Presentation 10 Feb 2, 2019

Addressing Sexual Relationship Concerns for the Patient Treated for Cancer

2019 HEALTH: A TEAM APPROACH 2/2/2019

SARAH JAX, MA, APRN, AOCNP MINNESOTA ONCOLOGY - PLYMOUTH

Objectives

 Discuss causes of in patients treated for cancer  Identify strategies for evaluating sexual health concerns of patients  Identify hormonal and non-hormonal therapies and resources for patients with sexual health concerns

©AllinaHealthSystem 1 Presentation 10 Feb 2, 2019

Common issue with our patients

. 30-100% of cancer survivors complain of sexual dysfunction . 50-75% of women with breast cancer report persistent problems with sexual functioning . Physical sexual side effects can be temporary or long-term . The emotional impact of cancer on sexuality is real

Female sexuality

(male and female sexual response cycle)  Excitement, plateau, and resolution  Basson model (female sexual response cycle)  Emphasis on psycho emotional processes (intimacy)  (innate desire) occurs at a number of places in the sexual response cycle  Rewards /satisfaction (physical, , lack of negative )  motivation  SEPARATION OF SEXUALITY FROM INTIMACY

Basson Model

Basson R. Women's sexual dysfunction: Revised and expanded definitions. CMAJ. 2005;172:1327–33.

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Sexual health and survivorship

 Menopausal status before treatment  Some issues may already be present before starting treatment  Treatment effects  Surgery  Direct effect on anatomy (body image and self-esteem concerns)  Changes in hormones (eg. oopherectomy)  Medical therapy (chemo and endocrine therapy)  Side effects of chemotherapy  limit sexual interest or arousal  Vaginal dryness  Radiation therapy  Acute erythema, discoloration, breast edema, arm mobility

Barriers to discussion

 Patient perspective  Fear of dismissal  Fear of discomfort of provider  Assumption - lack of treatment options available  Provider perspective  Assumption that patient will bring up if concern present  Time constraint  Assumptions about patients (age, overall prognosis, current partner)

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Evaluating sexual health

 Sexual activity ≠ Intimacy  Intimacy by itself is valued by patient  Other ways to be intimate (not just penetrative intercourse)  Questionnaires  Can aid in evaluation of sexual health (recall 7 days – 4 weeks), but tend to be long and not suited for clinical setting  Female Sexual Function Index  Body Image Scale  Personal Assessment of Intimacy in Relationships

Evaluating sexual health

 Sexual history  Taking history early on shows importance of topic to provider and signals to patient that it’s ok to discuss  “I always ask patients about any concerns they may have about intimacy (sexuality)”  Ask both during AND after treatment  Approach with few assumptions  Open-ended questions  Privacy is essential

 PLISSIT model

 BETTER model

Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS.

PLISSIT model

• Invites patient to enter into a discussion about sexual health • “I’d like to review how you’re doing as it relates to both sexuality and intimacy. Is that okay?” Permission

• Normalizes that issues related to sexual health are common Limited • “A common complaint is pain during intercourse. Is this something that is happening with you?” Information

• Offer advice that can be actionable and easy to incorporate if possible Specific • “If you have trouble with vaginal dryness, it may help to use a lubricant before and during sex.” Suggestions

• If one is not comfortable with issues brought up or does not know what to advise, offer expert consult locally or other resources Intensive • “It sounds like you might benefit from seeing an expert in sexual health. Can I suggest a referral?” Therapy

Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS.

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BETTER model

Bringing up the topic • Providers are encouraged to raise the issue of sexuality with patients

Explaining that sex is a part of • The helps to normalize the discussion and may help patients to feel less quality of life embarrassed or alone in having a problem.

Telling patients that resources • This step suggests to patients that even if the nurse does not have the will be found to address their immediate solution to the problem or question, there are others that can concerns help.

• Patients may not be ready to deal with sexual issues at the time a problem is Timing the intervention identified; however, patients can ask for information at any time in the future.

Educating patients about sexual • Educating patients about potential side effects from treatments does not mean that they will occur. However, informing patients about sexual side side effects of treatment effects is as important as informing them about any other side effects.

• It is not necessary to describe in detail what was discussed; however, a brief Recording notation that a discussion about sexuality or sexual side effects occurred is important.

Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS.

Sexual dysfunction diagnoses**

 Female orgasmic disorder  Female sexual interest/arousal disorder  Genito-pelvic pain/penetration disorder  Includes vaginismus (pain with penetration of vagina from smooth muscle spasms) and dyspareunia (pain with intercourse)

** Lifelong vs. acquired; generalized vs. situational ** Symptoms should be present ≥ 6 months ** Result in distress or inability to respond sexually or achieve pleasure

Management of Sexual Dysfunction – BODY IMAGE

. Look at oneself. Think of how strong her body is. . Exercise . Eat healthy . Support groups . Find clothing one feels comfortable in and makes her feel good . Find “sexy” clothing she feels comfortable having her partner see her in . Seek professional counseling - there may be underlying depression or

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Management of Sexual Dysfunction – DESIRE

• Complex: involves the brain, emotions and previous experiences • Focusing on desire may not be the first step • Motivation increases with sexual satisfaction as well as non-sexual rewards (satisfying a partner, wanted, intimacy) • Set small goals and build on them • Try sensate exercises to regain physical intimacy • Progression of touch between partners

Management of Sexual Dysfunction – AROUSAL

. Influenced by emotional and psychological factors . Process: blood flow to the genitals ↑ in response to physical and mental stimulation which creates lubrication, swelling . Arousal will increase comfort during penetration . Use devices AKA “toys” . Try /

Management of Sexual Dysfunction – DYSPAREUNIA (painful sex)

. Can easily become a memory and deter future sexual activity . Menopause: lack of hormones causes dry vagina/vulva; vestibule is dry and thin . Treat by focusing on arousal, lubrication, positioning, hormones(?), toys, pelvic floor PT . Lidocaine?

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Treatment of Dyspareunia

 Nonendocrine therapies **FIRST LINE OF THERAPY**  Lubricants and Moisturizers  Sexual enhancement devices  Counseling  Endocrine therapies  Vaginal estrogen (eg. Vagifem, Estrace)  DHEA  Compounded product, or  Intrarosa (prasterone) – intravaginal steroid for moderate to severe pain related to vulvovaginal atrophy – FDA approved Nov. 2016 ** Hasn’t been evaluated in survivors of cancer **NOT RECOMMENDED AT THIS TIME**  Ospemifene (Osphena) – oral tablet – estrogen agonist/antagonist  No apparent estrogenic effects elsewhere in body (endometrium and breast)  Hasn’t been evaluated in survivors of cancer **NOT RECOMMENDED AT THIS TIME**

Lubricants and Moisturizers

. Lubricants: generally short-acting products designed to make vaginal penetration more comfortable; use with . Water based – may need to reapply . Silicone based (Überlube, Pink Silicone, etc.) – best for post-menopausal women; may interact with silicone toys (do spot check) . Oil based – coconut/grape seed (use refined, organic)

. Moisturizers: help balance pH, hold water in place on vaginal wall; use twice weekly in vagina . Oils . Silicone lubricants . Replens – performed head-to-head with estrogen; not recommended for sensitive skin . RepHresh – not recommended for sensitive skin . Luvena – may work for women with recurrent infection; not recommended for sensitive skin . HYALO GYN® - hyaluronic acid derivative component applied intravaginally every 3 days

***AVOID products with polyethylene glycol, propanediol, polypropylene glycol and glycogen

Sexual enhancement devices

• Vibrators • Dilators • Positioning devices • Cuffs/bumpers

 Smitten Kitten 3010 Lyndale Ave S Minneapolis, MN 55408 https://www.smittenkittenonline.com

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Books and Written Resources

. American Cancer Society . Sexuality for the Woman with Cancer . The Lovin’ Ain’t Over for Women with Cancer – Ralph and Barbara Alterowitz . Becoming Orgasmic – Julia Heiman . Woman Cancer Sex – Anne Katz . When Sex Hurts – Goldstein, Pukall, Goldstein . The Elusive Orgasm – Vivienne Cass, PhD . Sexy Ever After: Intimacy Post-Cancer (ebook) – Patty Brisben & Keri Peterson, M.D. . Sexy After Cancer ~ Meeting Your Inner Aphrodite on the Breast Cancer Journey- Barbara Musser . And in Health: A Guide for Couples Facing Cancer Together –Dan Shapiro, MD

Websites

. AASECT.org . American Cancer Society – Sexuality for the Woman with Cancer . Breastcancer.org –Sex and Intimacy . Susan G. Komen . National Cancer Institute – Body changes and intimacy . Livestrong.com – Dating and Sex after Cancer . Sexualityresources.com – A Woman’s Touch sexuality resource center . drannekatz.com

Referrals

. Minnesota Oncology Sexual Health program - Multiple locations . Park Nicollet Clinic –medical and counseling services, 952-993- 2786 . University of Minnesota – Center for Sexual Health – promotes sexual health of individuals, couples, and families of all backgrounds and ages by providing assessment and treatment. Medical and counseling services, 612-625-1500 . Sky Hill - clinic – Edina, 952-562-7837 . Lauren Fogel, PsyD, LP – psychologist, relationship problems, sexual health concerns, LGBT concerns – Allina Nicollet Mall Clinic, 612-333-8883 . Lori Anafarta, MA, LMFT, CST – sex therapy & counseling for individuals, couples– Forest Lake area, 651-775-2084 . Jan Swanson, Psy.D., LP, ABPP – individual/couples counseling; sex therapy, 612- 870-0216

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References

Basson, R. (2005) Women's sexual dysfunction: Revised and expanded definitions. CMAJ, 172, 1327–33.

Dizon, D. S., Suzin, D., & McIlvenna, S. (2014). Sexual Health as a Survivorship Issue for Female Cancer Survivors. The Oncologist, 19(2), 202–210. http://doi.org/10.1634/theoncologist.2013- 0302

Katz, A. (2007). Breaking the silence on cancer and sexuality: A handbook for healthcare providers. Pittsburgh, PA: ONS.

Minnesota Oncology (2016). Vaginal and Vulvar Lubricants and Moisturizers handout.

Contact info

Sarah Jax, MA, APRN, AOCNP Nurse practitioner, Survivorship program coordinator & APP lead

Minnesota Oncology – Plymouth [email protected] (office) 763-519-7457 (cell) 701-388-8770

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