Upon hearing a cancer diagnosis a person’s world changes immediately and forever. The person becomes a patient. The patient has to make myriad decisions about treatment plans, and the possibility of surgery, radiation, and chemotherapy. These treatments, while life-saving, are also life-altering. The side effects can modify body image, reduce or end fertility, change sexual identity and sexual function. Approximately 60 percent of cancer survivors have long-term sexual dysfunction. Oncology teams (who may focus more on the life-saving aspects of care) aren’t always taking the time to discuss fertility or sexual health matters as much as they should. But the good news is that our practice can help save a women’s eggs, or a man’s sperm for future use; mitigate and reverse most hormonal changes, and starting in September, we will also offer treatment for men with urological or sexual complaints in our practice. Our newest colleague, Rachel S. Rubin, MD, is specially trained to treat hormonal and sexual dysfunction in both men and women.

Talking about sexual health outside of the bedroom, in the office of a compassionate physician is key to holistic wellness. The emotions of being a cancer survivor can be overwhelming in and of themselves, but to add infertility or sexual dysfunction to the list of health issues can be daunting. We’re here to help you get back on track.

For Men
Following prostate cancer treatment, for example, the ability to have and maintain an erection becomes difficult and for some men, impossible, without help from a medical practice such as ours. Many men may not feel comfortable talking about these intimate issues, but there is help. Our compassionate and caring staff can help men who experiene treatable symptoms. It’s not just about physical symptoms, cancer affects sexual identity and when men are unable to perform as they could prior to cancer treatment, it can have a serious and detrimental effect on one’s psyche. Getting the courage to seek help is the first step to getting back to the “new normal.”

For Women
Breast cancer, when surgery is required, may alter a woman’s body and can hinder sexual identity and function. Breasts, once part of the sexual experience for both partners, are no longer the same. Even when reconstructed, the breasts may feel different, lack the pleasurable sensitivity they once had, or might even be painful and distracting. Sensation might even be completely gone. Partners may also feel hindered by the feeling of the new breasts. This can be uncomfortable for both partners. With any cancer treatment (i.e. chemotherapy, surgical removal of the ovaries or even hysterectomy) a patient may find herself in early/premature menopause with hot flashes, night sweats, disturbed sleep and weight gain. This is also accompanied by vaginal dryness, and pain with genital touching or intercourse. There are options to help enhance the sexual experience that we have available at the office, and that are not available anywhere else.

A wonderful Newsweek article about these issues does a deeper dive from both the patient and physician perspective that we welcome you to read for additional information.

If you are just starting cancer treatment, going through it, or are in the post-treatment phase and are facing future or current fertility concerns, hormonal deficiencies, or sexual dysfunction, we can help. Please call our office at (202) 293-1000 to make an appointment with one of our caring and compassionate members of Dr. James A Simon’s team.

The phases of a cancer diagnosis might be compared with those of dealing with the death of a loved one: denial, bargaining, anger, and eventually acceptance. Fortunately for many, there IS life after cancer. A sexual life too, that part of one’s life may have been put on the back-burner during cancer treatment. The statistics on survivorship are astounding, creating a “before” and “after” picture for many.  It is important to understand both of them. Progression-free survival rates indicate no new tumors have formed. Whereas disease-free survival rates refer to remission, cancer free. The death rate from breast cancer has fallen 34% since 1991. Following the grueling chemotherapy, radiation, and/or surgery, it might not immediately occur to patients and their partners to re-connect through sexual activity.  I would encourage you or anyone you know in the survivorship phase, however, to make it a priority. Absent sexual activity, all genital tissues (skin, mucus membranes, and muscles), suffer from disuse atrophy. The good news is this: with the intention to connect or reconnect with your partner, and the use of various products available (if necessary), solutions to sexual activity may result in your “new normal.” Your body image, to the degree it suffered during cancer treatment may need a boost and a re-boot. A renewed sexual life can often help.

Sexual Healing
Whether due to cancer, certain medications that interfere with sexual response such as antidepressants, or menopause, sexual response changes during a lifetime. Menopause can be a premature consequence of cancer treatment. Both chemotherapy and pelvic radiation can result in menopause regardless of a woman’s age. Lubricants and vaginal moisturizers are readily available, but I caution you to look at the ingredients, as some may be irritants to those delicate tissues. Ingredients such as those found in spermicides, benzyl alcohol, and materials such as latex can cause discomfort for some.

With the sudden onset of menopause from surgery, radiation or chemotherapy, many women find that they experience intense vaginal dryness, and pain with sex (usually at the time of penetration). To mitigate this issue, vaginal moisturizers which are used on a routine basis whether one is having sex or not, can help to bring water into the vagina. Think about vaginal moisturizers like the moisturizer you use on your skin…you don’t just apply it when you are getting your picture taken. You use it on a regular basis. And lubricants (they aren’t the same as moisturizers) which come in oil, silicone, water-based, and mixtures of each of these can solve the dryness and lack of natural lubrication missing after some cancer treatments. Lubricants are used at the time one is having sex. They help the vagina operate as it once did naturally, and can make sexual activity more pleasurable by easing friction and lessening pain.

Enhance Sexual Pleasure
The marketplace has been flooded with sex-positive devices to enhance the sexual experience for both men and women. Toys, vibrators, dildos, and much more have piqued the curiosity of people who want to try something new. A medically accurate fantastic and friendly site middlesexmd.com/ can help educate you and your partner about new products, techniques and “tools” to keep your sensual side smoldering. Our office stocks a variety of such sexual aids and can help with proper selection, especially when sexual function is hampered. Keeping an open and honest discussion with your partner about your needs and interests, as they change in the “new normal” can alleviate anxiety and further build on a relationship that has endured and surpassed, the diagnosis of cancer. Get personal. Have fun. Explore.
To learn more please call the office at (202)293-1000 or email the practice at info@dev.loebigink.com.

As a reproductive specialist, board certified in reproductive endocrinology and infertility, this blog post has special significance for me. While you may not need the information provided here, you may know someone who does. Please “Pay It Forward”, “Pass It On”.

Women experiencing a cancer diagnosis is a life-altering experience; however, so is infertility. Breast cancer treatment is one cancer type that can have permanent effects on fertility because ovarian removal, injury (i.e., chemotherapy or radiation) and/or suppression is often part of the treatment strategy. Additionally, each year approximately 71,500 women in the United States are diagnosed with a gynecologic cancer, according to the Center for Disease Control (CDC). These cancers include cervical, gestational trophoblastic disease (GTD), primary peritoneal, ovarian, uterine/endometrial, vaginal and vulvar cancers. Because of the nature of cancer as it relates to fertility, I would like to provide more information about fertility options at the point of a cancer diagnosis so that patients can benefit from fertility preservation strategies before treatment begins because three out of four patients are interested in having a family one day.

How Treatment Affects Fertility
Treatment, including chemotherapy, radiation, and surgery can cause damage to organs involved in reproduction, such as the ovaries, fallopian tubes, uterus, and cervix. Ovarian suppression, used to slow or stop estrogen-receptor positive cancers, can be reversed following treatment. However, other treatments such as chemotherapy, radiation and some surgeries can cause women to experience early and permanent menopause.

Weighing the Options Before Treatment
There are several methods to preserve future fertility if patients are able to compete one of these prior to chemotherapy or radiation.

Embryo freezing is a primary method of fertility preservation for women, according to Cancer.Net a patient site from the American Society of Clinical Oncology (ASCO). After taking fertility drugs for two weeks a woman’s eggs are collected and fertilized by sperm though in vitro fertilization. The embryos are frozen until the woman is ready to become pregnant. Although fertility drugs increase estrogen during fertility treatment, aromatase inhibitors can keep the levels low for women with estrogen-sensitive cancers thereafter.

Oocyte (unfertilized egg) freezing is similar to embryo freezing, except that the eggs are frozen without being fertilized by sperm. This is a particularly important option for women who are not currently “partnered” or do not want to choose a sperm donor.
Fertility-preserving surgery is an option for cervical or ovarian cancer. Surgery can treat the cancer and help preserve a woman’s fertility. Surgery may also be used to “move the ovaries” out of harm’s way, should radiation be needed in an anatomically adjacent area. The ovaries can be “put back” in their normal location at a later time if needed for future fertility.

For girls who have not yet reached puberty, an experimental option is to try ovarian tissue cryopreservation, a process where an ovary or ovaries are actually removed from the body and frozen in pieces until needed following cancer treatment. At that time, the ovary or a part thereof can be re-implanted in the arm, abdomen or other easily accessible location for future egg retrieval. While this sounds like science fiction, some babies have already been born using this process.
During treatment, the oncology team may try ovarian shielding to ensure that the ovaries are not harmed during radiation therapy. In an effort to protect the ovary by reducing its exposure to chemotherapy an attempt can be made to “turn off/turn down” the ovary’s blood supply using other medications. This approach has had mixed results, but has few downsides. One cancer treatment has commenced and premature menopause results, patients may consider surrogacy or adoption in addition to the options listed above.

Guidelines Broaden the Discussion
In 2013 the American Society of Clinical Oncology (ASCO) updated its clinical practice guideline on fertility preservation. One of the pivotal updates to the guideline was the change from the word “oncologist” to “healthcare provider”, to broaden the responsibility to more members of the medical team who can help lead discussions with patients to help them better understand their fertility preservation options. While I applaud this approach, I prefer that these men and women be called “healthcare professionals”.

The Future of Oncofertility
Because patients with cancer are enjoying greater survival rates in large numbers, there is a need to address the whole person, not just the removal of the cancer, because survivorship, for many, also includes raising a family. Teresa K. Woodruff, PhD, of Northwestern University Feinberg School of Medicine in Chicago and Thomas J. Watkins, MD professor of obstetrics and gynecology at Northwestern, coined the term “oncofertility” to describe oncologists and reproductive specialists working together preserve patients’ fertility while treating their disease.

Medical professionals can ensure that patients and their families have all the decision-making tools available about fertility preservation. Members of the ob/gyn and also oncology teams should address the future fertility options with patients at the point of cancer diagnosis and prior to initiating treatment.

Top Tips for Discussing Fertility with Patients
1. Discuss fertility preservation with all patients prior to and of reproductive age if infertility is a potential risk of therapy.
2. Refer patients who express an interest in fertility preservation (and patients who are ambivalent) to reproductive specialists.
3. Address fertility preservation as early as possible, before treatment starts.
4. Document fertility preservation discussions in the medical record.
5. Answer basic questions about whether fertility preservation may have an impact on successful cancer treatment.
6. Refer patients to psychosocial providers if they experience distress about potential infertility.
7. Encourage patients to participate in registries and clinical studies.
Reference: Key Recommendations: Fertility Preservation for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Top 10 Questions to Ask your Doctor about Fertility and Cancer Care
1. How does cancer affect my fertility?
2. Which cancer treatments can affect my fertility?
3. Which fertility preservation methods should I consider before cancer treatment begins?
4. How does the process of egg preservation work?
5. How long does this procedure take?
6. How soon after cancer treatment can I plan for a pregnancy?
7. My cancer type requires ovarian suppression. When can I become pregnant after ovarian suppression is reversed?
8. What are the side effects of these procedures?
9. I’m already pregnant and diagnosed with cancer. Will I be able to have children in the future?
10. Will my insurance cover these procedures?

To learn more please call the office at (202)293-1000 or email the practice at info@dev.loebigink.com.

USPTF Rebuttal: Why Women Still Need Pelvic Exams

Recently, the U.S. Preventive Services Task Force (USPSTF) concluded that there is limited evidence to support doing routine pelvic exams for women who are healthy and not pregnant. They say: “There is limited evidence regarding the diagnostic accuracy and harms of the routine screening pelvic examination to guide practice.”

An Absence of Evidence
Does this lack of evidence mean there is no benefit to routine pelvic exams? Absolutely not. The absence of evidence does not indicate the evidence of absence. In other words, if there is absence of or limited evidence for the benefits of routine pelvic exams that does NOT mean there is adequate evidence to recommend against them. In fact, these most recent draft guidelines don’t make much sense to me at all. Here are just a few reasons why:

  • Possibility of bias- The authors are all women from the West Coast of the US, and there isn’t a single gynecologist among them, so there is a significant absence of diversity (by gender, by geography, and by specialty) which could be a source of bias. In fact, most of the authors are not physicians, nor have they ever performed a routine pelvic exam.
  • “Insufficient” evidence- The authors note that “the current evidence is ‘insufficient’ to determine the balance of benefits and harms of the pelvic exam,” however, this didn’t deter them in drafting recommendations in favor of stopping routine pelvic exams.
  • The authors judged the effectiveness of the pelvic examination in reducing all-cause mortality, cancer- and disease-specific morbidity and mortality, and improving quality of life. These are all very “blunt instruments” (aka insensitive assessments) which are particularly obtuse in younger women where death and cancer related morbidity are rarely relevant, and almost never proximate in time.
  • The authors found only eight studies looking at the diagnostic accuracy of pelvic exams, and for only four medical conditions: ovarian cancer, bacterial vaginosis, trichomoniasis, and genital herpes. So in the studies evaluated, the only endpoint that would lead to mortality, cancer- and disease-specific morbidity and mortality, is ovarian cancer, and everyone knows that the pelvic exam is notoriously bad for detecting ovarian cancer. Furthermore, no one dies from bacterial vaginosis, genital herpes and vaginal trichomoniasis, all of which are treatable (and don’t cause death).
  • Finally, the authors did not recommend changes to current cervical cancer screening guidelines (aka pap smears with or without human papilloma virus (HPV) testing). Since these guidelines DO recommend routine cervical cancer screening, which does require–at a minimum–a vaginal speculum exam (not exactly the same as a pelvic exam), how is one to do this without a routine screening pelvic examination?

So, at the risk of being redundant, I strongly disagree with the conclusion of the USPSTF draft evidence review, but particularly as it applies to postmenopausal women. There is a lot more that goes into the routine gynecological visit, including the pelvic exam. The pelvic exam is needed to screen for conditions such as the genitourinary syndrome of menopause (vaginal atrophy, that affects more than 50% of postmenopausal women), fibroid tumors, abnormal or heavy menstrual bleeding, pelvic floor conditions, and cancers and precancers of the vulva, vagina, cervix and uterus, etc. Not to mention: gonorrhea, chlamydia, syphilis, hepatitis, HIV; spousal, alcohol and drug abuse; menopausal hot flashes and night sweats, sexual dysfunction, among many other conditions.

Missed Opportunities
Broadly, the conclusion to discontinue the routine pelvic exam runs counter to the goals of improving women’s health through preventive care. If pelvic exams are performed only when women complain of problems or have symptoms, we will miss opportunities to diagnose potentially fatal pelvic cancers and other conditions. Being asymptomatic is not the same as being healthy or not having a problem.
Sincerely,

Dr. James A. Simon, MD, CCD, NCMP, IF, FACOG

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