How can maintenance hormonal therapies, which keep my cancer under control, affect my sexual function?

Aromatase inhibitors[1] such as letrozole[2] (Femara), exemestane (Aromasin), and anastrozole (Arimidex) and other medications (like tamoxifen[3], a selective estrogen receptor modulator, or SERM) are often used to treat breast cancer and can exacerbate menopausal symptoms. These medications are very effective in controlling disease and preventing it from returning; however, they do have some side effects. Some research has linked SERMs with vaginal dryness and excessive vaginal discharge, vaginal tenderness, changes in orgasm, and diminished libido. But studies examining the effects of tamoxifen on sexual functioning in women are conflicting and inconclusive. The Breast Cancer Prevention Trial states that minor differences in sexual functioning were observed in tamoxifen users versus those not on the medication. In contrast, Mortimer, another researcher, demonstrated no changes in any phase of the sexual response cycle for women on tamoxifen. Some other concerns regarding tamoxifen include increased risk for uterine cancer, stroke, and blood clots.

The aromatase inhibitors block the conversion of testosterone to estrogen and significantly lower the levels of circulating estradiol. Although this action is often the objective of breast cancer therapy, it can aggravate menopausal symptoms, cause osteopenia and osteoporosis[4], and affect bone health. These drugs are notorious for causing severe vaginal dryness and can lead to reactive lowered libido. Women often avoid sexual intercourse because of pain and shy away from intimacy to prevent pain. Further scientific trials are needed to specifically address the sexual ramifications of these drugs.

What is the relationship between sexuality, terminal illness, and the end of life?

Surprisingly, little is written about and neither is there significant research concerning sexuality and intimacy at the end of life. Many healthcare providers have major difficulty discussing palliative and end-of-life medical care for a variety of reasons. Healthcare providers are taught to preserve and save lives, so death is often misunderstood by doctors as a medical failure. A healthcare provider's personal discomfort with death may be a difficult issue for him or her to overcome.

Sexuality and intimacy are important facets in the death experience.

Sexuality and intimacy are important facets in the death experience. For those who are dying, the touch of a warm hand or the feeling of a caring embrace may be the only connection they have to the world. Intimacy may be a means to say goodbye and maintain emotional closeness with a terminally ill patient or person. Death and dying are often viewed as diametrically opposed to sex, intimacy, vitality, and love. Even when sexual intercourse is technically not feasible, closeness and humanness should be encouraged.

Perhaps the most important consultation I was involved in was when a young woman of 35 called me frantically; she was aware of the fact that she was dying from metastatic breast cancer and her last wish was for her husband to be permitted to be in bed with her and to hold her closely as life ebbed from her body. In a shaky, tired, distressed voice, she begged me to come to the hospital to write an order in her medical chart allowing this to happen. The nurses on the floor were uncomfortable with her husband in the bed with her. The best lesson is that sexuality, intimacy, and connectedness can be enjoyed throughout the life cycle, and it is only our discomfort with intimacy that precludes the human spirit from maintaining its peak of sexual dynamism. Although it may initially be uncomfortable, most dying patients would want closeness and sexual connections up until their passing.

  • [1] Drugs that suppress the body's natural production of estrogen by reducing production of the enzyme aromatase.
  • [2] An antiestrogen-type of medication in the class of aromatase inhibitors. It inhibits the conversion of testosterone to estrogens.
  • [3] A selective estrogen receptor modulator that is used in the treatment of breast cancer.
  • [4] A condition characterized by decrease in bone mass and density of the bones resulting in "thinning" of the bones, causing them to become more fragile.
 
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