Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Thank you for having me. The pleasure is mine.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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?  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center 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.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center

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? 

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center 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.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Oh my gosh. Yeah.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Yes.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Yes, yes, yes.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Right.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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?  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center 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.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Absolutely.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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?  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center 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?  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center 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.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Oh.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Absolutely.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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." 

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Yes. 

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center Or sometimes male patients can also benefit from pelvic floor therapy.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Yes, yes, yes, yes.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center Pelvic floor therapy has also become more popular for women. But men can also benefit from pelvic floor therapy.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Absolutely.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center I think for women, depending on what the, you know, what their complaints are, some women may be candidates for hormone replacement therapy.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Yes.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Absolutely.Sing it, sister. Sing it.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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.  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center Yeah.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center 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?  

Carmella Wygant, Clinical Psychotherapist, MD Anderson Cancer Center What I want to really also focus on is the importance of educating regarding lubricants.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center

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.  

Donna Herrera Bell, Advanced Practice Provider, MD Anderson Cancer Center Thanks, Carmella, for joining me today. It was a great discussion. And thank you for listening to the Cancerwise podcast from MD Anderson. If you enjoyed this episode, don't forget to follow or subscribe on Apple Podcasts, Spotify, YouTube or wherever you get your podcasts. And be sure to comment or review. For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MDAnderson.org.