Cancer and Its Impact on Women’s Sexuality
By Jennifer Berman, MD
Assistant Professor, Urology
Director, Female Sexual Medicine Center
David Geffen School of Medicine at UCLA
And Laura Berman, PhD
Director, The Berman Center, Chicago, Illinois
For women with cancer, sexual function can be affected in a variety of ways. Cancer and its treatments can disrupt the physical aspect of sexual function, relationship issues and the psychological wellbeing of the woman, including her self image and body image. All of these factors need to be taken into consideration and are potentially interactive. For example, a woman who is struggling with the psychological impact of the disease may feel less sexual because she is overwhelmed by anxiety associated with the treatment and diagnosis.
Her partner may be acutely aware of this and may pull back from sexual contact. When a partner pulls a way, a message may be sent to the patient that the partner is not interested, which could be interpreted to mean that the patient is no longer physically attractive or desirable to the partner. These thoughts can then contribute to feelings of loss, which increases the depression and psychological impact. While this is just one scenario, it points out how sexual feelings and activity may decrease as a result of many factors and can quickly become complicated once a cancer diagnosis is made.
The physical affects of cancer can be quite devastating and varied depending on the type of cancer. Pelvic surgeries can have significant effects. Most people do not realize that the nerve pathways associated with sexual function are not understood in women. In men who are diagnosed with early stage prostate cancer there is now a nerve-sparing surgery that can be done to prevent the loss of sexual function. The important nerves for erection and sensation are understood. For women, these nerve pathways are not mapped nor understood and thus there is no nerve-sparing surgery available for women, despite the fact that women frequently have pelvic surgeries, hysterectomies, oopherectomies (removal of ovaries), bladder suspensions, colon resections, etc.
The impact of these surgeries can be substantial and can influence a woman’s ability to reach orgasm, contribute to pain and loss of elasticity, and decrease lubrication and sensation. In addition, intercourse may become awkward due to pain or the presence of an ostomy (a surgically created excretory opening).
Chemotherapy also takes it toll on sexual function. Some types of chemotherapies damage ovaries, which has an impact on hormone levels, fertility, and menopausal symptomology. Chemotherapy can push a woman into an abrupt menopause, creating problems with hot flashes, urinary incontinence, vaginal dryness and difficulties with lubrication. Chemotherapy can irritate the mucous membranes that line the vagina, making the tissues more sensitive and more likely to tear, and causing more pain. These vaginal changes can increase susceptibility to yeast infections and increase the likelihood of contracting sexually transmitted diseases (STDs). Chemotherapy can also decrease sexual desire and a woman’s ability to respond to sexual stimuli.
Pelvic radiation is a treatment for some cancers and it, too, has implications for sexual function. It can create changes in the vaginal tissues such as vaginal scarring, irritation and pain. The vaginal walls may thicken, reducing the elasticity of the vagina, which is necessary for comfortable vaginal intercourse.
The majority of studies performed on female cancer survivors have focused on breast cancer patients because of the large survivor population. It has been found that 90% of patients resume sexual activity following their treatment; however, sexual dysfunction is present for many. The types of sexual dysfunction that they report include: hypoactive (low) sexual desire (64%); arousal disorder (42%); orgasmic disorder (44%); pain disorder (38%); and vaginismus or clenching of the outer third of the vaginal muscles (30%).
It is not surprising that low sexual desire is one of the most common problems suffered by cancer survivors. In fact, in women without a cancer diagnosis, about 43% report low sexual desire. However, after a cancer diagnosis there are other issues that can interfere. Initially, there may be a focus on survival as the foremost concern. Many patients tend to worry or experience negative emotions or even depression. Hormonal imbalance can be caused by a variety of factors associated with the treatment. Relationships that were already conflicted can become more so under the stress of cancer and its treatments. Even good relationships can suffer from the stress placed on them by this disease. Many of the difficulties that women experience after a cancer diagnosis can also be interactive. For example, changes in hormones can affect mood, desire, orgasm and pain.
Changes in sexual function and concerns about these changes need to be addressed. Unfortunately, most women do not turn to their therapists and doctors for assistance. Most women (62%) talk to their partner, and while that’s an important place to begin, they also need to begin to discuss these issues with professionals who may be able to help them. The UCLA Female Sexual Medicine Clinic has designed an approach that includes both medical and psychosocial evaluation. They recognize that women who are aging and going through menopause are already at higher risk for sexual dysfunction.
When cancer, or any other medical illness, enters the picture, additional problems can be created. Different kinds of medications can increase sexual dysfunction beyond those created by chemotherapy. For example, anticancer medications such as Tamoxifen, or anticonvulsants, antidepressants, antihypertensive agents, anti-ulcer drugs, birth control pills, neuroleptics and sedatives can affect arousal, desire, and orgasm. It is important to review these medications.
Sometimes modifications can be made to different medications, but if not, at least patients can understand how these drugs may affect them and look for other interventions to lessen their impact. For example, some medications can affect blood flow to the genitals and it is important to evaluate this. If inadequate blood flow is present, it’s more difficult to experience arousal and sensation and thus to reach orgasm. The medical evaluation looks at these factors, assesses hormone levels, and reviews other markers in the blood that may be indicative of other problems. There is increasing evidence that testosterone plays an important role in women’s sexual function, which may be disrupted by changes in ovarian function. Once an adequate assessment has been performed, interventions and strategies can be employed.
Women who are experiencing changes in their sexual function might think about some of the following options:
- Use sexual fantasy. As time goes on, and especially in relationships in which there is not as much novel stimulation, sexual fantasy is very powerful and useful in helping women to obtain orgasm.
- Hand held vibrators are excellent tools to assist in providing the kind of stimulation necessary for orgasm. A favorite recommendation by many couples is the “pocket rocket.”
- Change sexual positions. Positions that increase stimulation to the clitoris can be helpful in obtaining orgasm. Sexual positioning can also be important for comfort and reduction of pain.
- Practice both vaginal tightening and relaxing exercises to strengthen and offer control.
- Utilize dilation techniques either alone or with a physical therapist who is trained in managing difficulties associated with the vagina and pelvic floor. These techniques can reduce pain and increase the likelihood of comfortable and pleasurable sexual contact.
- Instruct your partner how to use the “teasing touch.” Most women like the lighter touch and this can be arousing and stimulating.
- Use a lot lubrication. There are many water-based lubricants available in pharmacies and grocery stores that can reduce pain and substitute for natural lubrication. Lubrication can make all the difference – don’t hesitate to be generous.
- If genital pain is present, consult your physician.
- Plan sexual activity at times when pain is lowest, for example, when pain medication is at its peak or at times of the day when fatigue and pain are less.
- Focus on feelings of pleasure or excitement. It is important to allow time for arousal.
- Communicate with your partner about pain. It may be important for you to be in control over movement to minimize pain.
- Don’t forget about VENIS! What is VENIS? Very Erotic Non-Insertive Sex. There are many different ways that partners can bring pleasure to each other. Many of these activities have been labeled foreplay, but in fact they are pleasurable sexual activities that can lead to satisfying sexual experiences that don’t include vaginal intercourse.
- Communication about sex is always important, but especially when there have been life-altering changes.
- Be aware that there are new pharmacological options to enhance sexual function. For example, there are many medications that can increase the blood flow to the genital area. The use of Viagra in women is being studied and there are several newer generation drugs that are currently in development. These tend to work best in women who have normal hormone levels. There are others, including phentolamine (an alpha blocker and blood enhancer) and prostaglandin (a smooth muscle relaxer) that can be applied topically.
- Hormonal agents can also be helpful, such as estrogen and testosterone. Even though hormonal interventions can be tricky for women who have hormone sensitive tumors, there are some options that can be considered for these women. For example, there are some vaginal estrogens that are not absorbed into the blood stream, including the products Estring and Vagifem. DHEA is a precursor to testosterone and is not a good option for women with breast cancer, but may be appropriate for women with other types of cancers. Additionally, there are new selective estrogen receptor modulators that are under development, which may have anti-estrogen effects in the breast, but positive effects in other parts of the body.
- There is also a mechanical device, called the Eros Clitoral Therapy Device, that increases blood flow to the clitoral area. It enhances sexual function by pulling blood into the clitoral area, while also functioning as a vibrator.
- The more sexual activity you engage in, the greater the likelihood that your sexual function will be preserved. Like many things, the old adage, “use it or lose it” applies to sexual function as well.
- Remember that acknowledgment, empathy, and expression of feeling is always important. Group therapy experiences with other women can provide a substantial amount of support. Involvement of your partner in therapeutic approaches, communications, and flexibility of sexual expression can all be helpful in understanding problems and finding solutions.