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August 2011, Supplement to Volume 15, Number 4
Article
Sexual Dysfunction in Multiple Myeloma: Survivorship Care Plan
of the International Myeloma Foundation Nurse Leadership Board
Tiffany A. Richards, MS,
ANP-BC, Page A. Bertolotti, RN, BSN, OCN®, Deborah Doss, RN, OCN®,
Emily J. McCullagh, RN, NP-C, OCN®, and the International Myeloma
Foundation Nurse Leadership Board
The
World Health Organization describes sexuality as a “central aspect of being
human throughout life and encompasses sex, gender identities and roles, sexual
orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is
influenced by the interaction of biological, psychological, social, economic,
political, cultural, ethical, legal, historical, religious, and spiritual
factors.” Currently, no research has been conducted regarding sexual
dysfunction in patients with multiple myeloma; therefore, information related
to the assessment and evaluation of sexual dysfunction is gleaned from other
malignancies and diseases. In this article, members of the International
Myeloma Foundation’s Nurse Leadership Board discuss the definition,
presentation, and causes of sexual dysfunction; provide recommendations for sexual
assessment practices; and promote discussion among patients with multiple
myeloma, their healthcare providers, and their partners.
At a Glance
·
Sexual dysfunction is caused by multiple factors and affects men and
women physically and psychologically, altering their relationships with their
partners.
·
Open and honest communication between patients and nurses, as well as
patients and partners, is fundamental in identifying and treating the
underlying issues.
·
Evidence-based practice recommendations have been developed for promoting
dialogue and assessment, education, and management practices among patients
with multiple myeloma and their healthcare providers and partners.
Sexual
dysfunction is characterized by physiologic or psychological changes that have
a negative impact on sexuality, leading to distress within relationships
(Shabsigh & Rowland, 2007). Sexual dysfunction occurs when the “sexual
response cycle—including desire, arousal, orgasm, and resolution—is disrupted”
(Tierney, Facione, Padilla, Blume, & Dodd, 2007, p. 299). In one study
among older adult patients, the most commonly reported sexual dysfunction among
women was decreased sexual desire and vaginal dryness, whereas men commonly
reported erectile dysfunction (Kagan, Holland, & Chalian, 2008). Sexual
dysfunction has been reported to affect 43% of women and 31% of men in the
United States (Ganz & Greendale, 2007). A review of the literature
regarding sexual function in patients with cancer is limited primarily to
patients diagnosed with prostate, breast, or gynecologic cancers. One study
focused on women with hematologic malignancies prior to hematopoietic cell
transplantation and found that 73% of patients reported decreased libido and
48% were dissatisfied with their overall sex life (Tierney et al., 2007).
Sexual
dysfunction occurs as a result of physical illness or psychological factors
rather than part of the normal aging process (Clayton & Ramamurthy, 2008).
Physical and emotional illnesses affect sexual function through a variety of
mechanisms such as disease, therapeutic interventions, depression, physical or
emotional trauma, or anatomic changes. Sexual dysfunction may be the presenting
symptom in patients with a physical illness (e.g., cardiac disease) (Clayton
& Ramamurthy, 2008).
To
gain an understanding of sexual dysfunction, the normal sexual response cycle
must first be understood. Historically, the sexual response cycle was described
by Masters and Johnson (1960) to be a linear, four-stage model consisting of
the excitement phase (arousal), plateau phase (full arousal, but orgasm not
achieved), orgasm, and resolution phase (after orgasm). However, Basson (2001)
developed a nonlinear approach to female sexual response that incorporates
intimacy, interpersonal relationships, and stimuli (see Figure
1).
Sexual Dysfunction
According
to the Diagnostic and Statistical Manual
of Mental Disorders, fourth edition (American Psychiatric Association,
2000), sexual dysfunction can be described as one of four main categories:
sexual desire disorder (decreased libido), sexual arousal disorder, orgasm
disorder, and sexual pain disorder (see Table 1).
The hallmark feature of sexual dysfunction is that it causes the individual
distress or relationship difficulties (Shabsigh & Rowland, 2007).
The
etiology of sexual dysfunction has been described as primary, secondary, or
tertiary. Sexual dysfunction that occurs from a direct illness is considered
primary. Secondary dysfunction occurs as a result of a symptom of an illness,
such as fatigue, incontinence, weakness, or overactive bladder. Sexual
dysfunction from emotional and psychological factors (e.g., depression, fears,
body image), is considered tertiary (Clayton & Ramamurthy, 2008).
Primary Causes
Physical
illnesses—including endocrine abnormalities, cardiovascular disease, pelvic
disease, cancer, renal insufficiency, and treatment-related side effects (pain,
medications, chemotherapy, or radiation)—may affect sexual functioning. In
addition, treatment of these illnesses or their associated complications,
particularly pharmacologic interventions, may worsen symptoms (Clayton &
Ramamurthy, 2008).
The
median age of patients with myeloma is about age 70, which may further increase
the likelihood of sexual dysfunction because of the presence of other
comorbidities and hormonal changes. In addition, patients undergoing treatment
for myeloma may experience an exacerbation of preexisting comorbidities
(diabetes, hypertension, or anemia) or develop them as a consequence of
treatment (steroid-induced diabetes or hypertension, stem cell transplantation,
or associated endocrine disorders) (Faiman, Bilotti, Mangan, Rogers, & the
International Myeloma Foundation [IMF] Nurse Leadership Board [NLB], 2008;
Miceli, Colson, Gavino, Lilleby, & the IMF NLB, 2008; Tariman, Love,
McCullagh, Sandifer, & the IMF NLB, 2008; Tauchmanovà et al., 2005).
Comorbidities
Sexual
dysfunction may result from endocrine abnormalities such as diabetes, androgen
deficiency, thyroid disorders, or estrogen deficiency (Clayton & Ramamurthy,
2008; Faiman et al., 2008). These conditions may arise from a variety of
factors, including disease complications and treatment-related toxicities. In
particular, therapy for myeloma places individuals at increased risk for
endocrine changes because of treatment with steroids (androgen deficiency and
diabetes), thalidomide (thyroid disorders), lenalidomide (thyroid disorders),
or stem cell transplantation (estrogen and androgen deficiency) (Faiman et al.,
2008). Sexual function also may be affected by other comorbidities such as
cardiovascular disease and renal disease.
Diabetes
Some
form of sexual dysfunction related to diabetes has been reported in about 75%
of men and about 61% of women (Bhasin, Enzlin, Coviello, & Basson, 2007).
Factors affecting diabetic sexual dysfunction include suboptimal glycemic
control, fatigue, altered body image, and end organ damage. Erectile
dysfunction from diabetes occurs as a result of dysfunction of the endothelial
and smooth muscle (reduced nitric oxide synthase), as well as autonomic
neuropathy (pelvic neuropathy) (Clayton & Ramamurthy, 2008). Interestingly,
men suffering from erectile dysfunction and diabetes are more susceptible to
developing other diabetic complications such as retinopathy, hypertension, and
microalbuminuria (Bhasin et al., 2007). Research regarding sexual dysfunction
among women with diabetes is limited, but women report difficulties with
desire, arousal, orgasm, lubrication, and dyspareunia (Bhasin et al., 2007;
Clayton & Ramamurthy, 2008).
Hormonal
The
exact mechanism of testosterone regulation in sexual dysfunction is not clearly
understood in either gender. However, reduced sexual activity and decreased
libido is found in both women and men. Androgen deficiency results as
testosterone levels decrease in men by 1%–2% annually (Clayton &
Ramamurthy, 2008). The most common causes of androgen deficiency are
categorized into primary testicular failure (radiation, chemotherapy, surgery,
or trauma) or secondary gonadal failure (excess drug and alcohol use, systemic
illness, glucocorticoid therapy, or deficiency of luteinizing hormone [LH],
follicle-stimulating hormone [FSH], or gonadotropin-releasing hormone). In
women, testosterone levels fall progressively from their 20s until they plateau
in their mid-40s. Currently, women do not have standard normal ranges because
they vary with the menstrual cycle. Risk factors for developing low
testosterone levels in women include bilateral oophorectomy, chronic
obstructive pulmonary disease (COPD), panhypopituitarism, and oral
contraceptives (Clayton & Ramamurthy, 2008; Davis & Tran, 2001). In
both men and women, autologous stem cell transplantation may decrease
testosterone levels and induce menopause in women (Chatterjee et al., 2000;
Tauchmanovà et al., 2005; Tierney et al., 2007).
Estrogen
deficiency may occur as a result of natural menopause, premature ovarian
failure, or bilateral oophorectomy (Nappi & Lachowsky, 2009; Tierney et
al., 2007). Decreased estrogen levels may lead to decreased libido, decreased
vaginal lubrication, and dyspareunia (Nappi & Lachowsky, 2009).
Thyroid
Hypothyroidism
or hyperthyroidism may affect sexual function in men and women in a variety of
mechanisms, including decreased desire, erectile dysfunction, menstrual irregularities,
and in some cases, infertility (Bhasin et al., 2007). In addition, men and
women with hypothyroidism may develop fatigue or depression, leading to sexual
dysfunction (Bhasin et al., 2007). Patients with multiple myeloma who develop
hypothyroidism while undergoing treatment with thalidomide or lenalidomide have
been reported in the literature (de Savary, Lee, & Vaidya, 2004; Menon,
Habermann, & Witzig, 2007). Therefore, patients receiving these drugs who
develop sexual dysfunction alone or in combination with other symptoms of
hypothyroidism such as dry skin, hair loss, fatigue, and weight gain should be
evaluated for this disorder (Bhasin et al., 2007).
Cardiovascular Disease
Cardiovascular
disease, including hypertension, atherosclerosis, vascular disease, or a
cerebral vascular event, have systemic effects that include sexual dysfunction
(Reffelmann & Kloner, 2006). In particular, men with erectile dysfunction
have an increased incidence of cardiovascular events (Reffelmann & Kloner,
2006). The risk of cardiovascular events among women who have cardiovascular
disease is unknown. One study conducted among postmenopausal women showed a
greater incidence of decreased sexual satisfaction among women with peripheral
vascular disease; however, an increased risk of cardiovascular events was not
noted (Lane & Thayer, 2008; McCall-Hosenfeld et al., 2008).
The
prevalence of self-reported sexual dysfunction among patients with hypertension
ranges from 14%–35% (Manolis & Doumas, 2008). In comparison, self-reported
sexual dysfunction in nonhypertensive men ranges from 15%–74%, possibly
reflecting differences in the study populations and data collection methods
(Manolis & Doumas, 2008). Although no large studies have been conducted
among women, one study did report that 42% of hypertensive women versus 19% (p
< 0.001) of nonhypertensive women reported sexual dysfunction (Doumas et
al., 2006). Factors correlating with sexual dysfunction include increased
systolic blood pressure, increasing age, and beta blockers (Doumas et al.,
2006).
Although
patients with hypertension should receive anti-hypertensives, clinicians should
be aware that beta blockers and thiazide diuretics may worsen erectile
dysfunction and decrease libido, whereas angiotensin receptor blockers may
reduce the incidence of erectile dysfunction. Calcium channel blockers and ACE
inhibitors are thought to have little effect on erectile dysfunction; however,
additional studies are needed to evaluate their effect on sexual dysfunction
(Manolis & Doumas, 2008). Patients with myeloma receiving treatment with
either dexamethasone or prednisone are at increased risk of developing
hypertension and require close monitoring of their blood pressure during
treatment (Faiman et al., 2008). Patients should be encouraged to make
lifestyle changes (e.g., exercise, low-sodium diet, weight loss) to reduce the
need for treatment with antihypertensives and, thereby, improve overall sexual
function (Faiman et al., 2008).
Renal Disease
Women
with end-stage renal disease may develop alterations in hormone levels (FSH and
LH) that lead to ovarian dysfunction, particularly in patients receiving
dialysis (Anantharaman & Schmidt, 2007). Men with renal disease develop
decreased levels of testosterone, both free and total, because of alterations
in LH, FSH, and elevated estrogen levels. In men and women, increased levels of
prolactin from decreased creatinine clearance have been noted (Anantharaman
& Schmidt, 2007).
Women
with chronic kidney disease tend to report difficulties with decreased libido,
inability to achieve orgasm, vaginal dryness, and dyspareunia (Anantharaman
& Schmidt, 2007). Men with kidney disease report diminished libido,
erectile dysfunction, infertility, and oligospermia related to low levels of testosterone.
In addition, renal insufficiency decreases production of erythropoietin leading
to anemia, which decreases oxygenation to tissues and may hinder sexual
function. In men and women, erythropoietin has been shown to increase sexual
function through normalization of FSH, LH, prolactin, and testosterone levels
(Anantharaman & Schmidt, 2007).
The
primary effects of disease on sexual dysfunction vary in the degree and the
type of dysfunction in both sexes. Nurses play a critical role in understanding
how diseases and treatments affect sexuality and sexual function. In patients
with myeloma, treatments may precipitate diseases such as diabetes,
hypertension, and anemia. In addition, myeloma may impact renal function,
mobility, and pain related to bone disease or neuropathy. Identifying these factors is an
important step in the identification and treatment of sexual dysfunction.
Secondary Effects
Patients
receiving treatment may experience disruptions in the sexual response as a
result of fatigue, weakness, pain, and alterations in body image (Clayton &
Ramamurthy, 2008). Many treatment regimens include steroids, which may cause
fatigue, proximal muscle weakness, weight gain, fluid retention, and decreased
concentration (Faiman et al., 2008). Sixty-three percent of patients newly
diagnosed with multiple myeloma present with compression fractures, resulting
in pain and diminished mobility, which may inhibit sexual function (Kyle &
Rajkumar, 2009).
As
previously mentioned, multiple myeloma generally occurs in later stages of
life. Lower urinary tract symptoms occur in about 63% of men and 67% of women;
these include urinary incontinence, overactive bladder, frequency, and nocturia
(Coyne et al., 2008). Lower urinary tract symptoms affect sexual health and
quality of life. Urinary incontinence may impact an individual’s sexual
function because of concerns of urine leakage, odor, or embarrassment. Younger
women with an overactive bladder have diminished self-esteem compared with
older women (Bruner & Calvano, 2007). Individuals with overactive bladder
plus voiding symptoms (e.g., weak, slow, or intermittent stream, hesitancy,
straining, dribble) have reported higher rates of decreased sexual satisfaction
than those with overactive bladder alone or urinary incontinence alone. In
addition, lower urinary tract symptoms correlated with higher rates of
depression that may further exacerbate sexual dysfunction (Coyne et al., 2008).
Men
with multiple myeloma also are at risk of developing prostate cancer during
their treatment course because of their age. Men who develop prostate cancer
may develop erectile dysfunction as a consequence of the diagnostic procedures
and treatment for prostate cancer. The risk of retrograde ejaculation is as
high as 20%–50% in men undergoing transurethral resection of the prostate
(Bruner & Calvano, 2007). Men who undergo surgical resection of the
prostate may experience erectile dysfunction with rates of 50%–80% (Bruner
& Calvano, 2007). Erectile dysfunction is not the only sexual dysfunction
associated with prostatectomy. Weakening of the orgasmic sensation (50%) and
involuntary loss of urine at orgasm (64%) have been reported, which may cause
avoidance of sexual encounters. Hormone therapy for prostate cancer lowers
testosterone levels, resulting in decreased semen production, erectile
dysfunction, low sexual desire, and less pleasurable orgasm (80% risk). In
addition, radiation therapy decreases the ability to have voluntary erections
in 40%–60% of men (Bruner & Calvano, 2007; Hughes, 2008).
Women
with a diagnosis of multiple myeloma may develop difficulties with sexual
function if they receive radiation to the pelvis. Radiation may cause delayed
arousal and orgasm through damage of the pelvic vascularity and nerves. Women
also may develop vaginal dryness, stenosis, and fibrosis leading to dyspareunia
and painful pelvic examinations (Hughes, 2008).
Pain
According
to Gevirtz (2008), “Many patients with chronic pain consider their pain
symptoms to be the major obstacle to enjoying sex with their partner” (p. 17).
Treatment of chronic pain improves libido and sexual function. Patients with
chronic pain often adapt to pain and make lifestyle adjustments (Gevirtz, 2008;
Kwan, Roberts, & Swalm, 2005); however, spouses may fear inflicting pain or
causing fractures in their partner, and this needs to be taken into
consideration when discussing sexual function (Kwan et al., 2005). Nurses play
an integral role in counseling patients on interventions to overcome obstacles
related to the disease or its treatment. Patients with myeloma may have chronic
pain that requires long-term opiate use; this also affects erectile function,
hormone levels, and libido.
Oral Contraceptives
Oral
contraceptives may cause decreased libido in a number of women; they also
affect sexual function by inhibiting androgen production and increasing the
amount of sex hormone-binding globulin, which decreases testosterone levels
(Clayton & Ramamurthy, 2008). However, the effect that oral contraceptives
have on decreased libido is unclear, with the literature reporting mixed
results. Prior to initiating
therapy, particularly with thalidomide or lenalidomide, patients’ beliefs
regarding contraception use should be addressed.
Tertiary Causes
The
impact of body image, depression, concerns about the future, abandonment
issues, and history of abuse may negatively affect sexual function (Clayton
& Ramamurthy, 2008; Frank, Mistretta, & Will, 2008). Discussions with
patients regarding potential psychological etiologies of sexual dysfunction are
important. In addition, exploring a patient’s cultural and religious beliefs
regarding sexuality is necessary to determine what affect these areas may have
on sexual function.
Body Image
In
a study of body image among patients with cancer, body image-related side
effects were reported as the most severe chemotherapy side effect (DeFrank,
Mehta, Stein, & Baker, 2007). The impact of multiple myeloma and its
treatments (e.g., steroids) produce temporary and permanent changes in
patients’ height, weight, or mood, as well as loss of hair; these may affect an
individual’s body image, thereby influencing sexuality (Faiman et al., 2008).
Although no studies have focused exclusively on patients with multiple myeloma,
the effects of cancer treatment on other patient populations have revealed
diminished sense of well-being, thus impacting body image (DeFrank et al.,
2007).
Intimate Partner Violence
The
prevalence of intimate partner violence (IPV) among women receiving healthcare
services is estimated to be 15% for those currently experiencing IPV and 44%
for lifetime prevalence (Coker, 2007). The consequences of IPV on sexual health
includes increased risk of sexually transmitted infections, pain during
intercourse, reduction in sexual pleasure or desire, and increased depression
rates (Coker, 2007).
Cultural Impact
Culture
is the shared beliefs, social norms, and material traits of individuals within
the same racial, religious, or social group (Fourcroy, 2006). Cultural
practices and beliefs may affect sexuality in a variety of ways, including
female genital mutilation, variations of sexual function, and lack of adequate
social support (Fourcroy, 2006).
When
discussing sexuality, nurses should be aware of the norms that exist across
different cultures (Shell, 2007). Among African Americans, discussion regarding
sexuality must occur one on one; however, a spouse or partner may be present.
The nature of the sexual dysfunction may not be provided if discussed in front
of other family members. One study among African Americans found that
participants rarely discussed the impact treatment had on sexuality, even to
close friends. In addition, nurses may encounter “insider/outsider” dilemma;
therefore, establishing and maintaining trust is essential (Shell, 2007).
Among
Asian Americans, discussions regarding sexuality are commonly considered taboo,
particularly among older adults. A review of the literature on the impact of
culture on sexual function found Pap smear screening rates are lower among
Asian American women, secondary to fear and/or embarrassment (Shell, 2007). In
addition, among Asian women, acculturation was found to be associated with more
liberal attitudes and increased sexual desire (Shell, 2007). One study found
that, among this group, obtaining information via the mail rather than in group
encounters was a preferred method of receiving information (Shell, 2007).
Therefore, discussions on sexuality should include assessment of culture and
occur as a one-on-one encounter with the patient (Shell, 2007).
Within
Hispanic culture, family involvement has been reported as a positive factor in
medical care and treatment (Shell, 2007). Healthcare decisions often are made
by more than one family member; therefore, discussion regarding sexuality may
be avoided. Because of patients’ reluctance to discuss sexuality, nurses may
need to be more assertive with this population (Shell, 2007).
Impact of Myeloma Treatment
Depression and Body Image
Disturbance
Depression
can lead to sexual dysfunction as well as body image disturbance (Hughes,
2008), which may not only be a symptom of depression but also a cause leading
to sexual dysfunction. Depression can be associated with pain, functional
decline, and decline in cognition. In addition, dependency on caregivers may
impact psychological well-being, particularly if patients require assistance
that minimizes their privacy (Hughes, 2008; Kagan et al., 2008). Although
depression may be treated successfully with pharmacologic intervention, sexual
side effects of antidepressant medications are common (Kagan et al., 2008;
Zemishlany & Weizman, 2008). Managing depression and body image disturbance
in patients receiving treatment for myeloma may be difficult and prompt
referral to a psychologist or psychiatrist is necessary.
Estrogen
deficiency occurring after ovarian failure results in depression and changes in
appearance (Tierney et al., 2007). The declining estrogen levels from cancer
treatments may alter sexual functioning through the loss of adequate
lubrication as well as changes in appearance, which may diminish self-image and
self-esteem (Tierney et al., 2007). Patients with erectile dysfunction may feel
a sense of inadequacy, leading to depression and body image disturbance, which
then can lead to sexual dysfunction. The partners of patients with erectile
dysfunction may feel pressured to have sexual encounters or feel a lack of
control because of patients’ use of phosphodiesterase type 5 inhibitor
medications (Kagan et al., 2008) (see Table 2). In
addition, younger patients with myeloma still in their childbearing years may
develop a sense of loss because of the infertility that occurs as a result of
treatment.
Myeloma Treatment
Disruption
of patients’ normal sexual function has been documented in patients with cancer
receiving traditional chemotherapy agents such as alkylating agents, vinca
alkaloids, and platinum-containing regimens (King et al., 2008). Traditionally,
cyclophosphamide and melphalan have both been used in low and high doses,
leading to infertility in men and women. High-dose therapy with melphalan
followed by autologous stem cell transplantation precipitate a chemically
induced menopause in younger women (Lee et al., 2006). These changes can result
in emotional and psychological sequelae, leading to decreased quality of life.
Vincristine and cisplatin temporarily or permanently damage parts of the
central nervous system, leading to erectile dysfunction and ejaculation
difficulties (Lee et al., 2006).
Disruption
of estrogen, androgen, and testosterone production secondary to steroids
(dexamethasone or prednisone) in patients with myeloma may decrease sexual
desire, result in dyspareunia from vaginal wall thinning, and trigger impotence
(Contreras et al., 1996; Kalantaridou & Calis, 2006). In addition, steroid
side effects include increased glucose levels, electrolyte imbalances, and mood
alterations (Faiman et al., 2008). Patients may experience body image changes
such as weight gain, hair loss, or cushingoid appearance, which can interfere
with sexual arousal (Contreras et al., 1996; Faiman et al., 2008).
Erectile
dysfunction and loss of libido have not been reported in patients treated with
bortezomib in clinical trials; however, erectile dysfunction and loss of libido
have been reported in patients with multiple myeloma receiving lenalidomide
therapy in clinical trials (Celegene Corp., 2010a). Impotence has been reported
in patients with erythema nodosum leprosum being treated with thalidomide in
clinical trials, but not in patients with multiple myeloma in clinical trials
(Celegene Corp., 2010b). Whether these side effects are dose dependent is
unknown. Although as yet undocumented in any formal studies, members of the NLB
have observed that sexual dysfunction is a common occurrence with many of the
novel therapies now being used in the treatment of multiple myeloma. Reports of
erectile dysfunction and decreased libido in patients receiving bortezomib and
lenalidomide are becoming a common experience for NLB members treating patients
with multiple myeloma. The causality of erectile dysfunction with thalidomide
has not been determined (Isoardo et al., 2004; Laaksonen, Remes, Koskela,
Voipio-Pulkki, & Falck, 2005; Murphy & O’Donnell, 2007). Some have
proposed that it may be related to neurogenic effects, diminished blood flow,
or visceral neuropathy. Although anecdotal reports exist of erectile
dysfunction without loss of libido, no formal studies have been conducted
(Isoardo et al., 2004; Laaksonen et al., 2005; Murphy & O’Donnell, 2007).
The
use of both thalidomide and lenalidomide are restricted because thalidomide
causes severe birth defects in humans and lenalidomide causes similar birth
defects in monkeys (Celgene Corp., 2010a, 2010b). Formal studies have not been
performed to determine if compliance with birth control regimens and the
personal surveys as required by the STEPS® (System for Thalidomide Education
and Prescribing Safety) program for thalidomide use and the RevAssist® program
for lenalidomide use have psychological effects and inhibit patients’ sexuality
or create fears that interfere with sexual desire. However, members of the NLB
feel that these reactions are possible and that they should be considered. In
addition, some patients may not enjoy intercourse with the use of barrier methods
that may be required in the STEPS® and RevAssist® programs (Celgene, 2010a,
2010b; Zeldis, Williams, Thomas, & Elsayed, 1999). Studies to assess
sexuality and desire in these settings are needed.
Assessment of Sexual Function
A
literature review conducted by Srivastava, Thakar, and Sultan (2008) found that
30%–50% of women describe difficulties in sexual problems as a result of
distress and interpersonal difficulty; 54% of women report one sexual problem
lasting at least one month. The most common sexual problems affecting women are
lack of interest, inability to achieve orgasm, and dyspareunia. Of those who
reported sexual dysfunction, only 21% sought intervention (Srivastava et al.,
2008). The most common sexual problems affecting men include erectile
dysfunction (problems achieving or maintaining an erection), decreased or
absent sexual desire, disorders of ejaculation or orgasm, and failure of
detumescence (sustained erection) (Kandeel, Koussa, & Swerdloff, 2001).
An
international survey of 27,500 men and women ages 40–80 was conducted by
Kingsberg (2004) to evaluate attitudes, beliefs, and health between intimate
partners. A subanalysis of participants from the United States revealed that
only 14% reported that a physician had inquired about sexual function within
the preceding three years (Kingsberg, 2004). Reluctance on the part of
healthcare providers and patients to discuss sexuality has been well documented
in all disease states (Harsh, McGarvey, & Clayton, 2008). Studies suggest
that oncology nurses and physicians are reluctant to discuss sexual health with
their patients (Harsh et al., 2008). In addition, patients are hesitant to
disclose sexual dysfunction or seek medical treatment for sexual function
(Harsh et al., 2008). A need exists for more open and improved communication
between doctors, nurses, and their patients about sexuality issues.
According
to Srivastava et al. (2008), healthcare providers need to provide an
environment that promotes discussion of sexual dysfunction. Patients may feel
uncomfortable or embarrassed discussing sexual function; therefore, healthcare
providers need to engage in effective communication and develop interpersonal
skills. In addition, a nonjudgmental attitude, frank discussions, and
emphasizing that sexual health is an integral part of their overall health may
reduce the stigma associated with sexual dysfunction. Engaging in effective
communication and interpersonal skills provides patients with an environment in
which they feel comfortable and less embarrassed. Bridge statements facilitate
the flow from less comfortable to comfortable discussions. For example, “Has
anyone talked to you about how your illness and treatments affect your ability
to have sex?” or “Do you have any sexual concerns that you would like to talk
about?” Questions should be asked in a professional nature and direct eye
contact should be used (Bruner & Berk, 2004; Srivastava et al., 2008; Zator
Estes, 2002). Maintaining a relaxed, open, and nonjudgmental appearance is
important as well when discussions regarding sexuality occur (Tomlinson, 1998).
Models such as PLISSIT, ALARM, and BETTER have shown to be effective in the
assessment of sexual function (Hughes, 2008) (see Figures
2, 3, and 4).
To
assess sexual dysfunction, a thorough medical history, including sexual and
psychological history, should be conducted at the initial visit (McVary, 2007;
Srivastava et al., 2008). Current medications should be reviewed to determine
their role in decreased sexual functioning (see Table
3). Discussions surrounding sexual function at the initial visit enable
patients to bring up concerns as they arise during their course of treatment.
Assessment of the patient and their partner’s sexual behavior, attitudes, and
expectations may be beneficial in determining how treatment may affect their
relationship (McVary, 2007; Srivastava et al., 2008).
Physical Examination
The
physical examination of all patients, regardless of gender, should include both
a vascular and neurologic assessment. Evaluation of blood pressure, peripheral
pulses, skin integrity, and general appearance may reveal evidence of
peripheral vascular disease, secondary sex characteristics, and cardiovascular
disease (McVary, 2007; Srivastava et al., 2008). Women with sexual dysfunction should,
in addition to this workup, receive a genital examination to evaluate for
estrogen deficiency, sexually transmitted disease, vaginal trauma, and bladder,
vaginal, or rectal prolapse (Srivastava et al., 2008). Men with sexual
dysfunction should undergo a penile assessment, examining for scrotal swelling
or tenderness and areas of discoloration, masses, or trauma (McVary, 2007). If
the oncology practitioner cannot perform the physical assessment, the patient
should be referred to a specialist (gynecologist or urologist) for
interdisciplinary consultation.
Laboratory Testing
Laboratory
studies that may be beneficial include lipid profiles, thyroid function
(thyroid stimulating hormone, T3, T4), hormone levels (estrogen, luteinizing
hormone, sex hormone binding globulin, and free testosterone) (see Table 4), and prostate-specific antigen (McVary,
2007; Srivastava et al., 2008). An important consideration when evaluating for
testosterone level in both men and women is that it is “secreted by the adrenal
glands and testes in men and by the adrenal glands and ovaries in women.
Testosterone exists as both unbound (free) fractions and bound fractions: sex
hormone-binding globulin and testosterone-binding globulin” (Hansen, 2003, p.
400). Unbound (free) testosterone is the active portion (Margo & Winn,
2006; National Menopause Society, 2005). The role of androgens in women has
gained recognition; however, normal values have yet to be fully determined and
vary with age. Androgen deficiency in women has not been clearly defined (Davis
& Tran, 2001). Many women have reported improved libido, increased energy,
and a sense of well-being with testosterone replacement (Shifren, 2004).
Testosterone therapy, however, is unsuitable for women suffering from
postmenopausal symptoms, having a history of breast or uterine cancer, or
having cardiovascular or liver disease (National Menopause Society, 2005).
Radiographic Findings
The
use of Doppler flow and ultrasound imaging may be of assistance in detecting
erectile dysfunction, ejaculatory problems, or vascular flow impairments (Sáenz
de Tejada et al., 2005). In addition, sleep studies may help to diagnose sleep
apnea, which may affect male erections (Basson & Schultz, 2007). Evaluating
for neurogenic issues with an electromagnetic vibrating device may be useful,
although not definitive. In women, vaginal temperature and vibratory sensory
testing may assist in diagnosing sensory loss (Srivastava et al., 2008).
Measuring vaginal blood flow and oxygen tension within the vagina, clitoris,
and labia may be beneficial (Mayer et al., 2007). Patients with myeloma require
a bone survey to determine if a current or impending fracture is contributing
to pain or causing risk during sexual activity.
Treating Sexual Dysfunction in Men
Pharmacologic
and nonpharmacologic interventions are available to patients and may restore
erectile function. Phosphodiesterase type 5 inhibitors have been shown to
improve erectile dysfunction; side effects may include short duration of
action, flushing, headaches, changes in visions, tachycardia, and the potential
for prolonged erection (Bruner & Calvano, 2007; McVary, 2007). For patients
currently receiving nitrate therapy, the use of phosphodiesterase type 5
inhibitors is an absolute contraindication because it may result in hypotension
(McVary, 2007). Other interventions for the treatment of erectile dysfunction
include intracavernous or transurethral injections, testosterone replacement,
vacuum erection devices, surgical interventions, and/or psychotherapy (Bruner
& Calvano, 2007; McVary, 2007). The use of intracavernous or transurethral
injections is an absolute contraindication in patients with multiple myeloma,
thrombocytopenia, sickle cell disease or trait, or history of priapism because
of increased risk of priapism with the injections (McVary, 2007).
Treating Sexual Dysfunction in Women
Sexual
dysfunction in women may occur at all stages of life and involves loss of
interest or desire, decreased arousal, difficulty achieving orgasm, or
dyspareunia. The most common sexual disorder in women is low sexual desire
(22%) (Fourcroy, 2003). Researchers have reported these effects with androgens
such as testosterone replacement for treatment of decreased libido (Fourcroy,
2003).
Side Effects of
Testosterone
The
potential side effects of testosterone and other androgen therapies include
acne, lowering of high-density lipoprotein, changes in liver function,
increased hair growth, voice deepening, or clitoral engorgement (Davis et al.,
2008; Margo & Winn, 2006). In one study of women who were randomized to
either placebo or two different testosterone dose levels, three women were
diagnosed with breast cancer and 13 women developed vaginal bleeding (Davis et
al., 2008). Of those women with vaginal bleeding, two women had proliferative
endometrium.
Fertility Preservation
Although
the median age of patients diagnosed with myeloma is 66 years, some patients
are diagnosed in their 20s and 30s (King et al., 2008). Therefore, nurses need
to be aware of the implications that chemotherapy and radiation may have on
fertility in younger patients. The effects of chemotherapy and radiation may
lead to infertility in 30%–75% of male patients aged 18–45 years (King et al.,
2008). In women, the effects of chemotherapy and radiation may lead to
premature menopause, thereby leading to a loss of fertility. In a study
conducted by Schover et al. (1999), only 50% of cancer survivors diagnosed
prior to age 35 recalled receiving information regarding the risks cancer
treatment may have on their fertility (King et al., 2008).
Nurses
have the opportunity to discuss risks of infertility to patients and also to
discuss options regarding fertility preservation (King et al., 2008).
Currently, the American Society of Clinical Oncology recommends sperm
cryopreservation for men and embryo cryopreservation for women. Other available
options offered at specialty centers include testicular sperm extraction and
testicular freezing for men, and oocyte freezing or ovarian tissue freezing for
women (Lee et al., 2006).
Referrals
If
the cause of sexual dysfunction is related to psychological factors, a referral
to a clinical psychologist, certified sex therapist, or marriage and family
therapist is appropriate. These specialists may be certified by the American
Association of Sex Educators or hold a diploma from the American Board of
Sexology. If the dysfunction is physiologic, referral to the appropriate
specialist (e.g., gynecologist, endocrinologist) is indicated. Because sexual
dysfunction may be multifactorial, multiple referrals may be necessary.
Building a referral network of specialists to optimize treatment of sexual
dysfunction is imperative (see Figure 5).
Summary
Sexual
dysfunction is caused by multiple physical and psychological factors, including
comorbidities, medical treatments, lack of psychological well-being, altered
body image, and cultural and societal influences. Both men and women are
affected by sexual dysfunction, altering their relationships with their
partners. Encouraging open communication between patients and healthcare
providers, as well as between patient and partner, is essential in treating the
underlying cause of the problem. Identifying sexual dysfunction and providing
the necessary education and specific interventions is imperative. Resources to
manage sexual side effects and to address reproductive issues and birth control
are needed. Patients deserve to have any sexual difficulty carefully assessed
and appropriately managed.
The authors gratefully
acknowledge Brian G.M. Durie, MD, and Robert A. Kyle, MD, for critical review
of the manuscript; Lynne Lederman, PhD, medical writer for the International
Myeloma Foundation, for preparation of the manuscript; and Lakshmi Kamath, PhD,
at ScienceFirst, LLC, for assistance in preparation of the manuscript.
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Tiffany A. Richards, MS,
ANP-BC, is a nurse practitioner in the Department of Lymphoma/Myeloma at the
University of Texas MD Anderson Cancer Center in Houston; Page A. Bertolotti,
RN, BSN, OCN®, is an oncology practice nurse in the Cedars-Sinai
Outpatient Cancer Center at the Samuel Oschin Comprehensive Cancer Institute in
Los Angeles, CA; Deborah Doss, RN, OCN®, is a clinical research
nurse in the Jerome Lipper Multiple Myeloma Center at Dana-Farber Cancer
Institute in Boston, MA; and Emily J. McCullagh, RN, NP-C, OCN®, is
the clinical coordinator in the Adult Bone Marrow Transplant Service at
Memorial Sloan-Kettering Cancer Center in New York, NY. The authors take full
responsibility for the content of this article. Publication of this supplement
was made possible through an unrestricted educational grant to the
International Myeloma Foundation from Celgene Corp. and Millennium: The Takeda
Oncology Company. Richards is a consultant and advisory board member for
Millennium: The Takeda Oncology Company, and Bertolotti and Doss are on the
speakers bureaus for Celgene Corp. and Millennium: The Takeda Oncology Company.
The content of this article has been reviewed by independent peer reviewers to
ensure that it is balanced, objective, and free from commercial bias. No
financial relationships relevant to the content of this article have been
disclosed by the independent peer reviewers or editorial staff. Mention of specific
products and opinions related to those products do not indicate or imply
endorsement by the Clinical Journal of Oncology Nursing or the Oncology Nursing
Society. (Submitted March 2011. Accepted for publication April 5, 2011.)
Author Contact: Tiffany A.
Richards, MS, ANP-BC, can be reached at tarichards@uwalumni.com,
with copy to editor at CJONEditor@ons.org.
http://dx.doi.org/10.1188/11.CJON.S1.53-65
