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Northwestern Medical Faculty Foundation
Sexuality and Bone Marrow
Failure Diseases: A Conversation
Timothy Pearman, Ph.D.
Director, Supportive Oncology
Associate Professor
Dept. of Medical Social Sciences
Dept. of Psychiatry and Behavioral Sciences
Feinberg School of Medicine
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A caveat:
Very little research has been done investigating
sexual dysfunction in bone marrow failure
diseases
“Bone marrow failure sexual function” (3
references on PubMed vs. 6164)
Most research has been done either in cancer,
cardiovascular or in stem cell transplant survivors
Therefore, some speculation is necessary
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What factors impact sexual
functioning?
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I. Age and sexual function
Age impacts sexual functioning in both males and
females
Males
Erectile dysfunction increases with age
ED increases with comorbid medical conditions
(diabetes, CVD, etc.)
Females
Menopausal impact on sexual functioning (vaginal
dryness, decreased libido, dyspareunia)
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I. Age
Sexual functioning decreases with age
independent of bone marrow failure
Difficult to determine relative impact of age vs.
hematologic abnormalities vs. treatment
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Massachusetts Male Aging Study:
Key Prevalence Study of ED
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Major Risk Factor for Sexual Dysfunction: Aging
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Female sexual dysfunction
Post-menopausal changes can lead to dysfunction
Incidence in cancer survivors: 30-100%
This, despite the fact that overall QOL is quite
good in female cancer survivors
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Medical Factors
Medications
Narcotics, disease-specific medications
Chronic disease
CAD, HTN, Dyslipidemias, PVD and depression
Lifestyle
Alcohol/Drug abuse
Stress
Smoking
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III. Medications
Antihypertensives/diuretics
Selective serotonin-reuptake inhibitors
(antidepressants)
Hormonal agents (e.g., antiandrogens)
Cytotoxic agents
H2 antagonists
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II. Major Risk Factors for Dysfunction:
Chronic Disease
Risk Multiplied*
Diabetes
Prostate disease
Peripheral vascular disease
Cardiac Problems
Hyperlipidemia
Hypertension
*Age-adjusted odds ratio.
4.1
2.9
2.6
1.8
1.7
1.6
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IV. Lifestyle
Alcohol, drug use
Inactivity/Deconditioning
Smoking
Stress
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High risk populations
Young
Old
Hematologic
(malignancies)
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Young
Very little research has investigated the impact of
childhood/adolescent treatment on sexual functioning (just
fertility)
Many survivors will not go through puberty without
hormonal treatment
Role of testosterone replacement unclear (Greenfield et al.,
2010)
45% report sexual dissatisfaction (Barrera et al., 2010)
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Hematologic (malignancies)
Few studies have looked extensively at sexual
functioning
Men function better than women
25-30% report sexual dysfunction attributed to
diagnosis
High risk of ED, decreased orgasm in men
>50% report dissatisfaction with sexual
functioning
GVHD can cause penile curvature, pain and ED
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Undertreatment
Numerous reasons
Only 14% of patients reported being asked about
sexual issues by their physicians (Pfizer Global
Study of Sexual Attitudes and Behaviors, 2011)
Thoughts? Provider driven? Patient driven?
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Undertreatment
71%: “ MD would
dismiss the issue.”
68%: “MD would be
embarrassed.”
74%: “No therapy
available.
“I should focus on my
illness and not on sexual
activity/health..”
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Screening
Few screenings are common in clinical practice
Importance of simply asking
NCCN guidelines recommend systematic
evaluation and treatment
Patients/family members, in general, are more
comfortable talking about this than you would
imagine (if only the same were true for treatment
providers!)
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Recommendations for treatment
providers
Discuss pretreatment sexual status
Provide information about possible sexual changes
before treatment
Make use of appropriate posttreatment
psychological, pharmacologic and mechanical
sexual aids
5 A’s: ask, advise, assess, assist, arrange follow up
(Sadovsky et al., 2010)
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Classification of ED:
Psychogenic or Organic?
Psychogenic
Sudden onset
Organic
Gradual onset
Complete immediate loss
Incremental
progression
AM erections present
Lack of AM
erections
Varies with partner and
situation
Lack of erections;
little variation
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Psychogenic Causes of Sexual Dysfunction
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Organic Causes of Sexual Dysfunction
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Why Discuss Sexual Health?
Treating this issue improves:
Quality of life
Patient satisfaction
Patient-clinician relationships
Sadovsky R et al, Cancer and Sexual Problems, J Sex Med, 2010; 7: 349-373
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Step-Care Approach
Men: first line therapy
Life style/medication modification
Counseling (Depression, body-image issues,
anxiety)
For ED: Androgen replacement if patient
hypogonadal
Oral therapy (PDE-5 Inhibitors)
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Step-Care Approach
Women: first line therapy
Sex therapy: focus not only on sexuality, but
intimacy
Vaginal estrogen
Cream, ring or tablet
Vaginal moisturizers (Replens, RepHresh)
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First-Line Therapy:
Medication Modifications
Modify drug regimens associated with ED
Antihypertensives/diuretics
Narcotics
Selective serotonin-reuptake inhibitors
Hormonal agents (e.g., antiandrogens)Consider
Intermittent Androgen Ablation Therapy
H2-receptor antagonists
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Step-Care Approach
Women: first line therapy
Vaginal estrogen
Cream, ring or tablet
Increases in serum estrogen
Clinical significance unclear
Vaginal moisturizers (Replens, RepHresh)
Again, clinical significance unclear
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Step-Care Approach to
ED Management
First Line Therapy
Life style/medication modification
Counseling
Androgen replacement
Oral therapy (PDE-5 Inhibitors)
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First-Line Therapy:
Oral PDE-5 Inhibitors
Phosphodiesterase type-5 (PDE-5) inhibitors
Sildenafil - Viagra
Tadalafil - Cialis
Vardenafil - Levitra
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Optimizing PDE-5 Inhibitor Therapy
Incorrect use/treatment failure
Patients should be advised
Sexual stimulation is needed
A number of drug trials may be required
Sildenafil, Vardenafil may be taken with food but
onset of action may be delayed
Risk factor modification may improve treatment
outcomes
Follow-up visits are essential
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Second-Line Therapy for
Management of ED
Vacuum constriction device
Intracavernosal injection
Alprostadil
Drug mixture* (trimix: papaverine,
phentolamine, alprostadil)
Transurethral alprostadil (MUSE®)
Topical therapy–creams/gels
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Vacuum Constriction Device
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Third-line Therapy: Penile Prostheses
Intolerance or lack of response to
other treatment modalities
Irreparably damaged erectile
tissue
Specific concomitant medical
conditions such as vascular or
neurological disease, chronic
renal disease, and genital trauma
(e.g., Peyronie’s disease)
>85% would undergo
surgery again and/or
recommend procedure
to a friend (n=178)
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What can I do to help my partner??
Normalize physical
response to treatment
Encourage open
communication with
partner
Include nongenital
foreplay to minimize
performance pressure
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What can I do??
Include sexual aids in the
bedroom
Focus on pleasure/arousal
rather than orgasm to limit
performance pressure
Use sexual positions that
are physically easiest
Encourage brief course of
sex therapy with
professional
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Psychotherapy
Discussion of sex after menopause/older age
Managing vaginal dryness
Managing ED
Sensate focus
Communication issues
Lifestyle modification: alcohol, smoking, exercise
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What can I do?
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What can I do?
Exercise is the most strongly
supported behavioral
intervention for fatigue (Mishra
et al., 2012)
Impact on fatigue, sleep, mood,
quality of life, physical
functioning
Surgeon General recommends
30 min moderate activity most
days
Consult with physician and/or
physical therapist
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Benefits related to sex
Changes in body composition
Increased self esteem
Decreased fatigue
Decreased risk of comorbid conditions
Decreased depression, anxiety
Increased quality of life
Increased desire (Cormie et al., 2013)
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Yoga
Look for churches,
community centers,
senior centers that
offer beginners’ yoga
Modifiable based on
physical challenges,
other medical
conditions, premorbid
physical activity level
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Partner yoga!
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Sleep Hygiene & Sleep Routines
Avoid caffeine after
noon
Within 2 hours of
bedtime avoid:



Stimulus control
15-20 minute intervals
Bedroom rule of two
Tobacco/nicotine
Alcohol
Exercise
Heavy Meals
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Conclusions
Sexual functioning is an important quality of life
issue for many patients.
Sexual dysfunction is highly prevalent and age is
a leading risk factor
Hematologic disease states and treatment can
cause or exacerbate impaired sexual functioning.
Treatment algorithm is goal-directed, stepwise
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Interventions (cont.)
Overall, interventions work better if include
education, self-efficacy, motivation components
In general, psychological interventions are feasible
and seem to work well (Brotto, Yule & Brecken,
2010)
Exercise, sleep can contribute to sexual health