Rashi Aggarwal, MD

Depression is the first affective episode in >50% of patients with bipolar dis­order, and is associated with consider­able morbidity and mortality.

The mean duration of a bipolar depres­sive episode is considerably longer than a manic episode; >20% of bipolar depressive episodes run a chronic course.¹ Evidence suggests that depressive episodes and symptoms are equal to, or more disabling than, corresponding levels of manic or hypomanic symptoms.²

Debate over appropriate therapy
Using antidepressants to treat bipolar depression remains controversial. Much of the debate surrounds concern that anti­depressants have the potential to switch a patient to mania/hypomania or to desta­bilize mood over the longitudinal course of illness.²

Several guidelines for informing the use of antidepressants in bipolar depression have been published, including the International Society for Bipolar Disorders task force report on antidepressant use in bipolar disorders³ and the guideline of the World Federation of Societies of Biological Psychiatry.⁴ To sum­marize the most recent consensus on treating bipolar depression, we devised the mne­monic No SAD Me:

No n-antidepressant treatments should be considered as monotherapy before antidepressants are used. Consider lith­ium, lamotrigine, olanzapine, quetiapine, or lurasidone first for bipolar depression.³

S afe-to-use adjunctive antidepressants can be considered if the patient relapses to a depressive episode after antidepres­sant therapy is stopped. Consider using a selective serotonin reuptake inhibitor (SSRI) and bupropion (1) for an acute bipolar I or II depressive episode when the patient has a history of a positive response to an antidepressant and (2) as maintenance treatment with SSRIs and bupropion as adjunctive therapy.^2,3

A void antidepressants as monotherapy. If using an antidepressant to treat bipolar I disorder, prescribe a mood-stabilizer concomitantly, even though the evidence for antidepressant-associated mood-switching is mixed and the ability of mood stabilizers to prevent such responses to antidepressant treatment is unproven.

D o not use tricyclic antidepressants (TCAs) or venlafaxine. Evidence does not show 1 type of antidepressant is more or less effective or dangerous than another. Nevertheless, TCAs and venlafaxine appear to carry a particularly high risk of inducing pathologically elevated states of mood and behavior.³

M onitor closely. Bipolar disorder patients who are being started on an antidepressant should be closely monitored for signs of hypomania or mania and increased psy­chomotor agitation. Discontinue the anti­depressant if such signs are observed or emerge.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Depression is the first affective episode in >50% of patients with bipolar dis­order, and is associated with consider­able morbidity and mortality.

The mean duration of a bipolar depres­sive episode is considerably longer than a manic episode; >20% of bipolar depressive episodes run a chronic course.¹ Evidence suggests that depressive episodes and symptoms are equal to, or more disabling than, corresponding levels of manic or hypomanic symptoms.²

Debate over appropriate therapy
Using antidepressants to treat bipolar depression remains controversial. Much of the debate surrounds concern that anti­depressants have the potential to switch a patient to mania/hypomania or to desta­bilize mood over the longitudinal course of illness.²

Several guidelines for informing the use of antidepressants in bipolar depression have been published, including the International Society for Bipolar Disorders task force report on antidepressant use in bipolar disorders³ and the guideline of the World Federation of Societies of Biological Psychiatry.⁴ To sum­marize the most recent consensus on treating bipolar depression, we devised the mne­monic No SAD Me:

No n-antidepressant treatments should be considered as monotherapy before antidepressants are used. Consider lith­ium, lamotrigine, olanzapine, quetiapine, or lurasidone first for bipolar depression.³

S afe-to-use adjunctive antidepressants can be considered if the patient relapses to a depressive episode after antidepres­sant therapy is stopped. Consider using a selective serotonin reuptake inhibitor (SSRI) and bupropion (1) for an acute bipolar I or II depressive episode when the patient has a history of a positive response to an antidepressant and (2) as maintenance treatment with SSRIs and bupropion as adjunctive therapy.^2,3

A void antidepressants as monotherapy. If using an antidepressant to treat bipolar I disorder, prescribe a mood-stabilizer concomitantly, even though the evidence for antidepressant-associated mood-switching is mixed and the ability of mood stabilizers to prevent such responses to antidepressant treatment is unproven.

D o not use tricyclic antidepressants (TCAs) or venlafaxine. Evidence does not show 1 type of antidepressant is more or less effective or dangerous than another. Nevertheless, TCAs and venlafaxine appear to carry a particularly high risk of inducing pathologically elevated states of mood and behavior.³

M onitor closely. Bipolar disorder patients who are being started on an antidepressant should be closely monitored for signs of hypomania or mania and increased psy­chomotor agitation. Discontinue the anti­depressant if such signs are observed or emerge.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Depression is the first affective episode in >50% of patients with bipolar dis­order, and is associated with consider­able morbidity and mortality.

The mean duration of a bipolar depres­sive episode is considerably longer than a manic episode; >20% of bipolar depressive episodes run a chronic course.¹ Evidence suggests that depressive episodes and symptoms are equal to, or more disabling than, corresponding levels of manic or hypomanic symptoms.²

Debate over appropriate therapy
Using antidepressants to treat bipolar depression remains controversial. Much of the debate surrounds concern that anti­depressants have the potential to switch a patient to mania/hypomania or to desta­bilize mood over the longitudinal course of illness.²

Several guidelines for informing the use of antidepressants in bipolar depression have been published, including the International Society for Bipolar Disorders task force report on antidepressant use in bipolar disorders³ and the guideline of the World Federation of Societies of Biological Psychiatry.⁴ To sum­marize the most recent consensus on treating bipolar depression, we devised the mne­monic No SAD Me:

No n-antidepressant treatments should be considered as monotherapy before antidepressants are used. Consider lith­ium, lamotrigine, olanzapine, quetiapine, or lurasidone first for bipolar depression.³

S afe-to-use adjunctive antidepressants can be considered if the patient relapses to a depressive episode after antidepres­sant therapy is stopped. Consider using a selective serotonin reuptake inhibitor (SSRI) and bupropion (1) for an acute bipolar I or II depressive episode when the patient has a history of a positive response to an antidepressant and (2) as maintenance treatment with SSRIs and bupropion as adjunctive therapy.^2,3

A void antidepressants as monotherapy. If using an antidepressant to treat bipolar I disorder, prescribe a mood-stabilizer concomitantly, even though the evidence for antidepressant-associated mood-switching is mixed and the ability of mood stabilizers to prevent such responses to antidepressant treatment is unproven.

D o not use tricyclic antidepressants (TCAs) or venlafaxine. Evidence does not show 1 type of antidepressant is more or less effective or dangerous than another. Nevertheless, TCAs and venlafaxine appear to carry a particularly high risk of inducing pathologically elevated states of mood and behavior.³

M onitor closely. Bipolar disorder patients who are being started on an antidepressant should be closely monitored for signs of hypomania or mania and increased psy­chomotor agitation. Discontinue the anti­depressant if such signs are observed or emerge.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

What a practitioner might identify and report as “psychiatric” symp­toms or signs cannot always be explained in terms of psychological stress or a psychiatric disorder. In fact, a range of medical¹ and neurologic² illnesses can mani­fest in ways that appear psychiatric in nature. Common examples are sleep and thyroid dis­orders; deficiencies of vitamin D, folate, and B₁₂; Parkinson’s disease; and anti-N-methyl-d-aspartate receptor autoimmune encephalitis.

People who have a medical illness with what appear to be psychiatric manifesta­tions often elude identification and diagno­sis because they do not visit a health care provider for any of several reasons, includ­ing difficulty obtaining health insurance. Instead, they might seek care in an emer­gency room (ER).

When such patients present for evalu­ation, it is easy—especially in a fast-paced ER—to miss the underlying cause of their illness. Some are then treated on the assump­tion that their diagnosis is psychiatric, while their medical illness goes unidentified.³

We propose a mnemonic, RULED O2uT, as a reminder in the ER (and any other set­ting) of the need to rule out physical illness before treating a patient for a psychiatric dis­order. To demonstrate how the work-up of a patient whose medical illness was obscured by psychiatric signs and symptoms could benefit from applying RULED O2uT, we also present a case.

CASE REPORT
A man with a medical illness who presented with psychiatric symptoms

Mr. Z, in his late 40s, is brought to the ER by his sister for evaluation of depressed mood of 6 to 8 months’ duration. He has no psychi­atric history.

On evaluation, Mr. Z does not remember an event or stressors that could have triggered depression. He describes complete loss of moti­vation for activities of daily living, such as per­sonal grooming. He has stopped leaving the house and meeting friends and family members.

Mr. Z’s sister is concerned for his well-being because he has been living without heat and electricity, which were disconnected for non­payment. Mr. Z reveals that he has not seen his primary care physician “for 20 or 25 years,” although he recently sought care in the ER of another hospital because of mild gait instabil­ity for several months.

Mr. Z has a blunted affect, with linear and goal-directed thought processes. He denies suicidal ideation. Laboratory testing, includ­ing a comprehensive metabolic panel, com­plete blood count, and urine toxicology and urinalysis, are negative.

A non-contrast CT scan of the head reveals foci of low attenuation in the left frontal corona radiata. Follow-up MRI of the brain, with and without contrast, shows extensive supratentorial and infratentorial demyelinat­ing lesions consistent with multiple sclerosis (MS). Several cerebral lesions in the white mat­ter are consistent with active demyelination.

Mr. Z is admitted to the neurology service and started on methylprednisolone for MS. The psychiatry consultation-liaison team pre­scribes sertraline, 50 mg titrated to 100 mg, for depression.

Detailed history means better overall evaluation
Mr. Z presented to the busy ER with psy­chiatric symptoms. It was easy to make a diagnosis of depression and refer him to the outpatient psychiatrist. However, a detailed history provided pertinent information about Mr. Z such as no regular medical check-ups, no family history of mental ill­ness, and gait disturbance in absence of physical injury. This enabled the physicians to conduct a thorough evaluation including a neurologic examination, laboratory tests, and imaging of the brain.

The 8 components of RULED O²uT
Rx interactions. Review medications that the patient is taking or recently stopped tak­ing, to rule out drug−drug interactions and adverse effects.

Unusual presentation. Be mindful of any unusual presentation. For example, sud­den onset of psychiatric symptoms with seizures or hypersensitivity to the sun with depression or psychosis.

Labs. Obtain appropriate blood work, including:
   • comprehensive metabolic panel
   • complete blood count
   • thyroid-stimulating hormone (myx­edema, thyrotoxicosis)
   • delta-aminolevulinic acid and porpho­bilinogen (acute intermittent porphyria)
   • antinuclear antibody (systemic lupus erythematosus)
   • B12 level
   • fluorescent treponemal antibody absorption test (neurosyphilis)
   • serum ceruloplasmin and copper (Wilson’s disease).

Examination. Perform a thorough exami­nation, including a proper neurological exam. This is especially important when you see signs, or the patient reports symp­toms, that cannot be explained by depres­sion alone. An abnormality or change in gait, for example, might be a consequence of injury or a manifestation of MS, stroke, or Parkinson’s disease. Additional testing, such as CT of the head or lumbar puncture, might be appropriate to supplement or clar­ify findings of the exam. Mr. Z’s neurologic exam revealed weakness in his left leg with variability in reflexes.

Drugs. Ensure that a patient presenting with new-onset psychosis is not taking dopa­minergic medications or steroids and, based on results of a toxicology screen, is not under the influence of stimulants or hallucinogens.

Onset and Office. Determine:
   • the time since onset of symptoms; this is crucial to differentiate psychiatric disor­ders and ruling out a nonpsychiatric cause of the patient’s presentation
   • if the patient gets a regular medi­cal check-up with her (his) primary care physician.

Thorough history. Obtain a thorough his­tory so that you have a clear picture of the patient’s current situation; this includes medical history and family history of neu­rologic and psychiatric disorders and sub­stance abuse.
 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

What a practitioner might identify and report as “psychiatric” symp­toms or signs cannot always be explained in terms of psychological stress or a psychiatric disorder. In fact, a range of medical¹ and neurologic² illnesses can mani­fest in ways that appear psychiatric in nature. Common examples are sleep and thyroid dis­orders; deficiencies of vitamin D, folate, and B₁₂; Parkinson’s disease; and anti-N-methyl-d-aspartate receptor autoimmune encephalitis.

People who have a medical illness with what appear to be psychiatric manifesta­tions often elude identification and diagno­sis because they do not visit a health care provider for any of several reasons, includ­ing difficulty obtaining health insurance. Instead, they might seek care in an emer­gency room (ER).

When such patients present for evalu­ation, it is easy—especially in a fast-paced ER—to miss the underlying cause of their illness. Some are then treated on the assump­tion that their diagnosis is psychiatric, while their medical illness goes unidentified.³

We propose a mnemonic, RULED O2uT, as a reminder in the ER (and any other set­ting) of the need to rule out physical illness before treating a patient for a psychiatric dis­order. To demonstrate how the work-up of a patient whose medical illness was obscured by psychiatric signs and symptoms could benefit from applying RULED O2uT, we also present a case.

CASE REPORT
A man with a medical illness who presented with psychiatric symptoms

Mr. Z, in his late 40s, is brought to the ER by his sister for evaluation of depressed mood of 6 to 8 months’ duration. He has no psychi­atric history.

On evaluation, Mr. Z does not remember an event or stressors that could have triggered depression. He describes complete loss of moti­vation for activities of daily living, such as per­sonal grooming. He has stopped leaving the house and meeting friends and family members.

Mr. Z’s sister is concerned for his well-being because he has been living without heat and electricity, which were disconnected for non­payment. Mr. Z reveals that he has not seen his primary care physician “for 20 or 25 years,” although he recently sought care in the ER of another hospital because of mild gait instabil­ity for several months.

Mr. Z has a blunted affect, with linear and goal-directed thought processes. He denies suicidal ideation. Laboratory testing, includ­ing a comprehensive metabolic panel, com­plete blood count, and urine toxicology and urinalysis, are negative.

A non-contrast CT scan of the head reveals foci of low attenuation in the left frontal corona radiata. Follow-up MRI of the brain, with and without contrast, shows extensive supratentorial and infratentorial demyelinat­ing lesions consistent with multiple sclerosis (MS). Several cerebral lesions in the white mat­ter are consistent with active demyelination.

Mr. Z is admitted to the neurology service and started on methylprednisolone for MS. The psychiatry consultation-liaison team pre­scribes sertraline, 50 mg titrated to 100 mg, for depression.

Detailed history means better overall evaluation
Mr. Z presented to the busy ER with psy­chiatric symptoms. It was easy to make a diagnosis of depression and refer him to the outpatient psychiatrist. However, a detailed history provided pertinent information about Mr. Z such as no regular medical check-ups, no family history of mental ill­ness, and gait disturbance in absence of physical injury. This enabled the physicians to conduct a thorough evaluation including a neurologic examination, laboratory tests, and imaging of the brain.

The 8 components of RULED O²uT
Rx interactions. Review medications that the patient is taking or recently stopped tak­ing, to rule out drug−drug interactions and adverse effects.

Unusual presentation. Be mindful of any unusual presentation. For example, sud­den onset of psychiatric symptoms with seizures or hypersensitivity to the sun with depression or psychosis.

Labs. Obtain appropriate blood work, including:
   • comprehensive metabolic panel
   • complete blood count
   • thyroid-stimulating hormone (myx­edema, thyrotoxicosis)
   • delta-aminolevulinic acid and porpho­bilinogen (acute intermittent porphyria)
   • antinuclear antibody (systemic lupus erythematosus)
   • B12 level
   • fluorescent treponemal antibody absorption test (neurosyphilis)
   • serum ceruloplasmin and copper (Wilson’s disease).

Examination. Perform a thorough exami­nation, including a proper neurological exam. This is especially important when you see signs, or the patient reports symp­toms, that cannot be explained by depres­sion alone. An abnormality or change in gait, for example, might be a consequence of injury or a manifestation of MS, stroke, or Parkinson’s disease. Additional testing, such as CT of the head or lumbar puncture, might be appropriate to supplement or clar­ify findings of the exam. Mr. Z’s neurologic exam revealed weakness in his left leg with variability in reflexes.

Drugs. Ensure that a patient presenting with new-onset psychosis is not taking dopa­minergic medications or steroids and, based on results of a toxicology screen, is not under the influence of stimulants or hallucinogens.

Onset and Office. Determine:
   • the time since onset of symptoms; this is crucial to differentiate psychiatric disor­ders and ruling out a nonpsychiatric cause of the patient’s presentation
   • if the patient gets a regular medi­cal check-up with her (his) primary care physician.

Thorough history. Obtain a thorough his­tory so that you have a clear picture of the patient’s current situation; this includes medical history and family history of neu­rologic and psychiatric disorders and sub­stance abuse.
 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

What a practitioner might identify and report as “psychiatric” symp­toms or signs cannot always be explained in terms of psychological stress or a psychiatric disorder. In fact, a range of medical¹ and neurologic² illnesses can mani­fest in ways that appear psychiatric in nature. Common examples are sleep and thyroid dis­orders; deficiencies of vitamin D, folate, and B₁₂; Parkinson’s disease; and anti-N-methyl-d-aspartate receptor autoimmune encephalitis.

People who have a medical illness with what appear to be psychiatric manifesta­tions often elude identification and diagno­sis because they do not visit a health care provider for any of several reasons, includ­ing difficulty obtaining health insurance. Instead, they might seek care in an emer­gency room (ER).

When such patients present for evalu­ation, it is easy—especially in a fast-paced ER—to miss the underlying cause of their illness. Some are then treated on the assump­tion that their diagnosis is psychiatric, while their medical illness goes unidentified.³

We propose a mnemonic, RULED O2uT, as a reminder in the ER (and any other set­ting) of the need to rule out physical illness before treating a patient for a psychiatric dis­order. To demonstrate how the work-up of a patient whose medical illness was obscured by psychiatric signs and symptoms could benefit from applying RULED O2uT, we also present a case.

CASE REPORT
A man with a medical illness who presented with psychiatric symptoms

Mr. Z, in his late 40s, is brought to the ER by his sister for evaluation of depressed mood of 6 to 8 months’ duration. He has no psychi­atric history.

On evaluation, Mr. Z does not remember an event or stressors that could have triggered depression. He describes complete loss of moti­vation for activities of daily living, such as per­sonal grooming. He has stopped leaving the house and meeting friends and family members.

Mr. Z’s sister is concerned for his well-being because he has been living without heat and electricity, which were disconnected for non­payment. Mr. Z reveals that he has not seen his primary care physician “for 20 or 25 years,” although he recently sought care in the ER of another hospital because of mild gait instabil­ity for several months.

Mr. Z has a blunted affect, with linear and goal-directed thought processes. He denies suicidal ideation. Laboratory testing, includ­ing a comprehensive metabolic panel, com­plete blood count, and urine toxicology and urinalysis, are negative.

A non-contrast CT scan of the head reveals foci of low attenuation in the left frontal corona radiata. Follow-up MRI of the brain, with and without contrast, shows extensive supratentorial and infratentorial demyelinat­ing lesions consistent with multiple sclerosis (MS). Several cerebral lesions in the white mat­ter are consistent with active demyelination.

Mr. Z is admitted to the neurology service and started on methylprednisolone for MS. The psychiatry consultation-liaison team pre­scribes sertraline, 50 mg titrated to 100 mg, for depression.

Detailed history means better overall evaluation
Mr. Z presented to the busy ER with psy­chiatric symptoms. It was easy to make a diagnosis of depression and refer him to the outpatient psychiatrist. However, a detailed history provided pertinent information about Mr. Z such as no regular medical check-ups, no family history of mental ill­ness, and gait disturbance in absence of physical injury. This enabled the physicians to conduct a thorough evaluation including a neurologic examination, laboratory tests, and imaging of the brain.

The 8 components of RULED O²uT
Rx interactions. Review medications that the patient is taking or recently stopped tak­ing, to rule out drug−drug interactions and adverse effects.

Unusual presentation. Be mindful of any unusual presentation. For example, sud­den onset of psychiatric symptoms with seizures or hypersensitivity to the sun with depression or psychosis.

Labs. Obtain appropriate blood work, including:
   • comprehensive metabolic panel
   • complete blood count
   • thyroid-stimulating hormone (myx­edema, thyrotoxicosis)
   • delta-aminolevulinic acid and porpho­bilinogen (acute intermittent porphyria)
   • antinuclear antibody (systemic lupus erythematosus)
   • B12 level
   • fluorescent treponemal antibody absorption test (neurosyphilis)
   • serum ceruloplasmin and copper (Wilson’s disease).

Examination. Perform a thorough exami­nation, including a proper neurological exam. This is especially important when you see signs, or the patient reports symp­toms, that cannot be explained by depres­sion alone. An abnormality or change in gait, for example, might be a consequence of injury or a manifestation of MS, stroke, or Parkinson’s disease. Additional testing, such as CT of the head or lumbar puncture, might be appropriate to supplement or clar­ify findings of the exam. Mr. Z’s neurologic exam revealed weakness in his left leg with variability in reflexes.

Drugs. Ensure that a patient presenting with new-onset psychosis is not taking dopa­minergic medications or steroids and, based on results of a toxicology screen, is not under the influence of stimulants or hallucinogens.

Onset and Office. Determine:
   • the time since onset of symptoms; this is crucial to differentiate psychiatric disor­ders and ruling out a nonpsychiatric cause of the patient’s presentation
   • if the patient gets a regular medi­cal check-up with her (his) primary care physician.

Thorough history. Obtain a thorough his­tory so that you have a clear picture of the patient’s current situation; this includes medical history and family history of neu­rologic and psychiatric disorders and sub­stance abuse.
 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Cancer therapy presents unique challenges to health care providers because of the evolving nature of managing a patient’s diagnosis, treatment, and recovery. Be conscientious about a patient’s mental health and physical health when considering treatment and support.

Sexual health is important

Sexual dysfunction is one of many variables a patient considers when deciding on a cancer treatment plan—particularly those who have a gynecological, gastrointestinal, or reproductive-tract cancer. Additionally, sexual dysfunction remains one of the major health complaints after many cancer therapies, which may be overlooked because of patients’ hesitancy to initiate discussion.

Many oncologic treatment options—surgery, chemotherapy, radiotherapy, and hormone therapy—are associated with sexual side effects, including radiation sequelae, erectile dysfunction, decreased lubrication, and vaginal atrophy.¹ Because sexual dysfunction often is multifactorial, an approach that involves psychological assessment and treatment usually is optimal. A mental health provider can explore the interactions of such factors as decreased self-esteem, negative body image, altered interpersonal relationships, and change or loss of libido when assessing reported sexual dysfunction.²

The mnemonic SEMEN can help you address sexual health topics with oncology patients:

Take a Sexual history at diagnosis and before treatment begins.

Provide Educational materials to warn of potential adverse sexual side effects of various treatments.

Maintain an open dialogue during cancer therapy. Discuss any adverse sexual side effects the patient may be experiencing.

Educate and treat your patient. Offer information on medications, devices, and techniques that target sexual dysfunction.

For men with erectile dysfunction, recommend a phosphodiesterase type 5 (PDE5) inhibitor (sildenafil citrate, tadalafil, vardenafil), a vacuum pump, or intracavernosal penile injection, such as synthetic prostaglandin E₁.

For men experiencing premature ejaculation, consider providing instruction on the “squeeze-pause” technique or prescribing a topical anesthetic cream such as lidocaine/prilocaine (available under the brand name EMLA), which is applied to the head of the penis and wiped off before intercourse. Some selective serotonin reuptake inhibitors, including fluoxetine, paroxetine, and sertraline, have been used off-label to treat premature ejaculation.

Women experiencing vaginal dryness or vaginal atrophy might benefit from vaginal estrogen (such as conjugated or estradiol estrogen tablets), an estradiol cream, or the estradiol vaginal ring. Other options include a vaginal moisturizing agent or lubricant.

Additional sexual education topics include:

• adjusting sexual positions

• enhancing foreplay

• seeking help from support organizations

• engaging a sexual therapist (recommend one who specializes in treating oncology patients).

Make Normality the goal after treatment or recovery. Encourage your patient to maintain a healthy sexual lifestyle by continuing discussions about sexual health, supporting healthy self-perception, and addressing possible future sexual dysfunction.

Being given a diagnosis of cancer, undergoing treatment, and surviving the experience are life-altering. Healthcare providers should be open to discussing patients’ past and current sexual practices; along with treating physical illness, you should attempt to maintain a sense of normality, which includes maintaining healthy sexuality.

Cancer therapy presents unique challenges to health care providers because of the evolving nature of managing a patient’s diagnosis, treatment, and recovery. Be conscientious about a patient’s mental health and physical health when considering treatment and support.

Sexual health is important

Sexual dysfunction is one of many variables a patient considers when deciding on a cancer treatment plan—particularly those who have a gynecological, gastrointestinal, or reproductive-tract cancer. Additionally, sexual dysfunction remains one of the major health complaints after many cancer therapies, which may be overlooked because of patients’ hesitancy to initiate discussion.

Many oncologic treatment options—surgery, chemotherapy, radiotherapy, and hormone therapy—are associated with sexual side effects, including radiation sequelae, erectile dysfunction, decreased lubrication, and vaginal atrophy.¹ Because sexual dysfunction often is multifactorial, an approach that involves psychological assessment and treatment usually is optimal. A mental health provider can explore the interactions of such factors as decreased self-esteem, negative body image, altered interpersonal relationships, and change or loss of libido when assessing reported sexual dysfunction.²

The mnemonic SEMEN can help you address sexual health topics with oncology patients:

Take a Sexual history at diagnosis and before treatment begins.

Provide Educational materials to warn of potential adverse sexual side effects of various treatments.

Maintain an open dialogue during cancer therapy. Discuss any adverse sexual side effects the patient may be experiencing.

Educate and treat your patient. Offer information on medications, devices, and techniques that target sexual dysfunction.

For men with erectile dysfunction, recommend a phosphodiesterase type 5 (PDE5) inhibitor (sildenafil citrate, tadalafil, vardenafil), a vacuum pump, or intracavernosal penile injection, such as synthetic prostaglandin E₁.

For men experiencing premature ejaculation, consider providing instruction on the “squeeze-pause” technique or prescribing a topical anesthetic cream such as lidocaine/prilocaine (available under the brand name EMLA), which is applied to the head of the penis and wiped off before intercourse. Some selective serotonin reuptake inhibitors, including fluoxetine, paroxetine, and sertraline, have been used off-label to treat premature ejaculation.

Women experiencing vaginal dryness or vaginal atrophy might benefit from vaginal estrogen (such as conjugated or estradiol estrogen tablets), an estradiol cream, or the estradiol vaginal ring. Other options include a vaginal moisturizing agent or lubricant.

Additional sexual education topics include:

• adjusting sexual positions

• enhancing foreplay

• seeking help from support organizations

• engaging a sexual therapist (recommend one who specializes in treating oncology patients).

Make Normality the goal after treatment or recovery. Encourage your patient to maintain a healthy sexual lifestyle by continuing discussions about sexual health, supporting healthy self-perception, and addressing possible future sexual dysfunction.

Being given a diagnosis of cancer, undergoing treatment, and surviving the experience are life-altering. Healthcare providers should be open to discussing patients’ past and current sexual practices; along with treating physical illness, you should attempt to maintain a sense of normality, which includes maintaining healthy sexuality.

Cancer therapy presents unique challenges to health care providers because of the evolving nature of managing a patient’s diagnosis, treatment, and recovery. Be conscientious about a patient’s mental health and physical health when considering treatment and support.

Sexual health is important

Sexual dysfunction is one of many variables a patient considers when deciding on a cancer treatment plan—particularly those who have a gynecological, gastrointestinal, or reproductive-tract cancer. Additionally, sexual dysfunction remains one of the major health complaints after many cancer therapies, which may be overlooked because of patients’ hesitancy to initiate discussion.

Many oncologic treatment options—surgery, chemotherapy, radiotherapy, and hormone therapy—are associated with sexual side effects, including radiation sequelae, erectile dysfunction, decreased lubrication, and vaginal atrophy.¹ Because sexual dysfunction often is multifactorial, an approach that involves psychological assessment and treatment usually is optimal. A mental health provider can explore the interactions of such factors as decreased self-esteem, negative body image, altered interpersonal relationships, and change or loss of libido when assessing reported sexual dysfunction.²

The mnemonic SEMEN can help you address sexual health topics with oncology patients:

Take a Sexual history at diagnosis and before treatment begins.

Provide Educational materials to warn of potential adverse sexual side effects of various treatments.

Maintain an open dialogue during cancer therapy. Discuss any adverse sexual side effects the patient may be experiencing.

Educate and treat your patient. Offer information on medications, devices, and techniques that target sexual dysfunction.

For men with erectile dysfunction, recommend a phosphodiesterase type 5 (PDE5) inhibitor (sildenafil citrate, tadalafil, vardenafil), a vacuum pump, or intracavernosal penile injection, such as synthetic prostaglandin E₁.

For men experiencing premature ejaculation, consider providing instruction on the “squeeze-pause” technique or prescribing a topical anesthetic cream such as lidocaine/prilocaine (available under the brand name EMLA), which is applied to the head of the penis and wiped off before intercourse. Some selective serotonin reuptake inhibitors, including fluoxetine, paroxetine, and sertraline, have been used off-label to treat premature ejaculation.

Women experiencing vaginal dryness or vaginal atrophy might benefit from vaginal estrogen (such as conjugated or estradiol estrogen tablets), an estradiol cream, or the estradiol vaginal ring. Other options include a vaginal moisturizing agent or lubricant.

Additional sexual education topics include:

• adjusting sexual positions

• enhancing foreplay

• seeking help from support organizations

• engaging a sexual therapist (recommend one who specializes in treating oncology patients).

Make Normality the goal after treatment or recovery. Encourage your patient to maintain a healthy sexual lifestyle by continuing discussions about sexual health, supporting healthy self-perception, and addressing possible future sexual dysfunction.

Being given a diagnosis of cancer, undergoing treatment, and surviving the experience are life-altering. Healthcare providers should be open to discussing patients’ past and current sexual practices; along with treating physical illness, you should attempt to maintain a sense of normality, which includes maintaining healthy sexuality.