Women, Cancer and Sexuality

Sex is an important part of life. It affects our zest for life and how we think of ourselves. Yet doctors and patients often don’t talk about how cancer treatment will affect a person’s sex life.

You might have started to wonder what will happen with your sex life. But you may not feel OK talking about it. Even just reading about sex here may seem a little strange at first.

The facts here are for all women who have or had cancer.

We hope it will help you learn more about cancer and sex, and help you start talking with your partner, doctor, and cancer team about your sex life and any problems you might have.

Dealing with the ‘loss’ you feel

It’s common to feel grief over the losses linked to your cancer diagnosis and treatment. You may also notice sadness, anger, and even hostility toward those close to you. Cancer changes your sense of self, that is, how you think of your body and yourself. This can disturb your well-being, and affect how you see yourself sexually. It can also affect your ability to maintain relationships.

Grief is a natural response as you give up or make compromises about ideas of yourself and begin to find new ways to cope with the changes in your life and your body. It may take time for you to recognize some of these losses and changes. Remember that “different” does not have to mean “bad.” But it means you might develop new feelings and changes may come up even after you think you are finished grieving or adjusting. It can help if you can share your grief with someone close to you. If there’s no one near you that you want to confide in, you might consider joining a support group, or if you prefer, seeing a mental health professional. Just as it’s important to take care of pain in your body, painful feelings also need to be dealt with.

Just what is “normal” anyway?

People think about sex in different ways, and they have sex in different ways, too. This makes it hard to say what’s normal. Normal for you and your partner is whatever feels right to both of you.

It’s also normal to want sex as you get older. Many men and women keep having sex until the end of their lives. It’s true that age may change your sexual response. But if you want to keep your sex life active, you probably can.

Cancer, sex, and sexuality

When you first learned you had cancer, you probably thought mostly of survival. But after a while other questions may have started coming up. You might be wondering “How ‘normal’ can my life be, even if the cancer is under control?” Or even “How will cancer affect my sex life?” It’s important to know that you can get help if you are having sexual problems after cancer treatment. There are many good treatments available.

Sex and sexuality are important parts of everyday life. The difference between sex and sexuality is that sex is thought of as an activity – something you do with a partner. Sexuality is more about the way you feel about yourself as a woman, and is linked to intimacy or your need for caring, closeness, and touch.

Feelings about sexuality affect our zest for living, our self-image, and our relationships with others. Yet patients and doctors often do not talk about the effects of cancer treatment on a woman’s sex life or how she can address problems she’s having. Why? A person may feel uneasy talking about sex with a professional like a doctor or even with a close sex partner. Many people feel awkward and exposed when talking about sex.

This information is for all women who have or have had cancer – regardless of their sexual orientation. We cannot answer every question, but we’ll try to give you enough information to help you and your partner have open, honest talks about intimacy and sex. We will also share some ideas about talking with your doctor and your cancer care team.

Keep in mind that sensual/sexual touching between you and your partner is always possible, no matter what kinds of cancer treatment you’ve had. This might surprise you, especially if you are feeling down or have not had any sexual touching or activity for a while. But it’s true. The ability to feel pleasure from touch almost always remains.

What is a normal sex life?

People vary a great deal in their sexual attitudes and practices. This makes it hard to define “normal.” Some couples like to have sex every day. For others, once a month is enough. Many people see oral sex (using the mouth or tongue) as a normal part of sex, but some believe it’s not OK. “Normal” for you and your partner is whatever gives you pleasure together. Both partners should agree on what makes their sex life enjoyable.

It’s common for people coping with cancer to lose interest in or desire for sexual activity at times. Doubts and fears, along with cancer and cancer treatment effects, can make you feel less than your best. Sometimes concerns about your health may be much greater than your interest in sexual activity. But as you get back to your usual routines, your desire for intimacy may return, too.

It’s OK to be interested in sex throughout your life. There are some who think sex is only for the young, and that older people lose both their desire for sex and/or their ability to “perform.” Those beliefs are largely myths. Many men and women can and do stay sexually active until the end of life. Still, it is true that sexual response and function may change over time with age. For example, more than half of men over age 40 have at least a little trouble with erections. For some of these men the problem is severe. Many women also notice changes as they get older, sometimes even before menopause begins. A decrease in sexual desire and problems with vaginal dryness may increase during and after menopause.

Sometimes, sexual problems center around anxiety, tension, or other problems in a relationship. Other times, they may be the result of a physical condition, a medical condition, or medicines that cause or worsen sexual difficulties. But most symptoms can be treated. We now have medicines, therapy, surgery, and other treatments that can help people deal with most kinds of problems they may have. If you want to keep your sex life active, you can likely do so.

If you’re in a relationship and one of you has a sexual difficulty, it affects both of you. If you are working on sexual problems, it works best when your partner can be part of the solution.

Keeping your sex life going despite cancer treatment

Here are some points to keep in mind as you continue your sex life during or after cancer treatment.

Learn as much as you can about the possible effects your cancer treatment may have on your sexuality. Talk with your doctor, nurse, or any other member of your health care team. When you know what to expect, you can plan how you might handle those issues.

Keep in mind that, no matter what kind of cancer treatment you have, you’ll still be able to feel pleasure when you are touched. Few cancer treatments (other than those affecting some areas of the brain or spinal cord) damage the nerves and muscles involved in feeling pleasure from touch and reaching orgasm. For example, women whose vaginas are painfully tight or dry can often reach orgasm through stroking of their breasts and outer genitals. For people with cancer, sexual touching is often satisfying. Pleasure and satisfaction are possible even if some aspects of sexuality have changed.

Try to keep an open mind about ways to feel sexual pleasure. Some couples have a narrow view of what sexual activity means to them. If both partners cannot reach orgasm through or during penetration, some may feel disappointed. But for people being treated for cancer, there may be times when intercourse is not possible. Those times can be a chance to learn new ways to give and receive sexual pleasure. You and your partner can help each other reach orgasm through touching and stroking. At times, just cuddling can be pleasurable. You could also continue to enjoy touching yourself. Do not stop sexual pleasure just because your usual routine has been changed.

Try to have clear, 2-way talks about sex with your partner and with your doctor. If you are too embarrassed to ask your doctor whether sexual activity is OK, you may never find out. Talk to your doctor about sex, and tell your partner what you learn. Otherwise, your partner might be afraid that sex might hurt you. Good communication is the key to adjusting your sexual routine when cancer changes your body. If you feel weak or tired and want your partner to take a more active role in touching you, say so. If some part of your body is tender or sore, you can guide your partner’s touches to create the most pleasure and avoid discomfort.

Boost your self-esteem. Remind yourself about your good qualities. If you lose your hair, you may choose to wear a wig, hat, or scarf if it makes you feel more comfortable. Some women prefer to wear nothing on their head. You may wear a breast form (prosthesis) if you have had a breast removed. Do whatever makes you feel good about yourself. Eating right and exercising can also help keep your body strong and your spirits up. Practice relaxation techniques, and get professional help if you think you are depressed or struggling.

How cancer treatment affects sexual desire and response

Lack of desire

Both men and women often lose interest in sexual activity during cancer treatment, at least for a time. At first, concern for survival is so great that sex may not be a priority. This is OK. Few people are interested in sex when they feel their lives are being threatened. When people are in treatment, loss of desire may be caused by worry, depression, nausea, pain, or fatigue. Cancer treatments that disturb the normal hormone balance can also lessen sexual desire.

If there’s a conflict in the relationship, one partner or both might lose interest in sex. Any emotion or thought that keeps a woman from feeling excited can interfere with desire for sex. Distracting thoughts can keep her from getting aroused. Her vagina then stays tight and dry, which can make vaginal penetration uncomfortable or painful.

Many people who have cancer worry that a partner will be turned off by changes in their bodies or by the very word “cancer.” These worries can affect desire, too.

Pain

Pain is a common problem for women during vaginal penetration (and/or intercourse). It’s often related to changes in the vagina’s tissues or size and vaginal dryness. These changes can happen after pelvic surgery, radiation therapy, menopause, or treatment that has affected a woman’s hormones.

Sometimes the pain sets off a problem called vaginismus. If a woman has vaginismus, the muscles around the opening of the vagina become tense without the woman being aware of it. This makes vaginal penetration difficult. Pushing harder increases the woman’s pain because her vaginal muscles are clenched in a spasm. Vaginismus can be treated with counseling and some special relaxation training.

Premature menopause

Another common way that cancer treatment can affect a woman’s sex life is by causing menopause earlier than expected. This is called premature menopause. Symptoms are often more abrupt and intense than the slow changes that happen during a natural menopause. When a woman’s ovaries are removed as part of a cancer surgery, or when the ovaries stop working because of chemotherapy or radiation to the pelvis, the loss of estrogen can cause hot flashes and vaginal atrophy (the vagina becomes tight and dry). Some women can take replacement hormones to help these problems. Women with cancers of the breast or uterus usually cannot take estrogen.

Women who have premature menopause sometimes have low androgen levels. This may be linked to lower sexual desire, but this link is not clear. If you are thinking of using hormones, it’s important to talk with your oncologist or nurse to learn about the benefits and possible risks of hormone therapy.

Orgasm

Women are usually able to have orgasms after cancer unless cancer or its treatment has damaged the spinal cord and caused the genital area to be numb. But even with spinal cord damage, there’s evidence that orgasm is possible, at least in some women.

Sometimes problems like pain during intercourse may distract a woman from reaching orgasm. In some cases, a woman might need to try different positions or types of genital touching. She might also need to practice having orgasms alone before going back to sex with a partner.

Pregnancy and fertility during and after chemo

If you think you might want to have children in the future, it’s important to talk to your doctor about this before starting chemo. You need to know if treatment will affect your fertility. Many chemo drugs can damage the ovaries, reducing their hormone output. Sometimes the ovaries recover after chemo, but sometimes they don’t.

During chemo, women should use birth control to keep from getting pregnant. Ask your doctor what kind of birth control is best and safest for you to use. Many of the drugs used to treat cancer can harm a fetus. If you want to get pregnant, talk with your doctor about how long you should wait after treatment is over.

After chemo, it may still be possible for some women to get pregnant. This is more likely to happen with younger women. Keep in mind that, even if you’re still having monthly periods, it’s hard to say whether you can get pregnant. Women who don’t want to become pregnant should use birth control, even after having chemo.

Early menopause with chemo

Women getting chemo often have symptoms of early menopause. These symptoms include hot flashes, vaginal dryness, vaginal tightness, and irregular or no menstrual periods. If the lining of the vagina thins, there may be a light spotting of blood after penetration.

Other chemo-related problems that may affect your sex life

Some chemo drugs irritate all mucous membranes in the body. This includes the lining of the vagina, which may become dry and inflamed. Yeast infections are common during chemo, especially in women taking steroids or antibiotics to treat or prevent bacterial infections. If you have a yeast infection, you may notice itching inside your vagina or on the vulva. You may also have a thick, whitish discharge, and you may feel some burning during sex.

Chemo can also cause a flare-up of genital herpes or genital warts if a woman has had them in the past. If you have a vaginal infection, see your doctor and have it treated right away. Infections can lead to serious problems because your immune system is probably weakened by chemo.

Yeast infections can often be prevented by not wearing pantyhose, nylon panties, or tight pants. Wear loose clothing and cotton panties to avoid trapping moisture in the vaginal area. Wipe front to back after emptying your bladder and do not douche. Your doctor may also prescribe a vaginal cream or suppository to reduce yeast or other organisms that grow in the vagina. Since your immune system may be weakened, it’s especially important to avoid sexually transmitted diseases. If you are having sex with someone, it’s important to practice safer sex from start to finish (use condoms or other barriers to avoid body fluids). Do this every time you have oral, anal, or vaginal sex.

During sexual intimacy, it’s important to avoid touching the vagina and the urethra with anything that has been used to stroke near the anus. Lingering germs from the bowel can cause infection if they get into these areas.

Chemo and sexual desire

Women who are getting chemo often notice decreased sexual desire. Physical side effects, such as upset stomach, tiredness, and weakness, can leave little energy for relationships. Sexual desire most often returns when a woman feels better. If a woman is getting chemo every 2 or 3 weeks, her sexual interest might only come back a few days before she’s due for her next treatment. After chemo ends, the side effects slowly fade, and sexual desire often returns to previous levels.

Women getting chemo also tend to feel unattractive. Hair loss, weight loss or gain, and sometimes infusion catheters (tubes in the vein for chemo or other drugs that stay in for weeks or months) can make it harder to have a positive sexual image of yourself.

Sex and pelvic radiation therapy

Radiation to the pelvic area often affects a woman’s sex life. If the ovaries get a large radiation dose, they may stop working. Sometimes this is just for a short period of time, but often it’s permanent.

If a woman has already gone through menopause, she may notice little or no change. This is because her ovaries have already stopped making hormones. But if she hasn’t reached menopause, radiation may cause sudden menopause with hot flashes and vaginal dryness.

Young women who get smaller doses of pelvic radiation, as they might during treatment for Hodgkin disease, may start to menstruate again as their ovaries heal. But with larger doses of radiation therapy, such as those used for cervical cancer, the damage is almost always permanent. Women who get radiation to the pelvis often become infertile. But no matter what the radiation dose, women younger than 50 should talk with their doctors before stopping birth control since it may be possible to become pregnant.

During radiation, tissues in the treatment area get pink and swollen, and may look sunburned. A woman’s vagina may feel tender during radiation treatment and for a few weeks afterward. As the irritation heals, scarring may occur. The thick walls of the vagina may become fibrous and tough. This means the walls might not stretch out as much during sexual excitement and activity.

The scarring that can occur after pelvic radiation can shorten or narrow the vagina. A woman can often keep tight scar tissue from forming by stretching the walls of her vagina with vaginal penetration during sex at least 3 or 4 times a week or using a vaginal dilator on a regular basis.

A vaginal dilator is a plastic or rubber tube used to stretch out the vagina. It feels much like putting in a large tampon for a few minutes. Even if a woman is not interested in staying sexually active, keeping her vagina normal in size allows more comfortable gynecologic exams. And gynecologic visits are an important part of follow up after treatment.

Radiation to the vagina can also damage its lining, making it thin and fragile. Many women notice some light bleeding after intercourse, but they felt no pain at the time. Rarely, women get ulcers, or open sores, in their vaginas, which may take several months to heal after radiation therapy ends.

Can a woman have sex while getting pelvic radiation?

As long as a woman is not bleeding heavily from a tumor in her bladder, rectum, uterus, cervix, or vagina, she can usually have sex during pelvic radiation therapy. The outer genitals and vagina are just as sensitive as before. Unless intercourse or touch is painful, a woman should still be able to reach orgasm, too. But some studies suggest waiting 4 weeks after radiation to let the swelling and inflammation decrease, and to reduce the risk of tearing the tissues.

A woman should follow her doctor’s advice about sex during radiation therapy. Radiation therapy from a machine outside the body does not leave any radiation in the body, so your partner will not come in contact with it.

Some women are treated with an implant. An implant is a radiation source put inside the bladder, uterus, or vagina for a few days. Intercourse may not be allowed while the implant is in place. Women treated with this type of radiation do not transmit radiation after the implant is removed.

Sex and hormone therapy

Hormone therapy may be used to treat cancers of the breast and the lining of the uterus. This treatment starves the cancer cells of the hormones they need to grow.

This can be done using medicines. For example, the drug tamoxifen keeps breast cancer cells from using estrogen. Other drugs – exemestane, anastrozole, and letrozole – keep testosterone from being converted to estrogen.

A few women have their ovaries removed or have their ovaries treated with radiation to make them inactive. This is another way to deprive a cancer of the hormones it needs to grow.

Any of these treatments will most likely cause symptoms of menopause. These include hot flashes, an interruption of the menstrual cycle, and vaginal dryness. In spite of these changes, a woman should still be able to feel sexual desire and reach orgasm. Sexual activity will not cause harmful increases in estrogen levels in the body.

Surgery for breast cancer can affect sexuality, too

Sexual problems have been linked to mastectomy and breast-conserving surgery (lumpectomy) – surgeries that remove all or part of the breast. Losing a breast can be very distressing. A few women even lose both breasts.

The most common sexual side effect from these procedures is feeling less attractive. In our culture, breasts are often viewed as a basic part of beauty and womanhood. If a breast is removed, a woman may feel less secure about whether her partner will accept her and still find her sexually pleasing.

The breasts and nipples are also sources of sexual pleasure for many women and their partners. Touching the breasts is a common part of foreplay. Some women can reach orgasm just from having their breasts stroked. For many others, breast stroking adds to sexual excitement.

Surgery for breast cancer can interfere with pleasure from breast caressing. After a mastectomy, the whole breast is gone and there’s a loss of sensation. Some women still enjoy being stroked around the area of the healed scar. Others dislike being touched there and may no longer even enjoy having the remaining breast and nipple touched.

Some women who have had a mastectomy feel self-conscious being the partner on top during sex. This position makes it easy to notice that the breast is missing. Some women who have had mastectomies wear a short nightgown or camisole, or even just a bra, with the prosthesis inside during sexual activity. Other women find the breast prosthesis awkward or in the way during sex.

Rarely, women may have long-term pain in their chests and shoulders after breast surgery. This is most often seen if the surgery removes the breast and the chest muscles under it. It may help to support the chest and shoulder with pillows during sex. It may also help if you avoid positions where weight rests on the chest or arm.

If surgery removed only the tumor (breast-conserving surgery: segmental mastectomy or lumpectomy) and was followed by radiation treatment, the breast may be scarred. It also may be different in shape, feel, or size. While the woman is getting radiation, the skin may become red and swollen. The breast also may be tender or painful in some places. Later on, some women may have areas of numbness or decreased sensation near the surgical scar.

There’s no physical reason breast surgery or radiation to the breasts should decrease a woman’s sexual desire. These treatments do not change her ability to have sexual pleasure. They don’t lessen her ability to produce vaginal lubrication, feel and enjoy normal genital sensation, or reach orgasm.

If a woman is past menopause and has been taking estrogen replacement therapy when breast cancer is found, her doctor may advise her to stop taking the hormones. Lower hormone levels may then cause the lining of the vagina to be thin, tight, or dry. These symptoms may be helped by water-based lubricants or a vaginal moisturizer. If not, a doctor can often prescribe a hormone cream for these problems.

Breast reconstruction

After mastectomy, the breast can be rebuilt so that it looks very much like the other breast. Breast reconstruction may restore the shape and size of the breast, but it cannot restore the previous feeling (sensation) in the breast. In a reconstructed (rebuilt) breast, the feeling of pleasure from touch on the breast and nipple may be decreased or even absent. The nerve that supplies feeling to the nipple runs through the deep breast tissue, and it might be cut during surgery. As a result, the preserved or rebuilt nipple has much less sensation. Sensitivity of the skin around the nipple may also be less intense, although some feeling may return over time. The skin on the rebuilt breast may get more sensitive with time, but usually does not give the same kind of pleasure as before mastectomy.

Breast reconstruction can help a woman enjoy sex more because it may help her feel whole and attractive. But it may not fully restore the physical feelings of pleasure she used to have from having her breast touched.

Female sexual problems caused by cancer treatment

Treatment Low sexual desire Less vaginal moisture Reduced vaginal size Painful intercourse Trouble reaching orgasm Infertility
Chemotherapy Sometimes Often Rarely – only if linked to menopause Often Rarely Often
Pelvic radiation therapy Often, if sex is linked with pain Often Often Often Rarely Often
Radical hysterectomy Rarely Often* Often Rarely Rarely Always
Radical cystectomy(removal of Bladder) Rarely Often* Always Sometimes Sometimes Always
Abdominoperineal (AP) resection Rarely Often* Sometimes Sometimes Rarely Sometimes*
Total pelvic exenteration(clearance) with vaginal reconstruction Sometimes Always Sometimes Sometimes Sometimes Always
Radical wide local excision vulvectomy (or partial vulvectomy Rarely Never Sometimes Sometimes Sometimes Never
Conization of the cervix Never Never Never Rarely, only if scar tissue forms Never Rarely
Oophorectomy (removal of one tube & ovary) Rarely Never* Never* Never – unless linked to menopause Never Rarely
Oophorectomy (removal of both tubes & ovaries) Rarely Often* Sometimes* Sometimes* Rarely Always
Mastectomy or radiation to the breast Rarely Never Never Never Rarely Never
Tamoxifen therapy for breast or uterine cancer Sometimes Often Sometimes Sometimes Rarely Need to use birth control
Aromatase inhibitor therapy for breast cancer Sometimes Sometimes Sometimes Sometimes Sometimes, if sex is painful N/A (only given to women after menopause)

*Vaginal dryness and size changes should not occur if you have one working ovary left or if hormone replacement therapy is given.

Dealing with sexual problems

When you first think of restarting sexual activity, you may be afraid it will be painful, or that you will never reach orgasm again. Your first sessions of lovemaking may not be what you expected. But just as you learned to enjoy sex when you started having sex, you can relearn how to feel pleasure after cancer treatment. People often realize that their sex life was less than ideal before cancer and change their sexual practices. Try to make the most of this chance to look at your sex life in a new way.

The areas of your genitals most sensitive to touch may be a little different, or perhaps touch that felt good before cancer treatment is now painful. You might find your favorite position for intercourse has changed. If your vagina or vulva has been affected by surgery, you will need time to get used to the new feelings you have during sex.

Vaginal dryness

Lubricants

Cancer treatments often reduce the amount of lubricant produced in your vagina when you are excited. You may need extra lubrication to make intercourse comfortable. If you use a vaginal lubricant, choose a water-based gel that has no perfumes, coloring, spermicide, or flavors added, as these chemicals can irritate your delicate genital tissues. Lubricants can usually be found near the birth control or feminine hygiene products in drug stores or grocery stores. Common brands include K-Y Jelly® and Astroglide®. Be aware that some of the newer lubricant products include herbal extracts (such as aloe or lavender), which may cause irritation or allergic reactions in some people. Also, warming gels can cause burning in some people. Be sure to read the labels, and talk with a nurse, doctor, or pharmacist if you have questions.

Petroleum jelly (Vaseline®), skin lotions, and other oil-based lubricants are not good choices for vaginal lubrication. In some women, they may raise the risk of yeast infection. And if latex condoms are used, they can be damaged by petroleum products and lotions. Also, watch out for condoms or gels that contain nonoxynol-9 (N-9). N-9 is a birth control agent that kills sperm, but it can irritate the vagina, especially if the tissues are already dry or fragile.

Before intercourse, put some lubricant around and inside the entrance of your vagina. Then spread some of it on your partner’s penis, fingers, or other insert. This helps get the lubricant inside your vagina. Many couples treat this as a part of foreplay. If vaginal penetration lasts more than a few minutes, you may need to stop briefly and use more lubricant. Even if you use vaginal moisturizers every few days, it’s best to use gel lubricant before and during sex.

Vaginal moisturizers

As women age, the vagina can naturally lose moisture and elasticity (the ability to stretch or move comfortably). Cancer treatments and risk-reducing surgery (such as removing the ovaries) can hasten these changes. Vaginal moisturizers are non-hormonal products intended to be used several times a week to improve overall vaginal health and comfort. You can buy them without a prescription. Vaginal health is not only important for sexual activity, but also for comfortable gynecologic exams.

Vaginal moisturizers are designed to help keep your vagina moist and at a more normal acid balance (pH) for up to 2 to 3 days. Vaginal moisturizers are applied at bedtime for the best absorption. It should be noted that it’s not uncommon for women who’ve had cancer to need to use moisturizers up to 3 to 5 times per week. Vaginal moisturizers are different than lubricants – they last longer and are not usually used for sexual activity.

Replens® and K-Y Liquibeads® are examples of vaginal moisturizers. Lubrin® and Astroglide Silken Secret® are other moisturizers that are marketed as longer lasting than typical lubricants. Vitamin E gel caps can also be used as a vaginal moisturizer. Use a clean needle to make a small hole in the gel cap and either put the entire capsule into your vagina or squeeze some of the gel onto your fingers and put them into your vagina. Be aware that vitamin E may stain undergarments.

Vaginal estrogens

Topical or systemic estrogen therapy is a treatment option for vaginal atrophy (when the vaginal walls get thinner and less stretchy) for most post-menopausal women. But hormone treatments can be a complex issue for many women and health care providers in the cancer setting.

Many women do well with local vaginal hormones to help vaginal dryness. These hormones are applied to and absorbed into the genital area, rather than taken by mouth. They come in gel, cream, ring, and tablet forms. Most are put into the vagina, although some creams can be applied to the vulva. Local vaginal hormones must be prescribed by a doctor and should first be discussed with your oncologist.

Premature menopause

If you have gone through premature (early) menopause because of cancer treatment, you may be bothered by frequent hot flashes, especially at night. Some women may be less interested in sex, though the decreased interest may be linked more to stress and poor sleep than to a shortage of hormones.

Female hormones in a pill or patch can help with vaginal dryness and hot  But because estrogens can promote cancers of the breast, uterus, and possibly the ovaries, and cause other health problems, too, doctors are less likely to prescribe them than they once were. Women who have vaginal dryness can now use tiny doses of estrogen in gels, creams, rings, or tablets by putting them right into the vagina. These methods focus small amounts of hormones on the vagina and nearby tissues, so that very little gets in the bloodstream to affect other parts of the body.

If you have questions or concerns about hormone therapy, talk with your doctor or health care provider about the risks and benefits as they apply to you. If you and your doctor decide that hormone therapy is the best treatment for you, it’s usually best to use it at the lowest dose that works for you and for the shortest possible time. It’s important that any woman taking hormone therapy be checked each year by her doctor.

If your doctor does not advise hormones for you, hot flashes can also be treated in other ways, such as by taking medicines that control the nervous system’s reaction to a lack of estrogen. Some drugs that are commonly used this way are the anti-depressants called serotonin reuptake inhibitors, like venlafaxine (Effexor®), fluoxetine (Prozac®), paroxetine (Paxil®), and others. Many women with milder hot flashes may do well with exercise and relaxation techniques alone. There are many ways to treat hot flashes – both with medicines, acupuncture and with minor changes in your environment. Talk to your doctor or nurse about what may work for you.

Reaching orgasm after cancer treatment

Almost all women who could reach orgasm before cancer treatment can do so after treatment, and it may be as easy as before. But for some it may take practice.

“I’m having trouble reaching orgasm. What can I do?”

If you enjoy being touched but still have trouble reaching orgasm, you may need to try something new to push yourself toward more excitement. Here are a few ideas that might help a woman reach orgasm.

  • Have a sexual fantasy during lovemaking. A fantasy can be a memory of a past experience or a daydream about something you’ve never tried. A strongly sexual thought can distract you from negative thoughts and fears about performing.
  • Use a hand-held vibrator for extra stimulation during your lovemaking. Hold it yourself, or ask your partner to caress your genitals with it. You can steer your partner to the areas that respond best and away from those that are tender or uncomfortable.
  • Change the position of your legs during sexual activity. Some women reach orgasm more easily with their legs open and thigh muscles tense. Others prefer to press their thighs together.
  • Tighten and relax your vaginal muscles in rhythm during intercourse or while your clitoris is being stroked. Or, tighten and relax the muscles in time with your breathing. This helps you focus on what you’re feeling. Contract your vaginal muscles and pull them inward as you inhale, and let them relax loosely as you exhale.
  • Ask your partner to gently touch your breasts and genital area. Experiment with your partner to find the type of touch that most excites you.

Feeling good about yourself and feeling good about sex

Sex is all too often viewed as something for the young and healthy. Sex appeal is judged by some as a skin-deep sort of beauty rather than something based on love, kindness, maturity, or a sense of humor. Based on looks alone, most people may not feel all that attractive to start with. And after being treated for cancer, their self-esteem can often fall even further.

Sometimes friends and lovers withdraw emotionally from a person with cancer. This may not be due to how the person looks, but may be caused by some feelings or thoughts in the person who’s doing the looking. When one partner cannot bear to look at the other’s ostomy appliance, for instance, it may be a sign of much deeper feelings. Maybe they’re angry because they have to take over the partner’s usual tasks of paying bills and doing housework. Or the ostomy may remind one partner of how sad they would be if the other person died. It might be easier not to love that person so much. A partner may even be more aware of their own chance of death, which can be upsetting, too. Yet all these feelings get blamed on a stoma, which is a small part of one partner’s body. The “well” partner, in turn, may also feel like a failure and know that they’re letting the partner who’s had cancer down at a time when they are most needed.

Don’t give up on each other. It may take time and effort, but keep in mind that sexual touching between a woman and her partner is always possible. It may be easy to forget this, especially if you are both feeling down or have not had sex for a while.

Chemotherapy changes the way you look

The most obvious change caused by chemo will likely be hair loss. You may expect to lose the hair on your head, but other body hair, such as eyebrows, eyelashes, and pubic hair, are often affected, too. You may also lose weight and muscle mass if you have trouble eating. On the other hand, many women gain weight during or after chemo. Your skin may get darker, become dry and flaky, or you may be very pale. Your nails may become discolored or ridged. And you may also have an infusion (IV) catheter or port placed in your chest or arm or abdomen (belly).

Some physical changes caused by chemo can be covered up or made less obvious. If you are just starting chemo, you may want to shop for a wig before your hair begins to fall out. If you have very long hair, you may even be able to have it cut off and made into a wig. This is costly, but some people find it worthwhile. Wigs are warm and often not comfortable, so you may decide to mostly wear your wig outside the home or hospital. You can also use scarves, turbans, hats, or caps. Some women leave their heads uncovered. Still others switch back and forth, depending on whether they are in public or at home with family and friends.

It’s a good idea for a couple to discuss how each feels about wearing a wig or head covering during sex. There’s no right or wrong decision.

Disguising weight loss, skin color and nail changes, and infusion catheters is a bigger problem. For the most part, clothes that fit well look better. Wearing something too tight or too baggy will draw attention to your weight change. High necks and long sleeves can hide a catheter, but may be too hot in warm weather. Look for thin fabrics that will be cool while covering you.

Ways to cope with changes in how you look

Feeling good about yourself begins with focusing on your positive features. Talk to your doctor about things that can be done to limit the damage cancer can do to your appearance, your energy, and your sense of well-being. When you are going through cancer treatment, you can feel more attractive by disguising the changes cancer has made and drawing attention to your best points.

This mirror exercise can help you adjust to body changes:

  • What do you see when you look at yourself in the mirror? Many people notice only what they dislike about their looks. When they look in the mirror, they see pale skin, hair loss, an ostomy, or skinny legs. They fail to see a classic profile, expressive eyes, or a nice smile.
  • Find a time when you have privacy for at least 15 minutes. Be sure to take enough time to really think about how you look. Study yourself for that whole time, using the largest mirror you have. What parts of your body do you look at most? What do you avoid seeing? Do you catch yourself having negative thoughts about the way you look? What are your best features? Has cancer or its treatment changed the way you look?
  • First, try the mirror exercise when dressed. If you normally wear clothing or special accessories to disguise changes from cancer therapy, wear them during the mirror exercise. Practice this 2 or 3 times, or until you can look in the mirror and see at least 3 positive things about your looks.
  • Once you are comfortable seeing yourself as a stranger might see you, try the mirror exercise when dressed as you would like to look for your partner. If you’ve had an ostomy, for example, wear a bathrobe or teddy you like. Look at yourself for a few minutes, repeating the steps in the first mirror exercise. What is most attractive and sexy about you? Pay yourself at least 3 compliments on how you look.
  • Finally, try the mirror exercise in the nude, without disguising any changes made by the cancer. If you have trouble looking at a scar, bare scalp, or an ostomy, take enough time to get used to looking at the area. Most changes are not nearly as ugly as they seem at first. If you feel tense while looking at yourself, take a deep breath and try to let all your muscles relax as you exhale. Don’t stop the exercise until you have found 3 positive features, or at least remember the 3 compliments you paid yourself before.

The mirror exercise may also help you feel more relaxed when your partner looks at you. Ask your partner to tell you some of the things that are enjoyable about the way you look or feel to the touch. Explain that these positive responses will help you feel better about yourself. Remember them when you are feeling unsure.

Changing negative thoughts

Your thoughts can make a sexual experience good or bad. Become more aware of what you tell yourself about how attractive or sensual you feel. You may be setting yourself up for failure with thoughts like, “How could someone want a woman with one breast?” Almost all of us have put ourselves down now and then. But there are ways to turn these thoughts around.

  • Write down the 3 negative thoughts you have most often about yourself as a sexual person. Some may be connected to your cancer treatment, but other thoughts may have started years ago.
  • Now write down a positive thought to counter each negative thought. For example, if you said, “No one wants a woman with a urostomy,” you could say to yourself, “I can wear a lacy ostomy cover during sex. If someone can’t accept me as a lover with an ostomy, then they’re not the right person for me.” The next time you are in a sexual situation, use your positive thoughts to override the negative ones you usually have. If you have a favorite feature, this is a good time to indulge yourself a little and play it up.

If negative thoughts intrude and you find yourself overwhelmed or discouraged, you may want to talk with your cancer team about working with a mental health professional. This can help you adjust to the changes in your body.

Rebuilding self-esteem

Feeling attractive is just one part of your self-image. Self-esteem can be described as a set of bank accounts:

  • One account contains the net worth of your physical self – what your body can do and how you look.
  • The second account is your social self – how easily you get along with others and the emotional support you can count on.
  • In the third account is the total sum of your achieving self – what you have done in school, work, and personal and family relationships.
  • The fourth account is for your spiritual self – your religious and moral beliefs and the strength they give you.

During your life, you make deposits in your accounts, but when a crisis like cancer comes up, you must also make withdrawals. Going through cancer treatment has costs. It takes time, and may take away some of your physical ability to function. It can harm your relationships with others, your career goals, and sometimes your faith. When funds from one of your accounts become low, you may need a “loan” from one of the others to balance your account.

Try to be aware of the costs of cancer in your life. Make a special effort to get new deposits for the accounts that remain active. By doing so, a drain from one area of your self-worth will not bankrupt you entirely. If your cancer treatment has affected your looks, focus on the love and care you get from friends and family who react to you with a deep level of intimacy. If treatment interrupts your work, use some of your energy to enrich your social or spiritual life.

Although you may sometimes feel that all your accounts are getting low, a more careful look should reveal some areas where “income” is still flowing in.

Good communication: The key to building a successful sexual relationship

The most important part in keeping a healthy sexual relationship with a partner is good communication. Many people react to cancer by withdrawing. They think their partner will feel burdened if they share their fears or sadness. But when you try to protect each other, each suffers in silence. No couple gets through cancer diagnosis and treatment without some anxiety and grief. Why not discuss those fears with one another so that you shoulder the load together rather than alone?

Sex is one way for a couple to feel close during the stress of an illness. But if you or your partner has been depressed and distant, a sexual advance might come across as a demand. You can bring up the topic of sex in a healthy, assertive way. It’s usually not helpful to accuse (“You never touch me anymore!”) or demand (“We simply have to have sex soon. I can’t stand the frustration!”). Instead, try to state your feelings positively. (“I really miss our sex life. Let’s talk about what’s getting in the way of our being close.”)

Overcoming anxiety about sex

Many couples believe that sex should always happen on the spur of the moment, with little or no advance planning. But sometimes you are dealing with a cancer-related symptom or treatment side effect that makes it impossible to be as spontaneous as you would have been in the past. The most important thing is to open up the topic for discussion and begin scheduling some relaxed time together. Couples need to restart their lovemaking slowly.

Part of the anxiety about resuming sex is caused by the pressure to satisfy your partner. One way to explore your own capacity to enjoy sex is to start by touching yourself. Self-stimulation (or masturbation) is not a required step in restarting your sex life, but it can be helpful. By touching your own genitals and bringing yourself pleasure, you can find out if cancer treatment has changed your sexual response without having to worry about frustrating your partner. It can also help you find out where you might be tender or sore, so that you can let your partner know what to avoid.

Many of us may have learned as children that self-stimulation was wrong or shameful. But it’s a normal and positive experience for most people. Most men and women have tried touching their own genitals at some time in their lives. Many people who enjoy good sex lives with their partners still masturbate sometimes. Men and women in their 70s, 80s, and 90s often still enjoy self-stimulation.

If you feel relaxed with the idea, try stroking not just your genitals, but all of the sensitive areas of your body. Notice the different feelings of pleasure that you can have.

Self-stimulation

  • Research has shown that self-stimulation is the most common sexual behavior in humans. Although more common in men, women also enjoy self-pleasuring.
  • Self-stimulation may not be OK with your personal and religious belief system and should not be forced. The most important aspect of being sexual is feeling comfortable with your personal thoughts and beliefs.
  • Self-stimulation is a real sexual behavior that doesn’t have to be seen as a negative alternative to sex with a partner. Many people in healthy relationships still self-stimulate.
  • You may discover that gently stroking not only your genitals but other areas of your body gives you a sense of well-being. Many women find their breast area, nipples, and other areas of their body highly sensitive to touch. Different women find different parts pleasurable. Take time to explore your body. Some areas may be sensitive from surgery or radiation; you may choose to avoid these areas for now. Try exploring these areas again later.
  • If you feel comfortable, plan for some private time when you won’t be interrupted and gently explore your body to find your erogenous (highly sensitive) areas. You may want to include your partner in your discoveries, or you may choose to keep these new discoveries private. Many find that they enjoy this erotic pleasure during their shower.
  • Some women feel happy with exploring and self-stimulating. Take time to find your comfort level with this type of sexual activity. The process differs from person to person, so don’t rush or force yourself to do anything that makes you uncomfortable.

Rekindling sexual interest

Every now and then we all have sexual thoughts or feelings, but sometimes we ignore or forget about them. Your sexual thoughts can be used to improve your sex life. Try keeping a “Desire Diary.” Here’s how:

  • Every day for a week, prepare a sheet of paper that will become your Desire Diary. Take it with you wherever you go. When you have a sexual thought or feeling, write it down. Note the time of day and whether you were alone or with someone. Also note what you did about the thought.
  • Look at your Desire Diary to see if there are any patterns, such as certain settings, people, or times of the day that help you feel more sexual.
  • Once you have noted some patterns, you can begin putting yourself in the situations that spark a sexual mood, such as exercising, planning a relaxed evening out with your partner, making a special effort to look and feel sexy, reading a steamy story, watching a movie with a romantic or sexual plot, or fantasizing about a sexual encounter.
  • Get your partner’s help at some point. Discuss any fears either of you may have about your sexual relationship. If you have questions about medical risks, you and your partner should discuss them with your doctor.

If these efforts fail to rekindle your sexual interest, think about seeking some sexual counseling.

Sexual activity with your partner

When you feel ready to try sexual touching with your partner, start with plenty of time and privacy. Plan for a time when you aren’t too tired and when any pain is well-controlled. You may want to create a relaxed environment. For example, you could light the room with candles or put on some soft, romantic music. Although you may feel a little shy, let your partner know that you would like to have some time to be physically close.

You could even make a date for this purpose. You might say, “I feel ready for sex again, but I’d like to take things slowly. Would you be in the mood tonight to try a little touching? I can’t promise that it will go perfectly, but we can have fun trying.”

It’s a good idea for couples to put some limits on their touching the first few times they try sexual activity after cancer treatment. A good way to start is with a special session devoted to all-over body touching. This is the way body touching works:

  • Each partner takes a turn touching and being touched. One partner lies face down on the bed, allowing the other partner to touch the entire back, from toes to scalp. After about 15 minutes, the partner lying down turns over so the front of the body can be touched.
  • The first time you try a touching session, avoid the breasts and genitals. Your goals are to feel relaxed and to experience sensual pleasure. It’s not important to get sexually excited. If you agree on these goals prior to starting, the touching should not be frustrating. This type of session takes the nervousness and pressure out of being close again.
  • While being touched, your job is to be self-centered and tuned in to your own feelings. Don’t worry about your partner’s thoughts or feelings. When you are doing the touching, enjoy the shape and texture of your partner’s body. Try many different types of touching, varying from light stroking to a firmer touch, much like a massage.
  • If you both feel relaxed during the first touching session, you can add some genital touching the next time. Over a few sessions, partners can slowly spend more time on genital caresses, until each one is able to reach an orgasm through stroking with a hand, or oral sex, if that’s comfortable for both of you.

Many couples don’t talk much about sex. But after cancer treatment, your sexual routine may need to change. This calls for clear communication. This is not the time to let embarrassment silence you. Be sure to let your partner know, either in words or by guiding with your hand, the kinds of touches you like best. Try to express your desires in a positive way. For example, “You have the right place, but I’d like you to use a light touch,” rather than, “Ouch! That’s too rough!” Save vaginal penetration until both partners really feel ready for it.

Making sex more comfortable

If you still have some pain or feel weak from cancer treatment, you might want to try new lovemaking positions. Many couples have found one favorite position, particularly for vaginal penetration, and rarely try another. The best-known way to have intercourse (or vaginal penetration) is in the “missionary position,” with the partner lying on top of the woman. But after cancer treatment, other ways might be more comfortable. You may be able to enjoy intercourse more if both of you lie side by side, either facing each other or with your back next to your partner’s front side. Another position that may work well is for you to sit or kneel astride your partner. This allows you to move more freely while your partner relaxes or touches you.

Frequently asked questions about sex and cancer

Can sex cause cancer?

For most cancers, there’s no link between a person’s sex life and the risk of cancer. Nor does having sex after cancer treatment increase the chances of cancer coming back or getting out of control. But viruses passed from one person to another through sexual contact have been linked to some cancers, including squamous cell carcinoma of the cervix, vulva, vagina, penis, and Kaposi sarcoma. Hepatitis B and hepatitis C viruses, which can be passed from person to person during sex, can increase the risk for liver cancer. Epstein-Barr virus, which causes mononucleosis (also called the kissing disease), seems to increase the risk of certain types of cancer, too.

These cancers are not caused by having sex itself, but by viruses that can be picked up during sexual activity with someone who already has the virus. News stories about viruses and cancer can be confusing. The roles of these viruses are not fully understood, but some can cause changes in the DNA of the cell. Most people who get these viruses never develop cancer.

There are other risk factors involved in cancer development, even in those cancers that are promoted by viruses. For example, women who smoke cigarettes have a higher risk of cervical cancer. Women who start having sex before age 18 also seem at higher risk for cancer of the cervix.

Many patients and their partners worry that cancer is contagious – that cancer itself can be passed from one person to another during sex. Despite this myth, a cancer cell from one person’s body simply cannot take root and grow in someone else. Not only are all cells fragile, needing the proper environment to survive, but the partner’s immune system would detect the cancer cell and destroy it. Cancer is not contagious.

Safer sex

Unless you know for sure that neither you nor your sexual partner has any disease, and that both of you are careful to avoid infection, you should practice safer sex. Examples of safer sex include:

  • Touching each other’s genitals with the hands
  • Oral sex with a man if he wears a condom from start to finish. A woman should never taste or swallow a man’s semen if she suspects he might have a sexually transmitted disease (STD).
  • Oral sex with a woman if a “dental dam” is used. A dental dam is a rubber sheet that is used to cover the woman’s vulva during oral sex. Or a sheet of plastic kitchen wrap that keeps the woman’s sexual fluids contained can be used instead.
  • Vaginal sex or anal sex wearing a condom. Condoms only work if they are used correctly, every time, from start to finish. Lots of water-based lubricant can help reduce the risk of the condom breaking. Never use lotion, oils, or petroleum jelly, which weaken latex condoms.

Can sex during treatment be harmful to a patient or partner?

A few chemotherapy drugs can be present in small amounts in vaginal fluids. You may want to use condoms while you are getting chemotherapy and for about 2 weeks afterward. Some types of radiation treatment require special precautions for a certain amount of time, too. Talk to your doctor or nurse if you have questions or concerns.

Keep in mind that some cancer treatments may cause harm to the fetus if you get pregnant, and precautions must be taken to be sure this doesn’t happen. Talk with your doctor about what kind of birth control will work best for you, and how long you will need to use it after treatment.

When should a person with cancer not have sex?

Ask your doctor if sexual activity may be a problem at any time during or after your treatment. Here are some general guidelines:

  • When recovering from surgery, intercourse can cause bleeding or strain the incision (cut). Sex may also increase your chance of infection. The time between your surgery and when it’s safe to resume your sex life varies. It depends on the type of operation and how well you are healing. Your surgeon can tell you when it’s safe to try sexual activity again.
  • Some types of cancer, like cancer of the cervix or bladder, may cause bleeding in the genital area or urinary tract. If this bleeding is worse after sex, talk with your doctor about it. You may need to stop having sex until the bleeding has stopped and the area has healed.
  • During chemotherapy, a person with an infusion catheter sometimes worries that sexual activity will harm it. As long as you take care not to rub against the dressing, sex should not cause any problems.
  • There are things you can do to try to prevent urinary tract infections. Some of the bacteria that can start an infection in the urinary tract or genital area can be washed away by urinating a few minutes after sex. Some doctors also suggest washing the genital area before sex and drinking extra fluids. If you have urinary tract infections often, your doctor may give you antibiotics to take after sex. This can help prevent infection.
  • If you notice any sores, bumps, or warts on your partner’s genitals or a white or greenish-gray fluid (other than semen) in the opening at the tip the penis, you should ask for an explanation of the symptom and decide whether it’s safe to have sex.
  • You can greatly reduce your chances of getting a sexually transmitted disease (STD) if your partner wears a condom from start to finish each time you have sex. For women with female partners, plastic film or dental dams can be used for oral sex.
  • The sperm-killing chemicals in contraceptives were once thought helpful in fighting bacteria and some viruses. But some studies showed a higher risk of getting HIV infection in women who used nonoxynol-9 (N-9), a popular ingredient in foam and gel contraceptives. Some lubricated condoms also have N-9, so you may want to check the label before you use them. If a woman’s vagina is irritated or dry, contraceptive foams, jellies, or films may make the problem worse and be painful. Water-based lubricants or vaginal moisturizers may be used to help with dryness. (Talk with your doctor about what methods might best meet your needs for preventing STDs or pregnancy.

You probably have many other questions that haven’t been addressed here. Don’t be afraid or embarrassed to discuss them with your doctor or other members of your health care team. Write them down now so you’ll remember to ask them at your next visit.

What about sex and advanced cancer or at the end of life?

A very ill person is not often seen as a sexual person, but sexual feelings exist in everyone, even in times of very poor health. Touching, caressing, sharing, and emotional intimacy are always important – even at the end of life.

When cancer is far advanced, a person’s needs for affection, sharing of feelings, and touch may become even stronger. Partners of patients can help by remembering how important physical closeness is, even when intercourse might be too much for the person with cancer.

Pleasure Solutions

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Pleasure Solutions offers a combination of online information, telephone support and products that will encourage people to explore their sexual lives.

We give clinicians peace of mind by providing a resource they can direct to. Adding the extra attention and time people need to help them plan and rediscover intimacy.

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