Sexologies 16 (2007) 292–298

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : h t t p : / / f r a n c e . e l s e v i e r. c o m / d i r e c t / S E X O L /

ORIGINAL ARTICLE / ARTICLE ORIGINAL

Sexuality after breast cancer

La sexualité après un cancer du sein
La sexualidad después de un cáncer de mama
A. Graziottin (MD)a,*, V. Rovei (MD)b
a
H. San Raffaele Resnati, Via Enrico Panzacchi 6, 20123 Milano, Italy
b
Department of Obstetrics and Gynecology and University Center of Reproductive Medicine, Sant’Anna Hospital,
University of Turin, Italy

Abstract Breast cancer (BC) may affect three main domains of women’s sexuality: sexual iden-
KEYWORDS tity, sexual function and sexual relationship. Age, lymphedema, side-effects of surgery, radio-,
Breast cancer; chemo- and hormonotherapy, pregnancy-related problems, infertility, iatrogenic premature
Female sexual function; menopause, with its cohort of symptoms secondary to the chronic loss of estrogens on the
Lymphedema; brain, on the sensory organs, on the pathophysiology of sexual response and on the function
Bilateral prophylactic of the pelvic floor, may all affect sexuality after breast cancer. Women carriers of BRCA muta-
mastectomy; tions, who might consider bilateral prophylactic mastectomy, may have a specific iatrogenic
Infertility; impact of surgery on their self-image and femininity. Unfortunately, biological factors, second-
Iatrogenic menopause; ary to the diagnosis and treatment of breast cancer, are usually understudied with respect to
the psychosocial ones. Physicians should improve their skill in understanding and listening to
Male breast cancer
sexual concerns and in addressing the basic biological issues that BC raises for female sexual
identity. Physicians should also at least diagnose and recommend clinical help for the most
common sexual symptoms in BC survivors: loss of libido, arousal disorders, dyspareunia, anor-
gasmia and loss of satisfaction. The best results will be obtained in sharing a "twin compe-
tence" with a good psychosexologist or a psychiatrist with an interest in this field, to whom
patients with clear psychodynamic or relational problems should be referred for specific
help, after having excluded or cured the potential biological roots of them. Attention to the
anatomy and function of the pelvic floor should become a mandatory part of a thorough clini-
cal gynaecological and sexological examination, to give BC survivors the right to a full diagno-
sis and competent help. This paper will focus on the biological factors that are of main inter-
est for the daily practice of health care providers.
© 2007 Published by Elsevier Masson SAS.

Résumé Le cancer du sein est susceptible d’affecter trois principaux domaines de la sexualité
MOTS CLÉS
féminine : l’identité sexuelle, la fonction sexuelle et la relation sexuelle. La sexualité après
Cancer du sein ; cancer du sein peut être affectée par une gamme de problèmes : l’âge, les lymphœdèmes,

* Correspondingauthor.
E-mail address: segreteria@studiograziottin.it (A. Graziottin).

1158-1360/$ - see front matter © 2007 Published by Elsevier Masson SAS.

doi:10.1016/j.sexol.2007.06.008
Sexuality after breast cancer 293

Fonction sexuelle
féminine ;
Lymphœdème ;
Mastectomie bilatérale
prophylactique ;
stérilité ;
Ménopause iatrogène ;
Cancer du sein chez
l’homme
les effets indésirables de la chirurgie, de la radio-, chimio- et hormonothérapie, les problèmes
liés à la grossesse, l’infertilité, la ménopause prématurée iatrogène — avec sa cohorte de
symptômes secondaires à la perte chronique d’estrogènes sur le cerveau, les organes senso-
riels, la pathophysiologie des réponses sexuelles et la fonction des structures périnéales. Les
femmes porteuses des mutations génétiques BRCA — pour lesquelles on envisage une mastec-
tomie bilatérale prophylactique — peuvent subir un impact chirurgical iatrogène sur leur
image et leur féminité. Malheureusement, les facteurs biologiques induits par le diagnostic et
le traitement du cancer du sein font en général l’objet de peu d’études en regard des facteurs
psychosociaux. Il appartient aux médecins d’améliorer leur compréhension et leur écoute des
inquiétudes sexuelles et de traiter les questions biologiques fondamentales d’identité sexuelle
que se posent les femmes atteintes d’un cancer du sein. De plus, les médecins devraient au
moins diagnostiquer et recommander une aide clinique pour les symptômes sexuels les plus
courants des patientes survivantes à ce cancer : perte de libido, troubles de l’excitation
sexuelle, dyspareunie, anorgasmie et perte de satisfaction. Les meilleurs résultats seront
obtenus par le « jumelage de compétences » avec un psychosexologue ou un psychiatre tra-
vaillant dans ce domaine. Les patientes présentant des problèmes psychodynamiques ou rela-
tionnels clairs après exclusion ou guérison des causes biologiques potentielles de ces problè-
mes devraient leur être orientées. L’anatomie et la fonction des structures périnéales
doivent faire l’objet d’une grande attention pendant l’examen gynécologique et sexologique
clinique, les survivantes du cancer du sein étant en droit de recevoir un diagnostic et une
aide qualifiés. Le présent article se concentre sur les facteurs biologiques d’un intérêt essen-
tiel pour la pratique quotidienne des infirmiers.
© 2007 Published by Elsevier Masson SAS.

Resúmen El cáncer de mama es susceptible de afectar tres principales dominios de la sexuali-

PALABRAS CLAVE
dad femenina: la identidad sexual, la función sexual y la relación sexual. La sexualidad post-
Cáncer de mama; cáncer de mama puede estar afectada por una gama de problemas: la edad, los linfoedemas,
Función sexual los efectos indeseables de la cirugía, de la radio-, quimio-, y hormonoterapia, los problemas
femenina; asociados a la gestación, la infertilidad, la menopausia prematura yatrogénica, con su coorte
Linfoedema; de síntomas secundarios y la pérdida crónica de estrógenos que afecta al cerbro, los órganos
Mastectomía bilateral sensoriales, la patofisiología de las respuestas sexuales y la función de las estructuras perinea-
profiláctica; les. Las mujeres portadoras de las mutaciones del cáncer de mama, (BRCA, siglas en inglés), a
Esterilidad; las que se propone una mastectomía bilateral profiláctica, son susceptibles de sufrir un impacto
menopausia quirúrgico yatrogénico sobre la imágen de su feminidad. Desgraciadamente, el estudio de los
factores biológicos inducidos por el disgnóstico y el tratamiento del cáncer de mama no suscitan
yatrogénica;
tanto interés, como el de los aspectos psicosociales. Corresponde a los médicos mejrar la com-
Cáncer de mama en el
prensión y la escucha de las inquietudes sexuales y tratar las cuestiones biológicas fundamenta-
hombre
les de idenntidad sexual que se plantean las mujeres que padecen de CM. Además los médicos
deberían al menos diagnosticar y recomendar una ayuda clínica para los síntomas sexuales más
corrientes en las pacientes que sobreviven al CM: pérdida de líbido, trastornos de la excitación
sexual, dispareunia, anorgasmia y pérdida de satisfacción. Los mejores resultados serán obteni-
dos por el trabajo conjunto de un buen psicosexólogo o de un psiquiatra que trabaje en ese
campo, y hacia quien deberian orientarse las pacientes que presenten problemas psicodinámicos
o relacionales claros, después de la exclusión o la cura de las causas bilológicas potenciales de
esos problemas. La anatomía y la función de las estructuras perineales deberían ser cuidadosa-
mente examinadas durante la exploración ginecológica y sexológica clínica, las sobrevivientes al
CM tienen el derecho de recibir un diagnóstico y una ayuda cualificadas. Este artículo se con-
centra sobre los factores bilológicos, que tienen un interés esencial en la práctica cotidiana de
los profesionales que dispensan cuidados de enfermería.
© 2007 Published by Elsevier Masson SAS.

Version abrégée et traitée pour un cancer du sein se retrouve confrontée,

Introduction
Les nombreux changements, défis et désordres personnels,
conjugaux et familiaux auxquels une femme diagnostiquée
peuvent affecter d’une manière complexe son identité et
sa fonction sexuelle de même que sa relation de couple,
impliquant des facteurs psychosociaux et biologiques. Les
médecins doivent s’attacher à mieux entendre et
comprendre les inquiétudes sexuelles et à traiter les ques-
tions biologiques fondamentales d’identité sexuelle fémi-
294
nine soulevées par le cancer du sein. D’excellents travaux
de recherche ont été menés sur les nombreuses questions
psychologiques auxquelles une femme doit faire face au
cours de cette difficile période de changement dans sa
vie. Le présent article fera principalement une mise au
point sur les facteurs biologiques les plus importants
susceptibles d’affecter le devenir sexuel après un cancer
du sein.
Identité sexuelle
Féminité, maternité, érotisme et rôle social contribuent à
la perception de l’identité sexuelle féminine, et tous ces
éléments peuvent être affectés — à des niveaux divers —
par le diagnostic et le traitement du cancer du sein.
Féminité
La féminité peut être gravement affectée par un certain
nombre de raisons biologiques.
● l’image corporelle : l’impact à court terme dépend du
type d’intervention et du besoin éventuel d’une radio-
ou chimiothérapie et d’une hormonothérapie adju-
vantes. Toutefois, des traitements plus conservateurs
ne semblent pas modifier significativement la qualité
de vie ni la sexualité des femmes à long terme ;
● le lymphœdème du bras : « Les problèmes de bras » sont
cités par 26 à 72 % des patientes selon les différentes
manifestations (douleur, picotements, engourdissement,
sensibilité cutanée, gonflement) ;
● ménopause iatrogène : les patientes jeunes sont les plus
vulnérables car une période plus longue d’insuffisance
de taux d’estrogènes et de testostérone adéquats peut
affecter la qualité de vieillissement du cerveau et des
organes sensoriels qui sont les cibles et les modulateurs
du désir sexuel et de l’excitation sexuelle centrale ;
● âge : son importance n’est pas limitée à l’impact poten-
tiel de la ménopause, mais aux différentes tâches et
objectifs individuels et sociaux des femmes en âge de
procréer, tâches dont la priorité évolue au cours des
décennies.
Maternité
Elle peut être le cœur d’une crise identitaire majeure diag-
nostiquée au cours de la période de fertilité. Sachant que la
plupart des rechutes de cancer se produisent dans les deux
à trois ans après le diagnostic initial, il est préférable de
conseiller aux patientes d’éviter toute grossesse pendant
trois ans, comme cela est indiqué dans les recommanda-
tions canadiennes sur le cancer du sein, la grossesse et
l’allaitement, publiées en 2002. Si la patiente présente
des ganglions axillaires, cette recommandation doit être
étendue à cinq ans, sachant toutefois qu’elle est seulement
basée sur des opinions. On pourrait expliquer aux femmes
traitées pour un cancer du sein et qui souhaitent avoir un
enfant, que la grossesse est possible et ne semble pas être
associée à une aggravation du pronostic ni à des rechutes
précoces. En tout état de cause, avant d’envisager une
grossesse, une patiente doit se soumettre à une évaluation
oncologique complète.
A. Graziottin, V. Rovei
Érotisme
Le cancer du sein peut affecter la sensualité, l’attractivité
et la réceptivité en raison de plusieurs facteurs :
● perte de sensations de plaisir des seins après chirurgie
(mastectomie partielle, particulièrement dans le cas de
reconstrution mammaire), qui peuvent réduire l’excita-
tion sexuelle ;
● une ménopause iatrogène (chimiothérapique) et/ou une
ménopause naturelle non hormonalement traitable qui
peut détruire le sens érotique de la femme ;
● dépression et anxiété, réactionnelles au cancer du sein,
qui peuvent affecter l’image de soi et la fonction
sexuelle (particulièrement le désir sexuel) en dehors de
voies hormonales (rapportées en moyenne chez 17 à 25 %
des patients du cancer du sein ;
● le rôle social peut représenter un domaine relativement
peu affecté par cette maladie, particulièrement chez les
femmes qui ont un bon niveau d’éducation ou qui occu-
pent un rôle social important, sauf dans la phase aiguë
ou dans les cas les plus graves et agressifs.
Fonction sexuelle
Chez les patientes qui ont survécu au cancer sein, les symp-
tômes de déclin sexuel les plus courants et éventuellement
induits par la perte d’hormones sexuelles, l’altération de
l’image corporelle et/ou l’impact de la chirurgie, sont les
suivants : perte de libido, troubles de l’excitation, dyspa-
reunie (secondaires aux troubles de l’excitation et dus à
des spasmes défensifs des muscles de pubococcygiens),
anorgasmie s’aggravant avec le temps (courante après une
chimiothérapie), perte de satisfaction (douleur et décep-
tion globale de l’expérience sexuelle), autant d’éléments
qui réduisent notablement la satisfaction rapportée par les
survivantes du cancer du sein. Les meilleurs résultats seront
obtenus par un « jumelage de compétences » en association
avec un psychosexologue ou psychiatre travaillant dans ce
domaine, et vers qui devraient être orientées les patientes
présentant des problèmes psychodynamiques ou relation-
nels clairs après exclusion ou guérison de leurs causes bio-
logiques potentielles. L’anatomie et la fonction des struc-
tures périnéales doivent faire l’objet d’une grande
attention pendant l’examen gynécologique et sexologique
clinique, les survivantes du cancer du sein étant en droit
de recevoir un diagnostic et une aide qualifiés.
Relation de couple
Le fait que l’adaptation et la qualité de vie (QdV) globales
des survivantes du cancer du sein soient positives (70 à 80 %
en moyenne) ne doit pas cacher une vérité plus doulou-
reuse : ces deux éléments sont vrais pour de nombreux
aspects de la qualité de vie, sauf la fonction et la satisfac-
tion sexuelle. Un médecin compréhensif et compétent peut
aider une femme et un couple à mieux faire face au stress
immense du cancer du sein, qui plus est du point de vue
sexuel, sans abandon de l’intimité sexuelle qui constitue
une part si importante de la QdV, particulièrement chez
les jeunes femmes et dans les jeunes couples.
Sexuality after breast cancer
Cancer du sein chez l’homme
Les conséquences sexuelles du cancer du sein chez l’homme
n’ont pas encore été systématiquement évaluées. Son
impact symbolique et pragmatique doit toutefois être pris
en compte car il représente une partie importante de la
qualité de vie des survivants du cancer du sein.
Impact sexuel de l’hormonothérapie
Les patientes traitées par du tamoxifène se plaignent sur-
tout de bouffées de chaleur (85 %), de sècheresse et/ou de
dyspareunie vaginales (47 %), de déclin du désir sexuel
(44 %), de difficultés pour atteindre l’orgasme et de symp-
tômes musculosquelettiques (43 %). Des études supplémen-
taires sont nécessaires pour évaluer l’impact des inhibiteurs
d’aromatase sur la sexualité de la femme après un cancer
du sein. La seule excellente étude publiée se concentre sur
les femmes post-ménopausées saines, ne souffrant pas de
carences estrogéniques, traitées aux inhibiteurs d’aroma-
tase après supplémentation en testostérone. Les patientes
atteintes d’un cancer du sein qui ont une bonne libido per-
sistante et des troubles de l’excitation vasculaire, peuvent
bénéficier d’une amélioration clinique significative grâce à
des médicaments vasoactifs comme le sildénafil qui n’a pas
de contre-indications chez ce type de patientes. Toutefois,
nous manquons d’études contrôlées sur ces sous-ensembles
de patientes.
Full Version
Introduction
Female sexual identity, sexual function and sexual relation-
ship may be dramatically wounded, physically and emotion-
ally, by the many changes and challenges the woman has to
face after breast cancer (BC) diagnosis and treatment. This
paper will focus on the most important biological factors
that may impair sexual outcome after BC diagnosis and
treatment.
Female sexual identity
Femininity
Femininity may suffer a major insult, for a number of bio-
logical reasons. The breast is a prominent personal and
social sign of femininity; breast surgery may greatly affect
body image (Dorval et al., 1998; Ganz et al., 2002; Graziot-
tin, 2006; Schover et al., 1995). Short-term impact depends
on the type of surgery performed (and their cosmetic
result) and the need for radiotherapy or chemotherapy,
and hormonotherapy. However, more conservative treat-
ments do not appear to significantly modify quality of life
(QOL) or women’s sexuality in the long term (Dorval et al.,
1998; Ganz et al., 2002; Graziottin, 2006; Schover et al.,
1995). Arm lymphedema may be the major side effect of
BC treatment. It may develop up to 20 years after breast
and lymph node surgery but it is uncommon among women
who underwent the simpler lymph node sentinel biopsy
(Nardone et al., 2005). The type of surgery and radiother-
295
apy are relevant in determining an increased risk of lym-
phedema (Nardone et al., 2005). Iatrogenic menopause is
particularly problematic for younger patients: 25% of BC
patients are premenopausal, and 15% are diagnosed before
the age of 45 (Graziottin, 1998; Graziottin and Castoldi,
2000; Graziottin, 2003; Schover et al., 1995). More so as
estrogen modulate the quality of brain aging with its cohort
of cognitive and emotional symptoms (Henderson, 2000)
and the quality of aging of sensory organs that are sexual
targets and sexual modulators of sexual desire and central
arousal (Graziottin, 1996). The importance of the age at
diagnosis is not limited to the potential impact of the
menopause, but to the different individual and social tasks
and goals of women’s reproductive years. Women younger
than 50 complain of more menopausal symptoms which con-
tinue to persist several years after the diagnosis of BC (Avis
et al., 2005; Ganz et al., 2003; Graziottin, 1996). Moreover,
a recently published evaluation of QOL in long-term
disease-free BC survivors shows a statistically negative
association of past chemotherapy and/or tamoxifen hormo-
notherapy with current QOL (Ganz et al., 2002).
Maternity
It may become the core of a major identity crisis for women
who are diagnosed with BC during their fertile age. Since
most BC recurrences appear within 2-3 years after initial
diagnosis, patients should be advised to postpone preg-
nancy for 3 years, in case of small tumors (< 2 cm) with no
lymph node involvement. In case of axillary node involve-
ment pregnancy should be postponed for 5 years (Helewa et
al., 2002). The risk of congenital abnormalities following
chemotherapy does not seem to exceed normal incidence
(Kasum, 2006), but effects of the antiestrogen tamoxifen
or of the aromatase inhibitors on human pregnancies have
not been reported so far to the authors’s knowledge. Preg-
nancy does not seem to increase the risk of recurrence of
BC, according to the most recent studies. However, breast
cancer survivors should be referred for a full oncological
evaluation, prior to attempting pregnancy (Blakely et al.,
2004; Helewa et al., 2002).
Eroticism
BC may affect sensuality, sexiness and receptiveness
through a decrement in pleasure with breast caresses,
that is reported by 44% of women with partial mastectomy
and 83% of those with breast reconstruction (Schover et al.,
1995). In addition, the loss of pleasurable sensations in the
breast after surgery may reduce sexual arousal, through
both a central and peripheral mechanisms. The arousal
impairment is likely to be associated with a complex sense
of loss: physical, for the lack of feedbacks from the breast
when caressed or kissed; and psychosexual, for the body
image wound that breast surgery variably involves (Graziot-
tin, 2006) and the impairment of the peripheral non-genital
arousal (Levin, 2002), which is a key contributor of women’s
sensuality and arousability. The iatrogenic menopause
caused by chemotherapy may dramatically devastate the
woman’s sense of eroticism for its consequences on sexual
function (loss of sexual desire, vaginal dryness and dyspar-
eunia), and the impairment of quality of life that menopau-
sal symptoms may cause. Of note, BC currently contraindi-
296
cates systemic hormonal therapy: therefore many meno-
pausal symptoms remain unaddressed in BC survivors (Gra-
ziottin, 1998; Graziottin and Castoldi, 2000; Graziottin,
2003). However, even if the ability to reach orgasm through
intercourse tends to be reduced, the ability to reach
orgasm through non coital caressing does not differ from
that of other women (Schover et al., 1995). Reactive
depression and anxiety are quite common among BC
patients, especially during the first year subsequent to BC
diagnosis. After this critical “recovery” period, the majority
of women do improve individually in terms of psychological
symptoms. However, once sexual difficulties have devel-
oped, they tend to be self-maintaining because couples
have learned to avoid the anxiety surrounding sexual inter-
actions by avoiding any intimacy (Baucom et al., 2005). In
particular, depression is significantly related to sexual
desire (Speer et al., 2005). Neurobiologically, the loss of
sexual hormones after the menopause reduces their effect
on the dopaminergic seeking-appetitive-lust system, which
affects the instinctual component of sexual desire. Psycho-
logically, the depressed mood associated with reduced vital
energy and reduced interactions with the partner affects
also the responsive component of the motivational side of
sexual desire.
Social role
Social role may represent an area relatively safe from BC,
particularly in well educated women, especially in the peri/
postmenopausal years (Carlsson and Hamrin, 1994; Ganz et
al., 2002). A recent study showed that neuropsychological
impairment is not directly associated with self-perceived cog-
nitive deficits or fatigue. However, 46% of patients reported
self-perceived cognitive deficits and 82% of the patients com-
plained about cancer related fatigue. These complaints were
more frequent among women who received standard-dose
chemotherapy (Mehnert et al., 2007).
Bilateral or controlateral prophylactic mastectomy
A recent Cochrane review focused specifically on outcomes
of more than 4,000 women undergoing Bilateral Prophylactic
Mastectomy (BPM) or Controlateral Prophylactic Mastectomy
(CPM) after BC diagnosis (Lostumbo et al., 2004). Focusing on
psychosocial outcomes, women generally reported satisfac-
tion with their decisions to have BPM/CPM but reported less
consistent satisfaction for cosmetic outcomes, often due to
surgical complications, such as unanticipated re-operations
(Frost et al., 2005; Lostumbo et al., 2004). With regard to
emotional well-being, most women showed an improvement
in cancer worry and psychological morbidity postoperatively.
Body image and feelings of femininity were the most
adversely affected (about 20% of the patients after BPM
had adverse effects on those domains) (Lostumbo et al.,
2004), even when a long follow-up period is considered
(Frost et al., 2005; Geiger et al., 2006).
Female sexual function
Sexual desire
Sexual desire has three major dimensions: biological,
motivational-affective and cognitive. Biological roots of
A. Graziottin, V. Rovei
sexual desire depend first on sexual hormones, which
seem to control the intensity of libido and sexual behaviour,
rather than its direction (Pfaus and Everitt, 1995). Loss of
estrogens, secondary to iatrogenic or naturally occurring
menopause, may contribute to inhibit the sexual drive and
the physical receptiveness; loss of androgens (Sands and
Studd, 1995), secondary to chemotherapy or ovariectomy,
may further worsen the picture. Sensory organs involution
after menopause may further reduce the biological basis of
libido. Motivational-affective and cognitive aspects of sex-
ual desire may be impaired by the negative impact that
breast surgery has on self-image, and the perception itself
of being an object of sexual drive (Graziottin, 2006). The
shift of the couple relationship towards more affective
dynamics may increase the emotional intimacy but reduce
the physical sexual drive.
Sexual arousal
The risk for arousal disorders is 5 times greater among BC
survivors than among non-cancer women with female sexual
dysfunction (Broeckel et al., 2002; Speer et al., 2005). Arou-
sal difficulties may be secondary to biological central diffi-
culties caused by the loss of sexual hormones, secondary to
iatrogenic or spontaneous menopause, which may be wor-
sened by depression, anxiety, chronic stress and insomnia.
Problems in non-genital peripheral arousal may be better
exemplified by "touch-impaired" disorders (Graziottin and
Castoldi, 2000). Nipple erection may be reduced both by
decreased breast sensitivity, secondary to surgery, and inhi-
bition, for the shame some women feel in exposing the oper-
ated breast. Impairment in genital arousal could be mainly
caused by estrogen loss, vaginal dryness and dyspareunia
(Graziottin and Castoldi, 2000). These conditions may cause
a defensive spasm of pubococcygeus muscle. The attention
to hyperactive, defensive conditions of the pelvic floor sec-
ondary to dyspareunia is mandatory in BC patients. They
should as well be taught how to relax the levator ani muscle
and encouraged to do a self massage with a medicated oil.
Self massage and stretching of the levator ani may rapidly
reduce dyspareunia and arousal disorders secondary to
hypoestrogenism that may not be treated with estrogens
because of BC. However, many physicians do currently con-
sider appropriate to reduce the vaginal symptoms with local,
topical treatment with low doses of estradiol, a bioidentical
hormone. Vascular problems have recently been claimed as
critical factors in female arousal disorders (Goldstein and
Berman, 1998; Traish and Kim, 2006). The anamnestic data
to be screened should therefore include: smoking, hyperch-
olesteremia, diabetic vasculopathy and severe atherosclero-
sis. BC patients, with persistent good libido, and vascular
arousal disorders might have a significant clinical improve-
ment with vasoactive drugs such as sildenafil, vardenafil or
tadalafil that would not be contraindicated in BC patients.
However, controlled studies are lacking.
Orgasm
Difficulty in reaching orgasm is higher in BCS patients
(Broeckel et al., 2002, Speer et al., 2005), with a signifi-
cant worsening in sexual functioning over 3 years of
follow-up and after chemotherapy (Schover et al., 1995).
However, orgasm reached through non coital caressing did
Sexuality after breast cancer
not differ from control women, probably because of the
inhibitory effect of dyspareunia on vaginal orgasm (Schover
et al., 1995), together with the effect of different domi-
nant neurochemical pathways (nitric oxide) androgen
dependent, essential for the clitoral response and vasoac-
tive intestinal peptide, estrogen dependent, more critical
for the vaginal response (Traish and Kim, 2006).
Satisfaction
Recently, Speer et al. (2005) showed a reduced satisfaction
(both physical and emotional) among BC survivors versus
controls and versus non-cancer women with female sexual
dysfunction using the Female Sexual Functioning Index.
Moreover, pain and an overall disappointing sexual experi-
ence might also be responsible for the significantly reduced
satisfaction reported by BC survivors (Speer et al., 2005).
Antiestrogens and aromatase inhibitors
During tamoxifen therapy, the most frequent sexual com-
plaints by postmenopausal BC survivors are vaginal dryness
and/or dyspareunia, decreased sexual desire (Morales et
al., 2004), and difficulties achieving orgasm than women
who are not taking this drug (Day et al., 1999; Merits et
al., 2002). Treatments with aromatase inhibitors are
related to an augmented risk for dyspareunia (Morales et
al., 2004; Davis et al., 2006).
Sexual relationship
A good quality of emotional intimacy may explain why BC
patients found it easier to discuss their sexual problems
with their partner during their illness than with doctors
and psychologists. When BC is diagnosed the demands of ill-
ness are superimposed on the normal demands of family life
and this may have a different impact on the family relation-
ships depending on the phase of the family life cycle when
the cancer is diagnosed: young women and couples seems
to be particularly vulnerable (Northouse, 1994). Focusing
on the physical aspect of the problem, breast surgery may
affect physical attractiveness and reduce easiness with
breast foreplay, although this is difficult to be openly
admitted as it seems rough, insensitive and/or unfeeling
(Graziottin, 2006). Moreover, a difficult penetration due to
hypoestrogenic vaginal dryness may also precipitate an
erectile deficit, when the partner perceives vaginal dryness
as a sign of refusal or somehow an indication of the "insen-
sitivity" of his sexual request and approach (Graziottin and
Castoldi, 2000). It’s crucial to give a more balanced help
also to partners of BC survivors.
Male breast cancer
The incidence of male breast cancer is rising; however,
mortality due to male breast cancer has not changed,
unlike female BC (Nahleh and Girnius, 2006). The treatment
of male breast cancer has been extrapolated from the
knowledge of female BC, despite the multiple differences
in the pathogenesis, biology and genetics of these two dis-
ease entities, especially the differences with regard to the
gender role of sexual hormones. However, the impact of
male BC on sexuality of men affected with this disease has
not been systematically studied to the Author’s knowledge.
297
Conclusion
BC may affect female sexual function, sexual response and
couple relationship in a complex way, involving both psy-
chosocial and biological factors, so closely interacting that
it is difficult to assert the relative weight of hormonal and
overall physical changes on psychosexual variations in BC
survivors. Physicians, and particularly the oncologists in
this specific field, should improve their skill in understand-
ing and listening to sexual concerns and in addressing the
basic biological issues that BC raises for female sex identity.
They should also at least diagnose and recommend clinical
help for the most common sexual symptoms in BC survivors:
loss of libido, arousal disorders, dyspareunia, anorgasmia
and loss of satisfaction. Best results will be obtained in
sharing a "twin competence" with a good psychosexologist
or a psychiatrist with an interest in this field, to whom
patients with clear psychodynamic or relational problems
should be referred for specific help, after having excluded
or cured the potential biological roots of them. Attention to
the anatomy and function of the pelvic floor should become
a mandatory part of a thorough clinical gynaecological and
sexological examination, to give BC survivors the right to a
full diagnosis and competent help. Further studies are
needed to assess both the impact of hormonotherapy on
women’s sexuality after BC: the only excellent study pub-
lished is focused on healthy postmenopausal women, estro-
gen repleted, treated with aromatase inhibitors after tes-
tosterone supplementation. More studies are needed as
well to assess the impact of BC in men and, last but not
least, the effect of different treatment intervention for
sexual disorders after BC. Finally, the overall adjustment
and QOL of BC survivors are positive in 70-80% of cases
except for sexual function and satisfaction. An understand-
ing and competent physician could help the woman and the
couple to cope better with the tremendous strain of BC,
also from the sexual point of view: without giving up the
sexual intimacy, that is such a critical part of QOL, particu-
larly in younger women and couples.
References
Avis NE, Crawford S, Manuel J. Quality of life among younger
women with breast cancer. J Clin Oncol 2005; 23: 3322-30.
Baucom DH, Porter LS, Kirby JS, Gremore TM, Keefe FJ. Psychoso-
cial issues confronting young women with breast cancer. Breast
Dis 2005; 23: 103-13.
Blakely LJ, Buzdar AU, Lozada JA, Shullaih SA, Hoy E, Smith TL,
et al. Effects of pregnancy after treatment for breast carcinoma
on survival and risk of recurrence. Cancer 2004; 100: 465-9.
Broeckel JA, Thors CL, Jacobsen PB, Small M, Cox CE. Sexual func-
tioning in long-term breast cancer survivors treated with adju-
vant chemotherapy. Breast Cancer Res Treat 2002; 75: 241-8.
Carlsson M, Hamrin E. Psychological and psychosocial aspects of
breast cancer and breast cancer treatment. A literature review.
Cancer Nurs 1994; 17: 418-28.
Davis SR, Goldstat R, Papalia MA, Shah S, Kulkarni J, Donath S,
et al. Effects of aromatase inhibition on sexual function and
well-being in postmenopausal women treated with testoster-
one: a randomized, placebo-controlled trial. Menopause 2006;
13: 37-45.
Day R, Ganz PA, Costantino JP, Cronin WM, Wickerham DL, Fisher B.
Health-related quality of life and tamoxifen in breast cancer
298
prevention: a report from the National Surgical Adjuvant Breast
and Bowel Project P-1 Study. J Clin Oncol 1999; 17: 2659-69.
Dorval M, Maunsell E, Deschenes L, Brisson J. Type of mastectomy
and quality of life for long term breast carcinoma survivors.
Cancer 1998; 83: 2130-8.
Frost MH, Slezak JM, Tran NV, Williams CI, Johnson JL, Woods JE,
et al. Satisfaction after contralateral prophylactic mastectomy:
the significance of mastectomy type, reconstructive complica-
tions, and body appearance. J Clin Oncol 2005; 23: 7849-56.
Ganz PA, Desmond KA, Leedham B, Rowland JH, Meyerowitz BE,
Belin TR. Quality of life in long-term, disease-free survivors of
breast cancer: a follow-up study. J Natl Cancer Inst 2002; 94:
39-49.
Ganz PA, Greendale GA, Petersen L, Kahn B, Bower JE. Breast can-
cer in younger women: reproductive and late health effects of
treatment. J Clin Oncol 2003; 21: 4184-93.
Geiger AM, West CN, Nekhlyudov L, Herrinton LJ, Liu IL, Altschuler
A, et al. Contentment with quality of life among breast cancer
survivors with and without contralateral prophylactic mastect-
omy. J Clin Oncol 2006; 24: 1350-6.
Goldstein I, Berman JR. Vasculogenic female sexual dysfunction:
vaginal engorgement and clitoral erectile insufficiency syn-
dromes. Int J Impot Res 1998; 10: S84-90.
Graziottin A. Libido. In: Studd J, ed. Yearbook of the Royal College
of Obstetricians and Gynaecologists (RCOG). London: Press-
Parthenon Publishing Group, 1996: 235-43.
Graziottin A. The biological basis of female sexuality. Int Clin Psy-
chopharmacol 1998; 13: S15-22.
Graziottin A, Castoldi E. Sexuality and breast cancer: a review. In:
Studd J, ed. The management of the menopause. London:
Parthenon Publishing, 2000: 201-20.
Graziottin A. Sexuality in postmenopause and senium. In: Lauritzen
C, Studd J, eds. Current Management of the Menopause. Lon-
don: Martin Duniz, 2003: 185-203.
Graziottin A. Breast cancer and its effects on women’s self-image
and sexual function. In: Goldstein I, Meston C, Davis S, Traish A,
eds. Women’s sexual function and dysfunction: Study, diagnosis
and treatment. UK: Taylor and Francis, 2006: 276-81.
Helewa M, Levesque P, Provencher D, Lea RH, Rosolowich V, Sha-
piro HM. Breast cancer, pregnancy, and breastfeeding. J Obstet
Gynaecol Can 2002; 24: 164-80.
Henderson V. Hormone therapy and the brain. Hormone therapy
and the brain. New York: Parthenon Publishing, 2000.
Kasum M. Breast cancer treatment–later pregnancy and survival.
Eur J Gynaecol Oncol 2006; 27: 225-9.
A. Graziottin, V. Rovei
Levin RJ. The physiology of sexual arousal in the human female: a
recreational and procreational synthesis. Arch Sex Behav 2002;
31: 405-11.
Lostumbo L, Carbine N, Wallace J, Ezzo J. Prophylactic mastect-
omy for the prevention of breast cancer. Cochrane Database
Syst Rev 2004; 4; (CD002748).
Mehnert A, Scherwath A, Schirmer L, Schleimer B, Petersen C,
Schulz-Kindermann F, et al. The association between neuropsy-
chological impairment, self-perceived cognitive deficits, fati-
gue and health related quality of life in breast cancer survivors
following standard adjuvant versus high-dose chemotherapy.
Patient Educ Couns 2007; 66: 108-18.
Merits M, Beckerman I, de Varies E, van deer Zee A. Tamoxifen
effects on subjective and psychosexual well being, in a rando-
mized breast cancer study comparing high-dose and standard
dose chemotherapy. Br J Cancer 2002; 86: 1546-50.
Morales L, Neven P, Timmerman D, Christiaens MR, Vergote I, van
Limbergen E, et al. Acute effects of tamoxifen and third-
generation aromatase inhibitors on menopausal symptoms of
breast cancer patients. Anticancer Drugs 2004; 15: 753-60.
Nahleh Z, Girnius S. Male breast cancer: a gender issue. Nat Clin
Pract Oncol 2006; 3: 428-37.
Nardone L, Palazzoni G, D’Angelo E, Deodato F, Gambacorta MA,
Micciche F, et al. Impact of dose and volume on lymphedema.
Rays 2005; 30: 149-55.
Northouse LL. Breast cancer in younger women: effects on inter-
personal and family relations. J Natl Cancer Inst Monogr 1994;
16: 183-90.
Pfaus J, Everitt B. The psychopharmacology of sexual behaviour. In:
Bloom FE, Kupfer DJ, eds. Psychopharmacology: the fourth gen-
eration of progress. New York: Raven Press, 1995: 743-58.
Sands R, Studd J. Exogenous androgens in postmenopausal women.
Am J Med 1995; 98: 76S-79S.
Schover LR, Yetman RJ, Tuason LJ, Meisler E, Esselstyn CB, Her-
mann RE, et al. Partial mastectomy and breast reconstruction.
A comparison of their effects on psychosocial adjustment, body
image, and sexuality. Cancer 1995; 75: 54-64.
Speer JJ, Hillenberg B, Sugrue DP, Blacker C, Kresge CL, Decker VB,
et al. Study of sexual functioning determinants in breast cancer
survivors. Breast J 2005; 11: 440-7.
Traish A, Kim N. Modulation of female genital sexual arousal by sex
steroid hormones. In: Goldstein I, Meston C, Davis S, Traish A,
eds. Women’s sexual function and dysfunction: Study, diagnosis
and treatment. UK: Taylor and Francis, 2006: 193-220.