Sexuality after cancer treatment: What women can expect

Sex might be the last thing on your mind as you start thinking about cancer
treatment options and cope with the anxiety that comes with a cancer diagnosis.
But as you start to feel more comfortable with yourself during treatment and
afterward, you'll want to get back to a "normal" life as much as you can. For
many women, this includes resuming sexual intimacy with their partners.

An intimate connection with a partner can make you feel loved and supported
as you go through your cancer treatment. But sexual side effects of cancer
treatment can make resuming sex more difficult. Find out if you're at risk of
sexual side effects after treatment and which treatments can cause these side
effects. Knowing more about your situation can help you feel more in control and
help you find a solution that will work for you.

Who's at risk of sexual side effects?

Women being treated for breast or gynecologic cancers are most likely to
experience side effects that make having sex painful or difficult. But cancers
anywhere in the pelvic region can cause these effects. Pelvic cancers
include:

• Bladder cancer
  
• Cervical cancer
  
• Colon cancer
  
• Ovarian cancer
  
• Rectal cancer
  
• Uterine cancer
  
• Vaginal cancer

Treatment for each of these cancers carries the risk of causing physical
changes to your body. But having cancer also affects your emotions, no matter
what type of cancer you have. These emotions can also impact your attitude
toward sex and intimacy with your partner.

What sexual side effects are most common?

The treatment you receive and your type and stage of cancer will determine
whether you experience any sexual side effects. The most commonly reported side
effects among women include:

• Difficulty reaching climax
  
• Loss of desire for sex
  
• Pain during penetration
  
• Reduced size of the vagina
  
• Vaginal dryness

Not all women will experience these side effects. Your doctor can give you an
idea of whether your specific treatment will cause any of these.

Common sexual side effects of selected cancer treatments

Treatment	Difficulty climaxing	Loss of desire	Painful sex	Reduced vaginal size	Vaginal dryness
Chemotherapy	 	X	X	 	X
Pelvic radiation	 	 	X	X	X
Surgery Radical hysterectomy	 	 	 	X	X
Radical cystectomy	 	 	X	X	X
AP resection	 	 	X	X	X
Vulvectomy	X	 	X	X	 
Hormone therapy Medications	 	X	X	X	X
Oophorectomy	 	 	X	X	X

Adapted from: American Cancer Society, 2005

How does cancer treatment cause sexual side effects?

Cancer treatments that are more likely to cause sexual side effects
include:

Chemotherapy
Many women experience a loss of libido
during and after chemotherapy. Often the side effects of the treatment, such as
nausea, hair loss, and weight loss or gain, can make you feel unattractive. Side
effects usually fade soon after treatment ends. But it may take time to rebuild
your self-confidence to bring back your desire for sex.

Chemotherapy can cause a sudden loss of estrogen production in your ovaries.
This can lead to symptoms of menopause, such as a thinning vagina (vaginal
atrophy) and vaginal dryness, which both can cause pain during penetration. Ask
your doctor about what you can expect from your chemotherapy drugs, as some can
cause permanent ovary damage. Depending on your cancer type, your doctor may
prescribe estrogen replacement therapy — also called hormone therapy
for menopause — to reduce the sexual side effects you experience.
However, women with breast or ovarian cancer should discuss this carefully with
their doctors, as some cancers are hormone sensitive and shouldn't be combined
with hormone replacement therapy.

Radiation therapy
Sexual side effects related to
radiation therapy are most common in women receiving treatment aimed at their
pelvic area. Radiation to the pelvis causes:

• Damage to the ovaries. The amount of
  damage and whether it's permanent depends on the strength of your radiation
  treatments. Damaged ovaries don't produce estrogen. This causes symptoms of
  menopause, such as vaginal dryness. If you've already been through menopause,
  you likely won't experience such symptoms.
  
• Changes in the vaginal lining. Radiation
  therapy can irritate healthy tissue in its path. This can cause the lining of
  your vagina to become inflamed and tender. Penetration during sex may be
  uncomfortable during treatment and for a few weeks afterward. As the lining of
  your vagina heals, it may become thickened and scarred, causing your vagina to
  tighten and resist stretching during penetration. Your doctor might recommend
  using a vaginal dilator to prevent scar tissue from forming after radiation.
  

Talk to your doctor about what you can expect from your specific radiation
treatments. Some side effects may be preventable. For instance, surgery to
relocate your ovaries to another part of your body might spare them from the
damage of radiation and preserve your fertility. Ask your doctor about your
options.

Surgery
Whether surgery affects your ability to have sex
will depend on your type of cancer, where it's located and its size. Surgeries
that are likely to cause sexual side effects include:

• Radical hysterectomy. Women with cervical
  cancer may opt for a radical hysterectomy to remove their uterus and related
  ligaments, as well as their cervix and part of their vagina. A shortened vagina
  usually doesn't change your ability to have sex, though it may take some
  adjustment. Women over 40 may also have their ovaries removed during this
  procedure. If you're premenopausal when your ovaries are removed, you'll
  experience menopause.
  
• Radical cystectomy. In this operation for
  bladder cancer, the surgeon removes your bladder, uterus, ovaries, fallopian
  tubes, cervix, the front wall of your vagina and your urethra. Your surgeon
  reconstructs your vagina, though it may be shorter or narrower than it was
  before surgery. This can make sex painful. If you haven't been through
  menopause, removal of your ovaries will cause early menopause.
  
• Abdominoperineal (AP) resection. AP
  resection is used if you have colon or rectal cancer. Your surgeon removes your
  lower colon and rectum. Without the cushion of the rectum, you might experience
  pain in your vagina during penetration. Some women who have an AP resection also
  have their ovaries removed. If you're premenopausal, this will cause premature
  menopause.
  
• Vulvectomy. You may undergo vulvectomy if
  you have cancer of the vulva. Your surgeon removes the entire vulva, including
  the inner and outer lips, as well as the clitoris. These play a major part in
  sexual arousal in women. Removing the vulva and the clitoris can make the area
  less sensitive and make it harder for you to reach orgasm.

There isn't a clear link between breast cancer surgery and decreased sexual
function. You may be self-conscious of your scars after surgery, which can cause
a loss of libido. However, women who undergo breast-saving surgery, rather than
complete removal of the breast (mastectomy), are more likely to enjoy breast
caressing.

Hormone therapy
If you have a hormone-sensitive cancer,
you might receive hormone therapy through medications, such as tamoxifen, or
through surgery, such as removal of your ovaries (oophorectomy). If your cancer
relies on hormones to fuel its growth, these measures can block or alter its
supply.

Both medications and surgery for hormone therapy cause menopausal signs and
symptoms, including vaginal atrophy and dryness. Removing your ovaries causes
permanent menopause. Side effects of hormone therapy medications usually wear
off after you stop taking them. Keep in mind though, that women taking hormone
therapy for cancer usually take these drugs for five years or more.

The vulva is the outer part of the female genitalia, including the labia and
clitoris.

What can you do to regain your sexual function?

Knowing what sexual side effects to expect before you begin your cancer
treatment can help you be more prepared to deal with them as you go through
treatment. If you experience sexual side effects, find out as much as you can
about what's impeding your sexual function. This will help you feel more in
control of the situation and help guide you to treatment options. You may also
want to:

• Talk with your health care team. You
  might be embarrassed to talk about the sexual side effects you're experiencing,
  but don't be. Though talking about sex can be awkward, you'll never find a
  solution if you don't let someone know what you're experiencing. Write down your
  questions if it makes you feel more comfortable. Also know that your doctor may
  be embarrassed or hesitant to talk about sex. Ask to be referred to a specialist
  or seek support from other members of your health care team, such as nurses and
  counselors.
  
• Talk with your partner. Let your partner
  know what you're experiencing and how he or she can help you cope. For instance,
  you might find that using a lubricant eases your vaginal dryness or changing
  positions helps you avoid genital pain during sex. Together you can think of
  solutions to ease you back into a fulfilling sex life.
  
• Explore other ways of being intimate.
  Intercourse isn't your only option for closeness with your partner. Consider
  spending more time together talking, cuddling or caressing. Connecting in other
  ways might help make you feel more comfortable and less anxious about the sexual
  side effects you're experiencing.
  
• Talk with other cancer survivors. Your
  health care team might be able to steer you to a support group in your town.
  Otherwise, connect with other cancer survivors online. If you're embarrassed
  about discussing sex face-to-face with strangers, the online environment
  provides you anonymity. Start with the American Cancer Society's Cancer
  Survivors Network.

It may simply take time for you to regain your sexual function after cancer
treatment. While that can be frustrating, know that if you had a positive and
satisfying sex life before cancer, you'll likely resume that after your
treatment.