Information on Sexuality and Cancer

When patients are diagnosed with cancer, they have many thoughts, fears, and questions, and most want to learn more about their disease and treatment. There also are practical issues to consider—paying for treatment, finding transportation, keeping a job, and juggling family responsibilities. Patients are dealing with huge decisions and coping with stressful changes.

It's understandable that sexuality may not be the primary focus for many cancer patients, at least not right away. Sexuality is an incredibly personal topic, and each person's experiences, feelings, and expectations are unique. But at some point, whether because of sexual changes, relationship issues, or difficulties with fertility, patients realize the impact of cancer on their sexuality.

Each patient's cancer journey is unique, so it's impossible to know what your experiences will be. You may undergo permanent changes in your body, physical discomforts, emotional struggles, and problems with fertility. But no matter the diagnosis or prognosis, you deserve the best quality of life, and this includes care of your sexual health. By learning about how your sexuality is likely to change and getting suggestions for healing, you become a partner and advocate in your own care.

This guide explores cancer and sexuality and answers some of the questions you might be asking:

1. What is sexuality?
2. What is a normal sexual response?
3. How can my cancer and cancer treatment affect my sexuality?
4. If my cancer and cancer treatment cause sexual changes, what remedies are available?
5. How can my cancer and cancer treatment affect my relationships?
6. How does cancer treatment affect fertility?
7. What additional resources are available to help answer my questions and concerns?

1. What is sexuality?

When you think of sexuality, your first thought may be the physical act of sexual intercourse. But sexuality goes beyond engaging in sexual activity.

As a human being, your sexuality is a part of your physical, emotional, intellectual, and social self. It affects how you think of yourself and how you relate to others, as well as how they relate to you, and it is a part of you throughout your entire life.

Since every person is different, it is difficult to define "normal" sexuality or sexual activity. Many factors may influence your sexuality, including your gender, sexual orientation, hormone levels, age, and personal perspectives, such as your views on sex and your religious beliefs and values.

You may have certain definitions of how you think a man or woman should look and behave, and these expectations play a part in your sexuality, too.

It's important to recognize what is normal for you—what makes you feel comfortable and satisfied—and that it may be different from what is normal for someone else. And it's equally important to remember that cancer and its treatment may cause changes in your sexual function, but they cannot take away the life experience and emotions that make you a sexual person.

2. What is a normal sexual response?

A "normal" sexual response involves a person experiencing one or more of the following phases:

• Desire
• Arousal
• Orgasm
• Resolution

Cancer and cancer treatment can cause changes in any phase of the sexual response. Understanding these phases may help you explain your experiences to your doctor or nurse. This may help them diagnose changes and prescribe remedies to help you.

This section contains more information on:

• Desire
• Arousal
• Orgasm
• Resolution

Desire

Desire happens when you feel interested in someone sexually. For example, if a man or woman walked by, you may feel an attraction to that person or begin to imagine that person as a partner. Desire may also come from feelings of sexual pleasure and tension in your body, or from a sexual fantasy. The more you think about sex, the more frustrated you may feel if you do not have a chance to have sexual pleasure. All of these feelings can be called “desire.”

Lack of desire is the most common sexual problem for all cancer patients. You may think, "I used to think about sex, but now it doesn't seem important to me," or "I want to have a sexual relationship, but I don't feel desirable or sexy," or "I just don't feel like having sex anymore."

Arousal

Arousal is sexual excitement, which may be caused by touching, stroking, fantasizing, or seeing or hearing sexual sights and sounds. Your heartbeat, pulse, and blood pressure rise. Your breathing may become deeper and heavier. In both men and women, blood flows into the genitals as part of sexual arousal.

• For women, arousal includes both mental excitement and the physical response of vaginal lubrication and expansion. The vagina becomes moist and expands. The outer genitals, including the clitoris, swell and turn a deeper color.
• In men, the penis becomes erect, and arousal includes getting and maintaining an erection sufficient for intercourse.

Most often, loss of desire and trouble getting mentally aroused go together. Instead of feeling good, sexual touch may seem annoying or you may feel “numb.” You may find yourself thinking that your body isn't responding the way it is "supposed to." But sometimes you feel turned on in your mind, but your body does not respond physically. You may feel interested in sex, even excited, but also frustrated that you have vaginal dryness if you are a woman, or do not get a firm erection if you are a man. Problems with physical arousal are often caused by damage to the body from cancer treatment.

• After cancer treatment, or just with normal aging, women may respond more slowly to sexual stimulation, produce less or insufficient lubrication, and may feel that breast or genital caressing does not bring pleasure.
• Changes with arousal in men include not being able to get or sustain an erection, having an erection that is not firm or reliable, or not having erections as frequently as desired.

Orgasm

A person who reaches a sexual climax has an orgasm. For men and women, this means a rhythmic contraction of the genitals, which causes intense, pleasurable feelings throughout the body. Overall, you may feel satisfaction, pleasure, and gratification.

• When women have an orgasm, the vaginal walls contract, and often waves of pleasure are felt in the clitoris and outer vagina. Many women enjoy reaching more than one orgasm, while others prefer to have one intense climax.
• When men have an orgasm, they experience an ejaculation, when the penis releases semen.

When changes with orgasm occur, men and women may find that it takes a longer time to reach orgasm, more stimulation is needed, or that orgasms cannot be achieved at all.

• Women may find that the clitoris or vaginal opening feels less sensitive. Some women have pain with sex or distracting thoughts about cancer or feeling unattractive. It takes some mental focus on pleasure for a woman to reach orgasm.
• After cancer treatment, some men experience "dry orgasms" in which muscles contract and they feel pleasure, but no semen comes out of the penis. Some men also find that their orgasms are weaker and less pleasurable.

Resolution

Resolution is when the body calms down and is no longer excited. Your heartbeat, pulse, and blood pressure return to normal, and blood drains from the genital area. Resolution happens rapidly after an orgasm. If a person doesn't have an orgasm, resolution happens eventually but just takes longer.

Women can have one orgasm right after another, known as multiple orgasms. Usually men have to wait a certain amount of time after an orgasm before becoming aroused again. This time, called the refractory period, can increase with age or medical conditions.

3. How can my cancer and cancer treatment affect my sexuality?

Cancer and its treatment may affect your sexuality, but every patient is different. Some patients experience sexual changes in all of the phases of sexual response, while others experience none.

The most common sexual change for cancer patients is an overall loss of desire. Most men and women are still able to have an orgasm even if cancer treatment interferes with erections or vaginal lubrication, or involves removing some parts of the pelvic organs. However, it is common for patients to need more time or stimulation to reach orgasm.

Unfortunately, when sexual changes do occur, they generally do not improve right away; indeed, they may persist until a good remedy is found. Finding the most helpful remedy may take time and patience because sexual changes can be caused by both psychological and physical factors.

Furthermore, the sexual changes caused by cancer treatment may be long term or permanent. Talk with your doctor, nurse, or another healthcare professional before treatment to learn about what to expect from your cancer or cancer treatment concerning your sexuality. By knowing what may happen, you may be better prepared and more knowledgeable about potential sexual changes.

This section contains more information on sexual changes caused by:

• Cancer Treatment in Women
• Cancer Treatment in Men
• Cancer Treatment Side Effects
• Emotional Effects
• Anxiety and Depression

Cancer Treatment in Women

It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Talk with your doctor to see whether it is safe for you to participate in sexual activities. Be aware that:

• If you are having sex during chemotherapy, you may wish to use barrier protection, such as condoms or dental dams (for oral sex), since chemicals can be found in vaginal fluid. Ask your doctor how long your particular chemotherapy stays in the bloodstream. It can range from hours to days.
• Radiation to you from an external machine does not make you radioactive or endanger a partner in any way. If you have a type of radiation therapy that involves using a source of radiation that stays in your body over time, there may be a short period (a few days or less) when your doctors want you to avoid sexual activity until the strongest radiation has left the body.
• Sex can be a problem if you have heavy bleeding in the genital area from cancer, if you have recently had surgery, or if your immune system is weak.

Cancer treatment can cause a variety of sexual changes. Even though the causes may be different—surgery, chemotherapy, hormone treatment, and radiation—the resulting changes are often similar.

• Surgery
• Chemotherapy
• Hormone Treatment
• Radiation

Cancer Treatment in Women: Surgery

• Some pelvic surgeries change the vagina. For example, radical hysterectomy shortens the vagina. When the bladder or colon is removed, parts of the vaginal wall may also be removed, making the vagina narrower. Loss of tissue around the vagina removes its "cushioning," and scar tissue may form in the area. These changes can sometimes cause pain with deep thrusting and penetration or in certain intercourse positions.
• When both ovaries are removed in a younger woman, she will have an abrupt menopause. The most typical result is vaginal dryness and pain, but some women experience a loss of sexual desire, as well. Also, the loss of the hormone estrogen reduces the blood supply of the vagina and thins the vaginal walls. The result is that the vagina feels dry and tight, especially during penetration.  It is unclear why many women who have sudden menopause lose some desire for sex. It may be because of the loss of androgens, hormones produced by the ovaries. However, several studies have found that a woman’s androgen levels after cancer can not predict her desire for sex. Many women find that if sex hurts, they stop looking forward to it, which interferes with desire. Medications, fatigue, and nausea also can be part of the problem.
• If some or all of the vulva is removed, a woman may lose some important erotic zones, especially if the clitoris is included. The vaginal entrance also may be narrowed, making penetration painful or difficult.
• After surgery on the breasts to remove a tumor, or a mastectomy to remove one or both breasts, a woman may lose the ability to feel sexual pleasure from nipple caressing. The loss of pleasure may lessen sexual desire or arousal, or caressing an untreated breast may trigger distracting thoughts about breast cancer.

Cancer Treatment in Women: Chemotherapy

• In women who have not yet reached menopause, chemotherapy can damage the ovaries, causing sexual changes. Alkylating chemotherapy drugs, especially at high doses, can destroy the function of ovaries so that they no longer produce hormones. This will cause sudden menopause, which is usually permanent. Women who stop having menstrual periods may experience vaginal dryness, pain, and a loss of desire, just like women whose ovaries were removed in surgery or damaged by radiation therapy.
• Lower doses of chemotherapy may temporarily stop a woman's periods. They may resume, along with hormone production, especially if a woman is under age 35 when she is treated.
• If chemotherapy causes mucositis (mouth soreness), it also may cause soreness in the vagina, making sexual intercourse extremely painful.
• If chemotherapy causes neuropathy (tingling or numbness) in the hands and feet, it also may cause numbness in the clitoris, though this has not been proved.

Cancer Treatment in Women: Hormone Treatment

• Some hormone treatments may cause sexual changes, but they are less likely to do so than chemotherapy.
• Most studies of women taking tamoxifen after breast cancer find that the hormone does not interfere with sexual desire. Since tamoxifen acts like a weak estrogen in the genital system, many women find it helps with vaginal dryness, although some women experience vaginal irritation.
• Raloxifene, which is also taken after breast cancer to prevent recurrence, also does not interfere with sexual desire in women, though it is less likely than tamoxifen to help with menopausal vaginal dryness.
• Aromatase inhibitor medicines, such as Arimidex, are increasingly taken to prevent breast cancer recurrence. Unfortunately, this class of medicines is likely to lead to vaginal dryness and pain with sex, but lubricants and moisturizers can help.

Cancer Treatment in Women: Radiation

• Radiation to the pelvis can damage the ovaries, leading to the same problems with vaginal dryness or pain as when both ovaries are removed in surgery or damaged by chemotherapy. A lower dose of radiation may cause less damage such that a young woman may recover menstrual periods. At higher doses, the menopause is permanent. (Post-menopausal women may experience a lack of desire because of the loss of androgens, hormones produced by the ovaries.)
• Radiation can do direct damage to the vagina. Inflammation in the vagina can cause the walls to stick together during healing, or it can result in narrow bands of scar tissue along the vaginal canal.
• Some women develop radiation ulcers, painful sores that take a long time to heal.

Cancer Treatment in Men

It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Talk with your doctor to see whether it is safe for you to participate in sexual activities. Be aware that:

• If you are having sex during chemotherapy, you may wish to use barrier protection, such as condoms or dental dams (for oral sex), since chemicals can be found in semen. You may want to ask your doctor how long your chemotherapy drugs will stay in your bloodstream, since it can range from hours to several days.
• Radiation to you from an external machine does not make you radioactive or endanger a partner in any way. If you have radiation therapy using implants in your body, such as seed implants for prostate cancer, there may be a brief period where your doctors want you to avoid sexual activity until the strongest radiation has left the body. After that you are not in danger of harming a partner or any other person who gets close to you.
• Sex can be a problem if you have heavy bleeding in the genital area from cancer, if you have recently had surgery, or if your immune system is very weakened.

Erectile dysfunction, also known as impotence, is when a man cannot get or maintain a firm erection. Some men experience erectile dysfunction because of cancer treatment. Erectile dysfunction also is much more common with aging, especially for men who are smokers, are overweight, or have diabetes, high blood pressure, or heart disease. Men who are already having some mild erection problems may find these get worse with cancer treatment.

Cancer treatment can cause a variety of sexual changes:

• Surgery
• Hormone therapy
• Radiation
• Chemotherapy

Cancer Treatment in Men: Surgery

• The most common types of cancer surgeries that cause erectile dysfunction are those that remove the prostate, prostate and bladder, or the lower part of the colon and rectum. These operations often cut or bruise important nerves that direct blood flow into the penis. Even though surgeons try to spare the nerves, many men end up with erection problems. (Nerve-sparing techniques work best for younger, healthy men who are having firm, reliable erections before cancer diagnosis.)
• If the prostate and the seminal vesicles (the small glands behind the prostate) are surgically removed, a man will experience "dry" orgasms, meaning that he will not ejaculate semen. The muscles still pump at the base of the penis, and the feeling of orgasmic pleasure still occurs, but about half of men say their orgasm feels weaker. A man can reach orgasm without having an erection, but it may take practice to find the right kind of stimulation.
• Some men with testicular cancer have an operation to remove the lymph nodes in their abdomen (retroperitoneal lymphadenectomy) or to remove some nodes that remain enlarged after chemotherapy. These surgeries sometimes damage the nerves involved in ejaculation, also resulting in dry orgasm.
• Another surgery that may damage these nerves is sigmoidectomy, done to remove colon cancer in the sigmoid colon.
• If both of the testicles are removed, a man will experience loss of desire for sex since testosterone, the hormone that helps men feel desire, is made in the testicles. This hormone can stimulate prostate cancer cells, so the goal of the surgery is to stop its production. About 20 percent of men, especially those under age 60, can still get erections and have orgasms after removal of both testicles, although it takes more effort and stimulation.

Cancer Treatment in Men: Hormone Treatment

• Many men with advanced prostate cancer do not have their testicles removed but instead take hormone therapy designed to "turn off" the testicles so that they do not produce testosterone. The sexual side effects are very much the same as described above with surgery to remove the testicles.
• Some men take hormone therapy for only a few months around the time of surgery or radiation therapy for prostate cancer. Unfortunately, in some men, sexual side effects of the hormones persist, and things do not go back to normal. This is also a limitation of using "intermittent" hormone therapy, in which hormones are given until a man's PSA blood test result (a test for prostate-specific antigen, a sign of prostate cancer) goes down to near zero. Then the man can stop the hormones for a few months. Some men recover sexually, but others continue to experience loss of desire and erection problems during the months off hormones.

Cancer Treatment in Men: Radiation

• Men who have radiation treatment in the pelvic area may develop erectile dysfunction because the radiation causes a gradual scarring in the tissue in the target area, which may include small blood vessels and nerves that are involved in erection. The changes after radiation therapy tend to be gradual, often not appearing until a few months after the treatment is over. The higher the dose of radiation near the base of the penis, the more likely it is that there will be a problem.
• Radiation treatment also can cause pain during ejaculation. Pain is most often temporary due to irritation of the urethra (tube that carries urine or semen) right after radiation therapy. Sometimes pain occurs later and is caused by a tight band of scar tissue in the urethra, called a stricture.  Radiation aimed near the prostate and seminal vesicles typically reduces semen to only a few drops.

Cancer Treatment in Men: Chemotherapy

After chemotherapy, only a few men experience new sexual changes. Sometimes high doses of drugs that can cause nerve damage result in erectile dysfunction or in dry orgasm, but this is much less common than after surgery or pelvic radiation therapy.

Men who get high doses of chemotherapy, especially if they are having a stem cell or bone marrow transplant, sometimes end up with low testosterone levels, even several years after treatment. They may notice loss of interest in sex and erection problems. A simple blood test can find this problem, and replacement hormones can be given.

Cancer Treatment Side Effects

Cancer treatment side effects, such as fatigue, nausea, vomiting, diarrhea, constipation, hair loss—including pubic hair—weight changes, scars, and sensitivity to tastes and smells may leave you feeling exhausted and uncomfortable. These side effects consume so much energy that sex may be the very last thing on your mind.

Fortunately, patients have options to help relieve their symptoms, and many patients take medicines to treat pain, nausea, anxiety, depression, or other symptoms. However, many of these medicines can decrease sexual desire, which combined with the effects of cancer treatment, may cause you to feel indifferent toward sex. Furthermore, many medicines taken for depression or anxiety may make it harder to reach orgasm.

Some of the medicines also may affect your mental state—how alert or sharp you feel, your mood, and how you interact with people—and so you may not be thinking or communicating clearly. This can negatively affect how you relate to your partner, making sexual contact difficult.

Therefore, if you are experiencing any symptoms or side effects—whatever the cause—ask your doctor or another member of your healthcare team to work with you to find other remedies or strategies to help you feel better.

Emotional Effects

Often during cancer treatment, patients' needs for intimacy and affection increase. Unfortunately, this happens when relationships may be strained by worry and concern.

Your emotions have a big impact on your sexuality. The way you feel about your body and yourself can influence how you interact with others. You may feel inadequate, out of sync with your partner, and not sure about what to do to feel better

The following are examples of ways that your emotions may affect your sexuality:

• Changes in your appearance may be stressful and cause you to feel unattractive or self-conscious. These changes may make you unable to focus on sexual excitement and pleasure. Surgery that changes your appearance can be especially difficult.
• Feeling negative emotions like anger or guilt may keep you or your partner from wanting to have sex.
• Feeling afraid may distract you and cause you not to care about sex.
• Being fearful of "giving your partner cancer" may affect your ability to be close to your partner. (You cannot give anyone cancer, nor can people "catch" cancer from you. For more information about what causes cancer, talk to your doctor.)
• Often patients' partners feel fearful of causing harm or pain, so you may feel confused or worried if your partner keeps you at a distance.
• Feeling "stressed out" may cause your sexual desire to decrease.
• Tension, anxiety, or trouble getting in the mood for sex can slow down the ability to reach orgasm.
• You may feel helpless and frustrated by changes beyond your control.
• You may be upset about or grieving changes in your fertility.
• You may fear rejection and decide to pull away before your partner can hurt you.
• You may feel embarrassed that your partner has had to act as your caretaker when you were ill and have trouble switching back to feeling like lovers.
• You may lose desire toward your partner because of a conflict between the two of you. Perhaps you feel desire when you see a sexy love scene in a movie but not when you get into bed with your partner.

Anxiety and Depression

Although most sexual changes after cancer are caused by physical changes, some result from anxiety or depression. Therefore, it is important to have depression and anxiety assessed before having any sexual changes evaluated or treated. This is also important since anxiety and depression share some common symptoms with treatment side effects.

Fortunately, the anxiety and depression many people feel during cancer treatment fades with time for most. But if the emotional reaction to cancer does not improve within a few months of treatment, patients may benefit from some counseling, which can be as effective as medication for depression and anxiety. Also, it's important to know that some medicines prescribed to treat depression or anxiety can have sexual side effects.

Anxiety

Anxiety about cancer can preoccupy your thoughts, interfering with your ability to enjoy many activities, including sex. Worry and fear about the future may make it hard to share intimacy and affection. Anxiety is a treatable condition, however, responding to both counseling and medicine. Symptoms can be physical or emotional and include:

• Feeling apprehensive or fearful
• Feeling worried
• Feeling that things are "out of control" or endless
• Feeling irritable, restless or edgy
• Feeling stressed or tense, sometimes physically in the muscles with neck or backache
• Having fast or irregular heartbeats
• Sweating
• Having an unsettled stomach, possibly with diarrhea or nausea
• Shaking or trembling
• Having nightmares or vivid images during waking hours of a particularly traumatic part of your cancer treatment

Depression

Depression is also treatable. It affects 15 percent to 25 percent of cancer patients and about 25 percent of cancer survivors. Depression is more than just crying and feeling sad; it can affect your quality of life, including your sexuality. In fact, loss of desire is a classic symptom of depression. Other emotional and physical symptoms include:

• Feeling sad, drained, restless, irritable, or anxious
• Losing interest in activities that you used to enjoy
• Feeling hopeless, helpless, guilty, or worthless
• Losing emotional expression—as if your emotional reactions are inappropriate or nonexistent
• Withdrawing socially from family, friends, pets, and other loved ones
• Experiencing problems with thinking clearly, such as having trouble concentrating, remembering, or making decisions
• Losing your appetite with weight loss, or overeating and gaining weight
• Having disrupted sleep, such as insomnia (sleeplessness), oversleeping, or waking up early
• Abusing drugs or alcohol
• Having thoughts of death or suicide

4. If my cancer and cancer treatment cause sexual changes, what remedies are available?

Because sexual changes can have many causes—especially for patients with cancer—your doctor should evaluate you physically, psychologically, and emotionally. For example, you may need to have lab work for thyroid functioning or hormone levels. Test results, combined with your descriptions of how you feel physically and emotionally, will help your doctor determine the cause of your sexual changes.

An important part of recovering is to try resuming sex when you feel ready. Do not rush yourself to "get better" as fast as you can, but try to avoid long periods without any sexual touching. Resolving sexual changes can be a slow process, but you need to start somewhere, even just with cuddling on the couch or "making out" as you may have done when you were a teenager.

Despite your cancer or cancer treatment, you should be able to feel sexually satisfied. It may require remedies from your doctor, time, patience, and an openness to try new experiences, but eventually you will enjoy sexual activity with your partner that feels right for you. Your personal comfort level with any medical or psychological treatments you try will play a big part in their success.

This section includes more information on:

• Remedies for Women
• Remedies for Men
• Suggestions for Patients With Ostomies
• Alternatives to Sexual Intercourse
• Self-Pleasure
• Conversation Starters With Your Doctor

Remedies for Women

Remedies for sexual changes in women range from over-the-counter options to those that require a doctor's prescription. If you feel embarrassed or uncomfortable about asking for items at a drugstore, you may be able to purchase some of them over the Internet with delivery to your home.

If you have surgery that changes the way your body looks, ask your doctor whether counseling or cosmetic or reconstructive surgery are options, perhaps even later, after you have healed from your cancer treatment.

If you have pelvic radiation, then your doctor may prescribe vaginal dilators to help keep the vagina from scarring or shrinking during cancer treatment. Dilators are cylinder-shaped and may be made out of hard plastic or softer silicone. They come in sizes from small ones similar to a finger or tampon to large ones often larger than the average erect penis. Women who are anxious or have pain should begin with a small dilator and work up to trying larger ones. The whole process should be as painless as possible. Dilators should be well lubricated, and dilation should always be gentle. Never force the dilator into your vagina. If you have trouble inserting the dilator, learning to control the muscles around the vaginal entrance may be helpful. Many self-help books or pamphlets for women describe Kegel exercises, a technique of learning to identify the muscles to tense and relax them at will. After pelvic radiation, the scarring process can go on for years, so using dilators or having intercourse may be a lifelong commitment. (Many doctors recommend that patients either have sexual intercourse or use dilators three times a week, but more research is needed to show how often is really necessary.)

To help with vaginal dryness, use over-the-counter, water-based or silicone-based lubricants. Look for unscented versions that are thin and watery, like the vagina's normal moisture. Avoid oil-based lotions like petroleum jelly or baby oil because these products may increase your risk of vaginal infections. Keep the lubricant by your side during sex since you may need to reapply it. Make sure both you and your partner spread some over your genital areas. Women who have chronic vaginal dryness may also want to use an over-the-counter vaginal moisturizer. These gels come in a tampon-type applicator for use three times a week before bedtime, and may take up to two months to reach their full effect. You and your partner can use the lubricant as you caress each other, helping to apply it to each other.

Most women who have had cancer, especially those age 50 or above, are told to avoid taking estrogen because it may increase the risk of breast cancer. However, if lubricants and moisturizers are not enough to make sex comfortable, you may want to consider a low-dose vaginal estrogen. Two forms of vaginal estrogen are helpful in restoring vaginal stretch and lubrication, with only minor amounts escaping into the bloodstream. The Estring, like the ring of a diaphragm without the rubber cup, stays in the vagina for three months at a time and slowly releases a form of estrogen. Some women prefer Vagifem, a suppository that melts inside the vagina. Although many doctors will prescribe these types of estrogen, some believe that there is no such thing as safe estrogen, especially for breast cancer survivors.

Nonhormonal vaginal creams or clitoral suction devices, which often are advertised on TV and the Internet, claim to enhance sex. However, it's a good idea to discuss these types of remedies and their effectiveness with your doctor or nurse before making any purchases. Many of the lotions that are supposed to increase excitement claim that research shows they work. Often the "research" is not published in a scientific journal and is only based on small groups of women.

When you are ready to have sexual intercourse, show your partner how to touch you in ways that are arousing and make you feel good. Find positions that give you control over movement and minimize deep penetration, such as by being on top or with you both lying on your sides.

Remedies for Men

Remedies for sexual changes in men range from over-the-counter options to those requiring a doctor's prescription. If you feel embarrassed or uncomfortable about asking for items at a drugstore, you may be able to purchase some of them over the Internet with delivery to your home.

Recovery of erections after cancer surgery in the pelvic area is typically gradual, taking one to two years. During this time, some doctors believe that using medical therapies that promote erections, whether by pill or injection into the penis, may ultimately help healing be more complete. Alprostadil is a medicine injected into the side of the penis to create an erection. Typically the dose is determined by some trial and error, beginning with an injection in a doctor's office. When getting ready for sexual intercourse, you must give yourself the injection about 10 minutes before you want to have an erection. Men often use pen injectors to make the process easier. Since some men have aching in the penis after injection, a urologist may prescribe a mixture of medicines for injection using a lower dose or including a local anesthetic to numb the tissue inside the penis. With any injection, side effects may include bruising at the injection site or, over time, developing some scar tissue in the penis. Alprostadil also can be given as a suppository that is put into the urinary opening of the penis, but this method is much less effective.

Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are pills taken by mouth before sexual activity. These pills belong to a class of medicines called phosphodiesterase-5 inhibitors. They do not produce an erection by themselves but make it easier to get one during sexual stimulation. They tend to work best for men who can get a lot of penile swelling, but not a completely firm erection. However, some urologists prescribe these pills to be taken daily or at least several times a week to encourage recovery of erections. Many men cannot use these pills successfully to have intercourse after pelvic cancer surgery or radiation therapy since their erection problems are more severe. Men with heart disease need to discuss with their doctor whether it is safe to use these medicines. They can cause low blood pressure in men who need nitroglycerin for chest pain.

A vacuum erection device (or vacuum constriction device) is a plastic tube that fits over the penis and by suction, helps the penis become erect. To keep blood trapped in the penis, the man slips a band from the base of the cylinder onto his penis before removing the pump. The erection tends to be cool to the touch and the skin somewhat blue in color, since the blood comes from the veins rather than the arteries. More expensive versions require a prescription and come with access to a "help line" to troubleshoot how best to use the pump.

If you have surgery that will change how your body looks, ask your doctor if implants or reconstructive surgery are an option. Men who have a testicle removed can have a silicone implant put into the scrotal sac. One treatment for erection problems is the penile implant. Bendable rods or a pump system is surgically implanted into the penis to help with erections. From the outside, the pump is less obvious. When inflated, the pump can create a very firm, thick erection but often with a minor loss of length. Men often try other treatments before deciding on a penile implant.

A few men who have intensive chemotherapy or a bone marrow or stem cell transplant end up with damage to the testicles that results in abnormally low levels of the hormone testosterone in the bloodstream. Survivors of testicular cancer may have low hormone levels because the remaining testicle is somewhat abnormal. Replacement testosterone can be given as a skin patch or a skin gel. A referral to an endocrinologist is necessary, and you cannot use this treatment if your testosterone levels are already normal or if you have had prostate cancer.

A variety of special latex bands or rings are available to help you maintain an erection with the alprostadil injection or the vacuum erection device. Some men try to use a band by itself. Never use a band around the penis unless it is made with a special safety handle or snap fastener so that it can be easily removed. Never leave a band on for more than 30 minutes.

When you are ready to have sexual intercourse, show your partner how to touch you in ways that are arousing and make you feel good.

Men usually find as they get older that their erection may lose firmness during lovemaking, but with stimulation, can become full again. This is normal, although cancer treatment may make the problem worse. If you are worried about being ready for vaginal penetration, you or your partner can caress your penis to restore a firm erection when you need it.

Some vitamins and herbs, which often are advertised on TV and the Internet, claim to fix erection problems. However, it's a good idea to discuss these types of remedies and their effectiveness with your doctor or nurse before making any purchases. In fact, most of these products are useless and may interact with prescription medicines, causing the medicines to be less effective.

Suggestions for Patients With Ostomies

Men or women who have had an ostomy (the surgical creation of an artificial opening for elimination of body waste) may feel self-conscious and uncomfortable with sexual activity. United Ostomy Associates of America Inc. provides guidebooks and fact sheets about having sex with an ostomy.

Here are suggestions that many survivors find helpful:

• Be careful about the amount and types of food you eat (or about drinking fluids if you have a urinary ostomy). It may be difficult for sexual activity to be spontaneous. Instead, make a "date" with your partner at a time when you don't expect to have a lot of ostomy activity. If you are able to irrigate your colostomy, it may be easier to schedule sex during a quiet period and to wear just a cap over the ostomy itself.
• Change your ostomy pouch, even if it is less than one-third full.
• Make sure your ostomy bag is empty and flat. You can tape it down or roll it up to keep it out of the way.
• If you feel discomfort, change positions. If you feel uncomfortable or self-conscious and want to cover up the pouch, consider wearing a camisole, shirt, or other sexy top or bottom. Women may choose to wear crotchless panties.
• Manufacturers make products that may help ease your concerns. Consider purchasing deodorant for the ostomy pouch, a pouch with a filter for odor or a colorful cover, or a pouch made for exercise that hangs sideways. On the internet you can find pouch covers or lingerie designed to help women feel feminine and attractive despite having an ostomy.

Alternatives to Sexual Intercourse

If traditional sexual intercourse feels painful or makes you uncomfortable, think about other ways to seek sexual pleasure and intimacy with your partner. By practicing sexual activities that are different from what you would normally do, you may be able to have an enjoyable experience without feeling pain or becoming tired. Sharing pleasure or reaching an orgasm from mutual caressing can relieve sexual frustration and help you feel like a lover again.

People sometimes feel uncomfortable with certain types of sexual activity; for example, having orgasms through hand caressing, oral sex, anal sex, or using a vibrator. Feelings of unease may come from cultural views, religious beliefs, or messages from your childhood.

Only you can decide what kinds of sexual touch are comfortable. Be sure to talk to your doctor, nurse, social worker, therapist, or chaplain if you feel unsure or conflicted. They are available to listen to your concerns and give you advice. From a medical or psychological point of view, most types of sexual activity are healthy and normal, as long as you do not hurt yourself or impose sex on someone who does not agree. However, some cultures and religions do set limits on what kinds of sex are "OK."

Here are suggestions that many survivors find helpful:

• Give yourself a lot of time to get "in the mood." Eat a romantic dinner by candlelight. Listen to sensuous music. Hold hands, caress each other, and allow time for foreplay so that you are as sexually aroused as possible.
• Enhance your sexual experience through techniques to help you relax, playing out fantasies, taking a shower or bath together, lighting scented candles, listening to arousing music, and talking about the fun you have had together in the past.
• When you are both fully aroused, try experimenting with each other in new ways. Give each other foot rubs and sensuous back rubs with scented oils. Use gentle touches, kissing, and fondling to stimulate your partner.
• Use your hands to stimulate yourself or your partner, or use your mouth to stimulate your partner.

Self-Pleasure

Whether single or in a relationship, caressing your own body and even bringing yourself to orgasm is one way to make yourself feel more comfortable with sex after cancer treatment. After a diagnosis of cancer, some patients feel as if their bodies have betrayed them. Pleasuring yourself can help you feel good about your body again, feel like a sexual person, and help you have good physical feelings instead of painful ones. Women who bring themselves to orgasm have an easier time having orgasms with a partner, so it also may be a way to enhance sex with a partner.

Masturbating is also a good way to find out whether your sexual sensitivity or sensations have changed after cancer treatment. For example, men can find out if they are able to have erections, and both men and women can find out if they are able to have orgasms. You can explore your sexual responsiveness and level of arousal without any pressure or expectation from someone else. If you are in a relationship, once you understand more of your own sexual readiness, invite your partner to participate.

Conversation Starters With Your Doctor

Many people avoid talking to healthcare professionals about sexual changes because they feel embarrassed, ashamed, or afraid. Some people feel guilty about "bothering" the doctor, or they worry about "being a good patient." However, all patients have a right to information that affects their quality of life, which includes sexuality. It's normal to feel uncomfortable or awkward, but your doctors, nurses, and social workers are a professional team and have training and experience talking about these issues. If you do encounter a doctor or other healthcare provider who dismisses your concerns and questions about sex, seek a second opinion.

Be as open as possible when providing information to help your doctor find the best solutions and remedies for you.

Listed below are suggestions for beginning a conversation:

• How do you expect that my cancer treatment will affect my sexuality?
• Is it safe for me to have sex? (It is usually safe to have sex during cancer treatment unless your doctor tells you not to. Sex can be a problem if you have bleeding in the genital area from cancer, if you have recently had surgery or radiation implants, or if your immune system is very weakened. Talk with your doctor to see whether it is safe for you to participate in sexual activities.)
• Should I be using contraception to avoid pregnancy during my cancer treatment?
• Are my sexual changes short term, or do you think they are permanent?
• I don't think about sex or feel interested in sexual activity. Why do you think I feel this way?
• I think about sex and would like to participate in sexual activity, but I don't feel that my body is responding the way it did before my cancer or cancer treatment. Why do you think this is happening?
• I feel tired all the time, and it's negatively affecting my sex life. Is there anything I can do to feel better?
• I've noticed changes with my erections since I started this new medicine. What do you think is causing this?
• What are some possible remedies that may help me enjoy sex again?
• How can I find more information about remedies for sexual changes? How do I go about trying one of them?
• My friend told me about a (treatment, herb, supplement, food, etc.) that may help my sexuality. Is it OK to try this?
• I feel embarrassed about starting sexual activity because my body is different. Is it an option for me to have cosmetic or reconstructive surgery? Can you refer me to a counselor?
• I feel nervous (or my partner feels nervous) about starting sexual activity. Could you please reassure me that it's OK? Are you sure that sexual activity won't negatively affect my cancer or cancer treatment?
• My partner told me that (he or she) is worried about catching my cancer or getting sick from my treatment. Could you please reassure us about this?

5. How can my cancer and cancer treatment affect my relationships?

At a time when your need for closeness and intimacy is greater than ever, you may feel as if you and your partner are being split apart. It's important to remember that even though your life has changed, you have not lost the ability to love and be loved.

Cancer and its treatment may change your outward appearance, but they cannot change the essence of who you are as a person. If you have experienced love and affection before cancer treatment, there is every reason to think that your partner, family members, and friends will continue to love and value you now. In fact, most partners are supportive, and often patients are more concerned about loss of attractiveness than their partners are. When partners do hesitate to initiate sexual activity, it is usually out of fear of being pushy or accidentally causing pain. Thus, communication is essential.

If you are in a relationship with another person, then you may have discovered that being close to someone involves many different things. Your sexuality depends on your sexual organs, brain, and hormones. It involves communication, intimacy, and physical elements. Sitting with your partner and sharing your feelings, holding hands, hugging, cuddling, and kissing can provide the intimacy and social support you need.

This section contains more information to help you keep your relationship healthy and positive:

• Advice for Single Patients
• Advice for Patients in a Relationship
• Advice for Partners

Advice for Single Patients

If you are single, you may have concerns about dating during or after cancer treatment. Questions about what to tell someone, or when to tell someone, become a major issue. Your doctor, nurse, social worker, therapist, or chaplain is available to listen to your concerns and give you advice.

Single patients who begin dating after cancer treatment often say that they develop a powerful "radar" around new people. They are able to tell the difference between people who are interested in only a temporary, casual affair and those who enjoy their company because of who they are.

When you have established trust and friendship, go ahead and tell your new partner about your cancer and cancer treatment. This needs to happen early enough so that your relationship can be based upon honesty, confidence, and acceptance.

It is normal to fear being rejected. If a partner rejects you because of your cancer, however, she or he may not be the person you want in your life. Every person has flaws, and a healthy, quality relationship should be formed with someone who accepts yours—just as you would accept your partner's.

Many people find that their love and commitment to a partner deepen when facing the challenge of cancer. Opportunities may arise for you to give and receive love in ways that will enrich all your new relationships.

Advice for Patients in a Relationship

As patients cope with their cancer, cancer treatment, and their own sexuality, they also need to consider how best to share feelings with their partners. This can be incredibly difficult for some people, especially those who didn't communicate well about their relationships before cancer.

If there is too much pressure on you or your partner, it may make either or both of you reluctant to initiate or participate in sexual activities. You may feel uncomfortable or nervous about your "first time" during or after cancer treatment. Your partner may be afraid of hurting you or afraid that the sexual part of your relationship is over. This may lead to mixed signals, arguments, or avoiding one another physically.

The good news is that with solid communication and realistic expectations, patients and their partners can develop a relationship that is fulfilling, sometimes even more than what was experienced before cancer. Some men or women even find sex comforting during cancer treatment because they need to feel close to a partner.

The following advice for sharing your needs and worries with your partner may help you become closer:

• Sometimes it's easier to face challenges when you know ahead of time what they are. Learn how the cancer and its treatment may affect your sexual relationship. Talk with your partner, and plan together how you will handle problems. This may help you both feel more in control at a time when many things seem to be out of your control.
• When discussing serious topics, pick a time and place that foster relaxation and privacy. Focus on one or two specific things you would like to change in your relationship, and ask for the changes in a positive way.
• Encourage your partner to share his or her feelings. He or she may need some of your encouragement to know that it's OK to talk about concerns. Invite your partner to share in conversations with your doctor or nurse, or talk to your partner about what you have learned when you come home. This will help him or her feel involved, and you both will feel that you are working as a team.
• Often, when people don't have sexual intercourse, they quit all forms of affection. It is important to continue with physical affection even if other sexual activity has stopped. Maintain your loving feelings together by kissing, hugging, cuddling, and caressing one another. Physical touch is extremely therapeutic and may even boost the healing process. If you want your partner to touch you in a certain way, show or tell him or her. Touch your partner when you feel tired, even if you aren't ready to have sexual intercourse. This sets the stage for more physical intimacy later when you do have energy and feel better.
• Be patient with yourself and with each other. Give yourself time to heal, physically and emotionally. If you have a day when you feel bad, allow yourself to have some space, and see how you feel the next day.
• Consider counseling. You and your partner may have a history of difficult communication, or perhaps your partner also may be grieving about the changes in your body, which is normal. Your doctor can refer you to a social worker or psychologist to meet together for some "coaching."

Advice for Partners

If you are a partner of a patient, you need to realize the importance of expressing tenderness and affection frequently. The best cancer treatment that you can provide is "hug treatment." Love and affection will reduce the feelings of "aloneness" and fear that most cancer patients have while going through cancer treatment. Some research scientists believe that sharing physical touch and closeness boosts the immune system and may contribute to good health.

So that your partner understands your expectations, it is important for him or her to know that a hug may be "just a hug" and not a request for sex. Enjoy touch for its own sake, even though it may not be sexual or an invitation to engage in sexual activity.

Conversation starters:

• We haven’t been holding hands or cuddling lately. Let’s take a stroll or watch a movie and act like we used to when we were dating.
• I haven't held your hand during a movie in a long time. How about if we go (or rent) a movie, so that I can hold your hand?
• I know you feel alone, but so do I. Can we talk?
• I don't always know where to touch you to make you feel good, but if you show me, then I'll feel less nervous.
• How about a hug?
• I feel a little unsure about our physical relationship because I'm worried about hurting you. Would it be OK if we talked to the doctor together at your next appointment? I think that would help me feel more comfortable.
• I know you don't have much energy today. Is there anything I can do for you?
• This is a difficult time for both of us, but I love you just as much now as I ever have. What could we do together to help us feel better?
• You are just as sexy to me today as you ever have been.

6. How does cancer treatment affect fertility?

Patients' fertility can be affected both during cancer treatment—when an unplanned pregnancy could be a serious problem—and later, if the cancer treatment causes infertility. For patients who want to have children, this can be devastating.

First, it is important to know that you should prevent pregnancy during chemotherapy or radiation treatment and for at least six months after treatment. Although cancer treatment may lower a man's sperm count or cause a woman's menstrual period to stop, a pregnancy may still be possible. Talk to your doctor or nurse about the best method of birth control for you.

Chemotherapy drugs and radiation to the pelvis cause genetic changes in sperm and oocytes (eggs). Embryos with genetic damage often miscarry early in pregnancy. There is also a risk of having a baby with a birth defect, but so few babies have been conceived during a parent's cancer treatment that no statistics exist on the risk of birth defects.

If a woman is pregnant and her husband is having chemotherapy, using a condom will keep the medicines from reaching the fetus through intercourse. Also, during the first few days after having radioactive seed implants for prostate cancer, men may ejaculate a radioactive seed in their semen. The doctor can advise when it is safe to resume intercourse and whether to use a condom.

By six to 12 months after cancer treatment, the sperm that were exposed to chemotherapy or radiation have all been ejaculated. Eggs that are healthy enough to be ovulated are also more likely to be undamaged. In fact, both the eggs and the stem cells that produce sperm have some ability to repair genetic damage during the first several years after cancer treatment. However, genetic damage is common in human embryos even when neither parent has had cancer treatment. A third of very early pregnancies miscarry because the embryo had genetic damage, often without a woman's ever realizing she was pregnant.

If a woman already is pregnant at the time of cancer diagnosis, she may be able to continue the pregnancy and have a healthy baby even if she needs chemotherapy, particularly if the pregnancy is past the first three months, when most organs are formed. This situation occurs occasionally in young women with breast cancer.

The following pages provide information about fertility after cancer treatment:

• Causes of Infertility
• Preserving Fertility in Women
• Preserving Fertility in Men
• Recovery of Fertility After Cancer Treatment
• Questions to Ask Your Doctor

Causes of Infertility

Cancer treatment can interfere with fertility in many ways, as the medicines and treatments that work to kill cancer cells also affect other cells, organs, and hormones in the body. Since every patient is different, your doctor may not be able to predict whether your cancer treatment will make you infertile. The effects from cancer treatment may be temporary or permanent. If fertility does recover, it won't necessarily happen right away.

Fertility after cancer treatment will be affected by age at the time of cancer treatment, especially for women; type of treatment; kind and dose of chemotherapy drugs used; amount and target area of radiation; type and extent of surgery; whether one or multiple cancer treatments are used; and how long treatment lasts.

This section contains more on:

• Causes of Infertility in Women
• Causes of Infertility in Men

Causes of Infertility: Women

Some cancer treatments, such as a hysterectomy, prevent pregnancy in women at any age.

Another cause of infertility in women is premature ovarian failure, which is when menopause occurs before a woman is 40. Premature ovarian failure happens when both ovaries are surgically removed, and it may also occur if the ovaries are damaged from chemotherapy or pelvic radiation therapy. Higher doses are more destructive than lower doses. Chemotherapy with alkylating agents, such as cyclophosphamide, is the most toxic and can directly damage the ovaries. Total body irradiation, typically used before a stem cell or bone marrow transplant, causes very high rates of infertility. However, a few young women have been able to have babies afterward.

Younger women and those who had lower doses of chemotherapy or radiation therapy are more likely to regain menstrual periods, though the periods may not occur regularly. Women over 35 are less likely to recover their fertility. This may be because a woman in her 30s has fewer eggs in reserve, so a larger percentage of eggs are destroyed. However, even young women are at risk for early infertility and menopause because the eggs in the ovaries may be damaged or killed by cancer treatment.

Causes of Infertility: Men

Cancer treatment can damage fertility, temporarily or permanently, in men, too. Men begin producing sperm cells at puberty and continue to be fertile for the rest of their lives. To produce permanent infertility, a cancer treatment must eliminate all of the stem cells in the testicles that produce new, mature sperm cells. This can happen if both testicles are removed, if the testicles get a high dose of radiation, or if very high doses of alkylating chemotherapy drugs are given. Men with testicular cancer, who are typically young, are likely to be infertile before they are diagnosed with cancer, but about half recover good fertility despite having a testicle removed and undergoing chemotherapy.

Preserving Fertility in Women

There are several ways to try to preserve fertility in women, but most remain experimental, with unknown success rates. Some options are not appropriate for certain patients, depending on the type of cancer.

• The most widely available and successful way of preserving fertility before cancer treatment is embryo freezing. This includes removing the eggs, fertilizing them in vitro (in a test tube) with the sperm of your partner or a donor, and then freezing and storing the embryos. It takes about two weeks from the start of a woman's menstrual cycle to get eggs to use for in vitro fertilization; waiting may be a problem with a fast-growing cancer like acute leukemia. Also, the hormones given so that more than one of a woman's eggs will ripen may stimulate breast cancer cells to grow, so researchers are trying to use different hormone combinations to make hormonal stimulation safer for these young women. Another option would be to simply harvest the one egg that ripens in a natural menstrual cycle, but the chance that the egg will fertilize, survive freezing, and later produce a live birth when transferred to the woman's uterus is less than 10 percent. Insurance rarely covers these procedures, and they often cost $5,000 to $8,000.
• A woman who has lost her uterus but still has at least one ovary could go through in vitro fertilization (IVF) to use her eggs and sperm from a partner or donor to create embryos. Another woman could then carry the pregnancy (surrogate or gestational carrier).
• Some women opt to have the eggs frozen unfertilized, particularly if they are not in a committed relationship. Later, the eggs can be thawed and in vitro fertilization attempted. Egg-freezing remains experimental and has resulted in fewer than 500 live births around the world.
• Some women have parts of their ovaries removed surgically and frozen before cancer treatment. Although some centers are banking ovarian tissue before cancer treatment, this technique is still experimental and has resulted in only a few pregnancies around the world.
• For women receiving chemotherapy, one option may be to take a hormone that puts the ovaries into temporary menopause during the cancer treatment. However, many infertility specialists doubt that the hormones truly prevent the chemotherapy from damaging the ovaries. The hormone shots are expensive, and it is possible that they could have some impact on the success of chemotherapy.
• For women receiving radiation treatment, it may be possible to move the ovaries out of the radiation area surgically. Sometimes they can be relocated at the sides of the pelvis, out of the radiation target field. There is a 50 percent chance that women will resume menstruating after this procedure.
• Adoption is another option.

Preserving Fertility in Men

Fertility preservation is much easier, cheaper, and more effective for most men. It simply involves collecting a sample of semen and freezing it. Sperm must be banked before any chemotherapy or pelvic radiation therapy begins in order to avoid storing damaged sperm. The sperm can be thawed later and used for intrauterine insemination or in vitro fertilization.

Many young men diagnosed with cancer have poor sperm quality because of the illness, recent anesthesia, or stress. Even if a man has only a few live sperm in his semen, however, they can be used with in vitro fertilization to give a good chance of a pregnancy. In this situation, when the sample is thawed, the healthiest sperm are captured and injected into the woman's harvested eggs using a robotic microscope in the laboratory.

Insurance generally does not cover the cost of the sperm banking, and storing one ejaculate for five years averages around $500. Some sperm banks have special payment plans for cancer patients. For men who no longer ejaculate semen but would like to bank sperm, a urologist may be able to collect sperm with outpatient surgery to retrieve them from the storage areas above the testicles or even from tissue inside the testicles.

Recovery of Fertility After Cancer Treatment

For some people, fertility does return after cancer treatment. However, it may take a long time.

For women, the return of menstruation may or may not signal fertility, but getting blood tests for hormones and other tests performed by an infertility specialist can give a better answer.

Women who have had chemotherapy or have had radiation treatment to the pelvic or abdominal area should consult an obstetrician before trying to get pregnant, to make sure that their heart, lungs, and uterus are healthy enough to avoid pregnancy complications. For example, when a girl or young woman has radiation that includes the uterus, it is important to know whether the uterus is normal in size and can expand enough during pregnancy.

Men often have low sperm counts or motility (the movement of the sperm) at the time their cancer is diagnosed, but this may improve after cancer treatment. Sperm quality may rise for several years following cancer treatment, depending on the drugs used, the doses, and each person's individual recovery. Even though men may produce sperm, the number and their ability to move may not be enough to conceive without some medical help. A semen analysis, in which a man's semen is examined under a microscope, can indicate whether a pregnancy is likely through intercourse or what type of infertility treatment will be needed. Because each person's situation is different, it is important to talk to your doctor before trying to start a pregnancy.

Questions to Ask Your Doctor

If you wish to have children after your cancer treatment, discuss the issue with your doctor as soon as possible. Understandably, thinking about the future and having children can be incredibly difficult while coping with a cancer diagnosis. But most options to preserve fertility need to take place before you begin chemotherapy or radiation therapy. You also may want to talk to a counselor familiar with cancer and fertility to prepare yourself for challenges and decisions.

Here are some questions you may want to ask:

• Is there anything that can be done before starting my cancer treatment to increase the likelihood that I will be able to have children after cancer treatment?
• I am interested in freezing eggs or embryos. Is this an option for me? Could you please give me more information?
• I am interested in sperm banking. Is this an option for me? Could you please give me more information?
• I stopped having my period, but could I still get pregnant? Should I be using birth control?
• For how long will we need to prevent pregnancy during cancer treatment? Are condoms the best method for us?
• My partner is pregnant. Is there any special reason to avoid sex during my cancer treatment?
• Will my cancer treatment cause me to be infertile? Do you expect this to be temporary or permanent?
• Now that my cancer treatment has ended, I would like to have children. Is it OK for us to try to become pregnant?
• We have been trying to get pregnant without success. Should we talk to an infertility specialist?

7. What additional resources are available to help answer my questions and concerns?

Often patients are not sure what to expect from their doctor or nurse when talking about sexual health or fertility during cancer treatment. Even healthcare providers in oncology sometimes do not know much about sex or fertility after cancer. If your doctor or nurse seems uncomfortable or dismisses your concerns, ask to see a specialist. This could be a mental health professional trained to treat sexual problems or a urologist or gynecologist with such training.

For more information about sexuality and cancer, you may call the National Cancer Institute's Cancer Information Service toll free at (800) 422-6237. A trained cancer information specialist will answer your questions.

Classes to improve your appearance during cancer treatment are available to help you look good and feel better. Contact the American Cancer Society toll-free at (866)-228-4327 to find out about classes near you.

More information on sexuality and cancer is available at these websites recommended by the U.S. News & World Report Library:

National Cancer Institute: Sexuality and Reproductive Issues
The site addresses the effect cancer and cancer treatment can have on all aspects of an individual's sexuality, including sexual desire and physical and psychological sexual dysfunction.

American Cancer Society: Sexuality
The website covers side effects of different treatments that affect an individual's sex life and ways to relieve some common problems. It also links to Web pages that address this issue and men and women separately.

Lance Armstrong Foundation: Physical Effects of Cancer
Provides links to different physical effects, including sexual dysfunction in men and women and fertility.

Cancerbackup: Sexuality and Cancer
From the United Kingdom, an information and referral service for those who have been diagnosed with cancer. The following link provides information on aspects of sexuality and cancer.

Fertile Hope
Nonprofit organization dedicated to helping cancer patients who are faced with infertility. Provides links to resources, including financial assistance for treatment.

United Ostomy Associates of America
Organization offers guidebooks and fact sheets about having sex for those with an ostomy.

Last reviewed on 06/01/2009

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