risks.

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How does sexual function change with cancer?

Cancer itself, obviously, is a diagnosis most people find scary. And there are psychological or emotional responses to having a diagnosis with cancer that certainly can affect a person's sexual function. It's not uncommon that people say sex was the last thing on my mind, or asking questions to help me preserve my sexual function after my cancer treatment was just too low on the list to ask, or I felt like it would be frivolous to worry about that. And so, therefore, side note, that topic frequently gets overlooked until a fair bit of function has been lost.

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Cancer can affect sexual function in more direct ways. Did you know most cancers that people survive actually happen in the sex organs? So breast cancer in women, prostate cancer in men. And then if you're open-minded enough to realize that cancers of the colon, and rectum, and anus, or the head and neck are cancers that can affect sexual function, really, cancers affect the sex organs directly.

Two thirds of cancer survivors have a cancer type that directly originated in the sex organs. So the tumor itself may be causing pain or physical discomfort, and that can interfere with sexual function. The treatment for most cancers is a systemic treatment that can affect the sex hormone physiology. We oftentimes are using treatments that block the sex hormones in prostate and breast cancer, gynecologic cancers. That can affect sexual function.

And then the overall side effects of cancer treatment, like fatigue, even weakness or pain, are all factors. Of course, we can imagine how they affect sexual function. These can be managed. First of all, people need to know that if you experience loss of sexual function, or decrease in libido or interest, or pain with sex, that these are not unexpected consequences of cancer treatment.

Women typically are not informed of those side effects of cancer treatment, so they feel that the problems they're experiencing are just them, or they're just in their head, or they're alone with these problems. And that, in itself, can be a huge barrier to recovery of function.

What about with chemo and radiation? Another popularly searched question is, can people have sex while they're receiving these treatments? I know these treatments often have some pretty debilitating side effects that go along with them.

Let's start with radiation. The most common places in the body to receive radiation for cancer, for women, are in the pelvic area for gynecologic cancers, or colorectal cancers, or to the breast. Now, certainly we use radiation to treat other cancer types, for example, head and neck cancers or brain cancers, which can certainly affect sexual function, they're just less common cancers.

Having sexual intercourse, vaginal intercourse or anal intercourse after pelvic radiation would be very, very uncomfortable in the acute phases. And so a period of time for recovery for most people is needed. Having oral sex after head and neck cancer radiation would be very difficult.

Radiation to the breast oftentimes, typically, actually, will cause changes to the skin and sensations in the breast. Many women have tenderness in the breast, and so a period of recovery is needed. I do think it's important if you're undergoing radiation to talk to your radiation oncologist about what's OK, and what kinds of activities are OK, and what is not OK. And if you don't specifically ask about sex, the best available evidence suggests it won't get addressed, so you've got to ask.

Chemotherapy is a systemic therapy. We want to only target the tumor. But of course, some people have tumors that have spread throughout the body, and chemotherapy is delivered through the blood vessels, so it goes everywhere.

Chemotherapy targets rapidly dividing cells. And so healthy organs like, say, the ovaries or the lining of the gastrointestinal tract can be affected. The mouth can be affected. And those systemic effects can interfere with sexual function. They can suppress the immune system. And therefore, it is also important to ask your doctor, is it OK to have sex?

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Now, before we hit record, you mentioned there's this intervention point when someone's being treated for cancer where it would be really beneficial if they talked to their doctor before they get treated about what the best treatment plan would be in order to kind of best meet their needs for their sexual function. Can you talk a little bit about that and why that's so important?

So when we counsel patients, especially women, about what to expect with treatment for cancer, we typically offer options. We talk about the relative risks and benefits of the various options, including side effects and expected impact on quality of life and length of life. We talk about effects of treatment on bowel and bladder function. We talk about when you might be able to return to work. We talk about effects of treatment on physical function, your regular physical activities.

We are skittish, when I say we, we doctors are skittish, about talking routinely about the effect on sexual function. But of course, pretty much everybody has sex, alone or with a partner, and pretty much everybody values their sexual function. And there's a big gap between those realities and our ability to talk about it.

It's therefore, unfortunately perhaps, becomes the responsibility of the person, him or herself, to ask the doctor. If I choose this treatment, what's the likely effect on my sexual function, short and long term? And how about if I choose that treatment?

Now, for men with prostate cancer, we actually have studies that help us counsel men to say X% of men will recover their erection function if they choose this treatment versus X% of men with that treatment. But urinary function and reproductive function are also important to men, and so men can choose which treatments they want based on all of those functional outcomes.

For women, the science is limited in terms of saying to women, if you choose to have, let's say, a bilateral mastectomy, to have both of your breasts removed and not reconstructed, versus if you choose to have them both removed and reconstructed, you could expect this degree of function, sexually, after treatment. We can do that work, just society hasn't yet invested in that.

And therefore, the onus is on women to ask those questions. The answer right now might be great question. We don't have an answer. But the more and more doctors get these questions, I think, the quicker we will come to an answer. Doctors like to have answers. I know those kinds of questions have motivated, heavily motivated, my work.

You mentioned that mastectomy, which is something else that comes up a lot in search, it's something that can make people feel less of themselves when they have their breasts removed. It can make someone feel less feminine, less self-confident. What are some ways that women who experience that who get mastectomies can feel more like themselves again, or maybe even regain some of that sexual function that they lost?

So about 100,000 women in the United States alone, every year, have one or both breasts removed. And a growing number of women are choosing to have their breasts removed preventively because they learn that they are at elevated risk for breast cancer. Many women think of their breasts as an essential part of their body, probably most women. And some women will not use the word mastectomy, they will use the term amputation to talk about the removal of their breast.

When I teach the medical students, I ask them to raise their non-dominant hand in the air. And I ask them, which would you rather give up-- your non-dominant hand or your ability to ever have sex again? Now, many of these students are interested in using their hands for their work, maybe they're future surgeons or obstetricians. And they usually laugh when I ask the question. It's not an obvious answer.

So asking a woman, would you rather have your breasts or not, most women would say, I'd rather have my breasts. If you asked women, would you rather go through life with no breasts but never get cancer, or two breasts and have a risk of cancer, it's a harder question to answer.

The response, the physical and emotional response to losing a breast does vary among women. I have some patients who say, I have one working breast and I focus on that one. I have other patients who say, every time I have sex, every time a hug somebody, I'm reminded of the cancer, and it's very distressing.

Can you imagine that there's been almost no work to describe the sexual function of the female breast? Almost everything written about the female breast is written in terms of lactation function, a very important function, don't get me wrong. But breasts have mobility. They have range of motion. Breasts have sensation, not just to touch, but to temperature, and to blowing, and to wetness.

Breasts have, obviously, a social function. And a really important part of our work right now-- funded by the National Cancer Institute-- is to describe, for the first time really, the full function of the breast in terms of female sexual function, with the hope that if we understand it better, we can preserve and restore it to help women function overall as people and also in their sexual lives.
How wild is it to you that it's 2019 and you're doing that in this year?

It is astounding. It really is. It's not to say that there hasn't been some good basic query of this topic. But it is that the query of the functioning of the female breast as a sexual organ, and the translation of that knowledge to preservation of that function in a context of a procedure that's done 100,000 times a year, is shocking.

Do you know in the last couple of years there have been five penis transplants in the world, meaning we are finding ways to restore not just the appearance of the male genital organ, but the outcomes that we're working towards are reproductive, urinary, and sexual. Whether or not penis transplant is successful is being judged by the functioning in all three domains.

There may be reasons, many reasons, why we can't do breast transplants in order to restore appearance and function after mastectomy. But if we can do penis transplants to restore urinary, reproductive, and sexual function in men who have groin injuries, certainly we can go well beyond just restoring form of the female breast after mastectomy. And the work I'm doing with my colleague Sliman Bensmaia here at the University of Chicago, and Magdalena Anitescu in anesthesia, and others is toward restoring function in the breast after mastectomy.

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Can sex cause cancer? Or can sex make certain cancers worse?

It is interesting to realize that there are some sexually transmitted infections that are causes of cancer. The most common would be human papillomavirus. We've come to understand the role of that virus in the development of cervical cancer, oral cancers, anal cancers. And thankfully, there's a vaccine for human papillomavirus that, in developed parts of the world, is rapidly causing a reduction in the incidence of these cancer types.

So yes, sexual activity, unprotected sex, meaning penile-vaginal intercourse or penile-anal or oral intercourse without a condom is a vector for a virus that can cause cancer. Other examples would be HIV. The HIV virus causes Kaposi's sarcoma. We see this rarely today because, fortunately, prevention efforts have really reduced the spread of HIV. Hepatitis virus can cause liver cancer. So unprotected or unsafe sex can be a vector for cancer.

Unfortunately, that's all the time we have for today's episode. Please stay tuned for next week's show, where Dr. Lindau will be answering questions about sex as it relates to aging populations. Once again, I'm Kat Carlton, and you've been listening to Things You're Too Embarrassed to Ask a Doctor. Music from today's episode is by Blue Dot Sessions. For more information on our show or to submit your own question, visit www.UChicagoMedicine.org/podcast or tweet us @tytepodcast.

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