Female Sexual Functioning After Cancer

Source: Livestrong

Survivors sometimes experience sexual dysfunction after cancer treatment. Knowing what some of the causes are and being able to describe your symptoms to your health care team can help you manage sexual dysfunction.

This information is meant to be a general introduction to this topic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Additional Resources section for questions to ask and for more resources.

Cancer and treatment can affect survivors in different ways. One area of life that might change is the ability to have or enjoy sex. These types of changes in women following cancer or treatment are sometimes referred to as female sexual dysfunction. The cause for concerns about female sexual functioning after cancer may be physical, emotional or a combination of both.

If you develop a sexual problem, there are a variety of ways to treat and manage it. Be sure to discuss any symptoms or concerns with your health care team as early as possible. You may want to ask about the possible impact of your cancer treatment on your sex life even before a problem occurs. Some women may feel uncomfortable discussing sexual concerns with a doctor or other members of the health care team. However, they can answer questions, refer you to a specialist if needed, and help you find solutions.

What are some indicators that may cause concern?

  • Loss of desire for sex
  • Negative thoughts and feelings during sex
  • Difficulty feeling sexual excitement and pleasure during sex
  • Difficulty reaching climax
  • Vaginal dryness and tightness
  • Pain when your genital area is touched or from sexual intercourse

 

These types of symptoms are not generally considered to be medical emergencies. For this reason, you may wonder if you should bring up the subject to a member of your health care team. Keep in mind that all of your physical and emotional concerns are important. This is especially true if you are experiencing pain during sex or feeling that your intimate relationship has become less enjoyable. Sexuality is an important part of your quality of life after cancer.

Prepare in advance to talk with your health care provider. Write down any questions and concerns you have about your sexual health. You may need to request extra time for your appointment to allow enough time for a discussion. If your provider cannot help you, ask for a referral to another health care professional who specializes in this area, such as a mental health professional trained in sex therapy or a gynecologist who treats sexual and pain problems.

Will all female cancer survivors experience sexual problems?

Not all survivors will experience sexual problems, but they are very common. It can be helpful to talk with your health care provider about when it is safe to have sex. When you are ready, it also helps to talk with your partner. Many partners hesitate to start sex because they do not want to pressure you or cause you physical pain. You can prepare for your sexual experience by taking time to get in the mood, focusing on pleasure rather than on whether you will have intercourse or reach an orgasm, and using vaginal moisturizers and lubricants if you notice dryness.

New sexual problems often begin during or soon after cancer treatment. Be certain to discuss any problems and symptoms with your health care provider—especially if you begin to notice any changes in your ability to have or enjoy sex. Some problems, such as loss of vaginal size and lubrication after radiation to the pelvis, may develop months or even years after cancer treatment is done.

What causes sexual functioning concerns after cancer?

There are many different causes of sexual functioning concerns in female cancer survivors. Some are physical causes. Others may be due to changes in how you feel about yourself, your body, or other aspects of your life after cancer.

Certain types of cancer, such as those that affect sexual organs, can put survivors at risk for problems. Approximately half of survivors of breast cancer and other cancers that affect the pelvic area (such as the cervix, ovaries, uterus, bladder, colon or vagina) develop long-term sexual problems. Yet, most problems are actually caused by treatment and not the cancer itself.

 

Some ways treatment can affect sexual functioning include:

  • Chemotherapy can damage the ovaries, causing hormonal changes and temporary or permanent menopause in younger women.
  • Radiation to the pelvic area can also damage the ovaries, triggering sudden menopause in younger women; Radiation to the vagina can irritate the delicate lining, decreasing the moisture produced with sexual excitement. Over time, scarring of the vaginal walls can make the vagina shorter and less able to expand with excitement. A few women develop sores in the vagina that take a long time to heal, or narrow areas that interfere with penetration.
  • Surgery for pelvic cancer may remove parts of a woman’s sexual organs, including areas of the vulva, part or all of the vagina, and one or both ovaries. Removing both ovaries is another treatment that leads to menopause. The vagina or vulva are sometimes rebuilt by the surgeon to make sex more comfortable.
  • Surgery for breast cancer may involve removing the whole breast, with or without reconstruction. Even partial mastectomy can interfere with pleasure from breast caressing if the nipple or underlying tissue was removed.
  • Medicines used to treat pain, nausea, depression or anxiety can decrease a woman’s desire for sex or make it difficult for her to reach a climax.

It helps to talk with your health care team about the risks for problems with sexual functioning before you begin cancer treatment. You may be able to choose a treatment that has fewer sexual side effects or at least you will be aware of potential problems so that you can get help as soon as they occur. If you have already undergone treatment, talk with your health care provider about finding ways to treat symptoms or concerns now.

 

Your emotional reaction to cancer diagnosis and treatment can also interfere with feeling attractive and sexual. It is common in the first year of a cancer diagnosis to have:

  • Sad or depressed feelings
  • Concerns about changes in the way you look
  • Stress in the relationship with your partner
  • Difficulty with self-esteem because of feeling ill and being unable to fill all your usual roles in the family and at work

Many women are somewhat uncomfortable with their sexual feelings. One in five women in the United States has had a negative experience, such as sexual abuse or rape. Many cultures and religions also take a negative view of women’s sexual pleasure. If you had some of these concerns before cancer, going through the illness may increase your distress. You may want to ask your health care provider for a referral to a licensed mental health professional who has experience working with cancer survivors.

Use the following tables about types of sexual issues and possible treatments to identify concerns that you have. Talk with your health care team about the issues that are most important to you.

Sexual Functioning Concerns

How to Find Help

Loss of desire for sex after cancer
  • Ask a member of your health care team to check your medications for possible side effects.
  • Get medical treatment for pain during sex that will not go away or fatigue that may be affecting your energy and desire for sex.
  • If you are in menopause, see a gynecologist or an endocrinologist. However, it is rare that women need extra testosterone for good sexual function. Women’s levels of testosterone after menopause are not related to their desire for sex. Testosterone for women was not approved by the Food and Drug Administration and may increase the risk of breast cancer in some women. DHEA or bioidentical hormones are not any safer for cancer survivors. Discuss other options with your health care team.
  • If there are no physical causes, see a licensed mental health professional to find out if your loss of desire could be related to feelings of depression, anxiety, low self-esteem, or relationship conflict.
Negative thoughts and feelings during sex
  • Women often find themselves distracted during sex by negative images and thoughts, for example about losing a breast or being infertile.
  • Try focusing on pleasurable feelings in your body or on a sexy thought or fantasy. If that does not help, ask for a referral to a mental health professional who can help you change negative feeling and thinking patterns
Difficulty feeling pleasure during sex
  • Lack of pleasure during sex may be yourself.relating to feeling anxious or depressed. If you have lost feeling in an area of your body that gave sexual pleasure you may need to find new caresses that you enjoy. Communication with your partner is crucial in making such changes.
  • Ask for a referral to a sex therapist who specializes in treating cancer survivors.
Vaginal dryness and tightness, making sexual activity uncomfortable or painful
  • Talk with a gynecologist who has expertise in menopause and problems with pain during intercourse.
  • Ask your gynecologist, for advice on using over-the-counter vaginal moisturizers 2-3 times a week plus water- or silicone-based vaginal lubricants before and during sexual activity. You also may benefit from learning to control the muscles around the vaginal entrance to avoid tension that makes penetration tighter. Practicing with vaginal dilators of increasing size may help. Some women can benefit from low-dose vaginal estrogen in a cream, tablet or ring form..Such hormones can help the vagina regain moisture and ability to stretch with less getting into the general blood circulation.
Difficulty reaching orgasm
  • Ask your health care team to check your medications. Antidepressants or anti-anxiety medicines may make it more difficult for you to have an orgasm.
  • Give yourself time. Try not to pressure yourself to have an orgasm. Try to have a goal of enjoying sex and getting as much pleasure as possible. An orgasm may then happen naturally.
  • The nerves that help a woman feel pleasure around the clitoris and in the vagina are rarely damaged by cancer treatment. Cancer or its treatment rarely will physically prevent you from having an orgasm.

 

Are there successful treatments for women with sexual concerns?

There are a number of treatment options that can help women with sexual functioning concerns. It is helpful to discuss problems and concerns with your healthcare provider as soon as you notice the changes. Long-term sexual problems can interfere with your relationship and often do not get better without help from a health care professional.

Loss of desire for sex is often a complex problem that needs both counseling and some medical help. There is no magic pill that can restore desire, but communication with your partner, patience, and experimenting with touch can often help. Vaginal dryness and pain are very common problems and may respond to over-the-counter products. You can use a vaginal moisturizer 2 or 3 times weekly plus a water- or silicone-based vaginal lubricant before actual caressing and intercourse. There are many ways to share pleasure and closeness with your partner. Even survivors who no longer have sex are able to find ways to continue to enjoy physical contact and deep intimacy with their partners.

Sometimes you may have a choice of a cancer treatment that is less likely to damage your sex life. Of course, the most important factor in choosing a cancer treatment is its ability to control cancer. However, your sexual health is also important.

Talk with your health care provider about treatment options for sexual concerns. The following table cites common methods that may be recommended, as well as some pros and cons for using them:

Treatment options for sexual functioning concerns

Pros

Cons

Vaginal moisturizers (such as Replens®, Hyalo-D®, or Luvena®)
  • Vaginal moisturizers are designed to keep the vaginal lining moist all the time. Some include prebiotic ingredients to help grow healthy bacteria and keep the vagina at a good pH.
  • Need to be used regularly at bedtime 2 to 3 times a week
  • May replace the need for lubricants during sex, although women may benefit from an extra lubricant for lovemaking even if they are using a moisturizer.
  • Can be costly and is not covered by insurance.
  • May be somewhat messy. Some women may need to use a mini-pad, but the discharge decreases after a couple of weeks.
Water- or silicone-based vaginal lubricants
  • Water-based lubricants last longer and work better than old-style gels. Silicone-based lubricants last even longer than the water-based ones but are more expensive and may stain sheets or clothing.
  • Can be purchased at most drugstores or over the Internet.Look for brands that do not contain perfumes or chemicals such as parabens or gycerine, and that try to keep the vagina at the same pH as is normal before menopause (4.5).
  • Even the best lubricant may wear off and need to be re-applied during sexual caressing or intercourse.
  • May not be effective enough to prevent pain if there is severe vaginal dryness.
Low-dose vaginal estrogen replacement (such as Estring, Vagifem)
  • Some women prefer these products to vaginal estrogen cream.
  • The Estring releases a small dose of hormone over three months.
  • The Vagifem suppository is used a couple of times a week.
  • Both Estring and Vagifem produce a low dose of estrogen. This is considered to be helpful treating vaginal dryness with very little hormone released into the bloodstream. Generally thought to be safer than pills, patches, or creams.
  • Some oncologists still worry about breast cancer survivors using these products.
  • A small study found that some women using suppositories still had levels of estrogen in their blood high enough to interfere with the benefits of aromatase inhibitors.
Find comfortable positions for intercourse
  • Certain positions may help avoid pain during sex.
  • Requires good communication between partners.
Learn to relax muscles around the vaginal entrance
  • Learn methods of relaxation to avoid pain during intercourse. Instructions for these “Kegel” exercises are easy to find on the internet
  • Women can use silicone vaginal dilators to practice muscle control, starting with a smaller size and going up to larger ones. Women should always use a water-based lubricant on the dilator and be gentle inserting the dilator.
  • Can help minimize pain, but may not relieve pain if tissue scarring is present in the vagina.
Herbal pills or genital lotions
  • Lotions may act as lubricants.
  • Herbal remedies may interfere with other medicines or may have unknown dangers.
  • No scientifically valid studies have identified lotions to help with sexual dysfunction.
  • Some lotions may be irritating to the skin or tissues. Lotions containing L-arginine may trigger episodes of genital herpes if a woman has a history of infection with this virus.

This doument was produced in collaboration with
Leslie R. Schover, Ph.D.
Professor of Behavioral Science, UT M. D. Anderson Cancer Center

 

Works Cited

American Cancer Society. “Sexuality and Cancer: For the Woman with Cancer and Her Partner.” Atlanta: American Cancer Society, 2001 (99-rev. 07/01-50M-no. 4657-HCP).
Downloadable version:http://www.cancer.org/Treatment/TreatmentsandSideEffects/PhysicalSideEffects/SexualSideEffectsinWomen/SexualityfortheWoman/index

Andersen, Barbara L. “Surviving cancer: The Importance of Sexual Self-Concept.” Medical and Pediatric Oncology33 (1999): 15-23. Carter J, Goldfrank D, Schover LR. Simple strategies for vaginal health promotion in cancer survivors. Journal of Sexual Medicine 8 (2010):549-59.

Derzko C, Elliott S, Lam W. Management of sexual dysfunction in postmenopausal breast cancer patients taking adjuvant aromatase inhibitor therapy. Current Oncology14 (Supplement 1).( 2007): :S20-40

Ganz, Patricia, Julia A. Rowland, Katherine Desmond, et al. “Life after breast cancer: Understanding women’s health-related quality of life and sexual functioning.” Journal of Clinical Oncology 16 (1998): 501-14.

Grumann, Mareile, Robert Robertson, Neville F. Hacker, and Greta Sommer. “Sexual Functioning in Patients following Radical Hysterectomy for Stage IB Cancer of the Cervix.” International Journal of Gynecologic Cancer 11 (2001): 372-80.

Jensen Pernille T., Mogens Groenvold, Marianne C. Klee, et al. “Longitudinal Study of Sexual Function and Vaginal Changes after Radiotherapy for Cervical Cancer.” International Journal of Radiation Oncology, Biology, and Physics 56 (2003): 937-49.

Schover LR. Androgen therapy for loss of desire in women: is the benefit worth the breast cancer risk? Fertility and Sterility 90 (2008): 129-40.

Stovall DW. Aprela, a single tablet formulation of bazedoxifene and conjugated equine estrogens (Premarin) for the potential treatment of menopausal symptoms. Current Opinion on Investigative Drugs 11 ( 2010):464-471.

 

Additional Resources

Medline Plus.
www.nlm.nih.gov/medlineplus/sexualproblemsinwomen.html

Detailed information about the causes and treatments of female sexual problems. Includes many links to other medically accurate web sites.

Your Sexual Health by the American Congress of Obstetricians and Gynecologists:

http://www.acog.org/publications/patient_education/bp072.cfm

Detailed information about the causes and treatments of female sexual problems. Includes an index of terms and information on how to discuss this topic with your healthcare provider.

 

LIVESTRONG Care Plan
www.LIVESTRONGcareplan.org

This free online tool was created to help you develop a personalized plan for post-treatment care. It can help you work with your oncologist and primary health care provider to address medical, emotional and social challenges that may arise after cancer treatment is completed. By answering some questions related to your cancer treatment, you will receive information about your follow-up care. This information includes symptoms to watch for in the future and steps you can take to stay healthy.

LIVESTRONG Cancer Navigation Center
www.LIVESTRONG.org/GetHelp

Email: Cancer.Navigation@LIVESTRONG.org
Phone: 1.855.220.7777 (English and Spanish)
Navigators are available for calls Monday through Friday, 9 a.m. to 5 p.m. (Central Time). Voicemail is available after hours.

The Navigation Center provides free, confidential one-on-one support to anyone affected by cancer. This is not a medical facility, but rather a center that provides the following support services:

  • Emotional Support—assistance coping with a cancer diagnosis, help accessing support groups, as well as peer-to-peer connections
  • Fertility Risks and Preservation Options—information on fertility risks and help accessing discounted rates for fertility preservation options
  • Insurance, Employment and Financial Concerns—information on employment rights and benefits, financial assistance and debt management, including insurance and billing issues as well as medication co-pay assistance

In addition to professional cancer navigators on staff, LIVESTRONG partners with specialty organizations such as Patient Advocate Foundation, Imerman Angels, Navigate Cancer Foundation and EmergingMed to provide support services.

 

American Cancer Society (ACS)
www.cancer.org

Email: Submit questions in English or Spanish from the “Contact Us” page.
Phone: 1-800-227-2345
TTY for deaf or hard of hearing callers: 1-866-228-4327

The American Cancer Society (ACS) offers information about many of the challenges of cancer and survivorship. You can search for information by cancer type or by topic. ACS provides a list of support groups in your area. ACS can connect you to support and services in your area. You can join online groups and message boards. Some information on the website is available in Spanish, Chinese, Korean and Vietnamese. ACS specialists can answer questions 24 hours a day by phone or email.

 

National Cancer Institute (NCI) — National Institutes of Health
www.cancer.gov

Online: The LiveHelp online chat service is available Monday through Friday from 8:00 a.m. to 11:00 p.m. Eastern Time.
Email: Send an email through the website.
Phone: 1-800-422-6237
Information specialists answer calls Monday–Friday, 8:00 a.m. to 8:00 p.m. Eastern Time.

The National Cancer Institute’s website provides accurate information about the challenges cancer can bring. You can search for information by cancer type or topic. You can find information about treatment and financial and insurance matters. You can also learn how treatments in development work and search for a clinical trial in your area. This site also has a good dictionary of cancer terms, drug information and other publications. Cancer information specialists can answer your questions about cancer and help you with quitting smoking. They can also help you with using the website and can tell you about NCI’s printed and electronic materials. The knowledgeable and caring specialists have access to comprehensive, accurate information on a range of cancer topics, including the most recent advances in cancer treatment. The service is confidential, and information specialists spend as much time as needed for thorough and personalized responses.